Care of the patient with chest tubes

Objectives

Describe the anatomy and physiology of the chest.

Explain how normal breathing occurs.
Identify three indications for chest tube placement.
Identify three basic compartments of the drainage
system and their functions.
List five examples of nursing responsibilities in caring
for a patient with a chest tube/drainage system.
Describe appropriate nursing documentation of a
patient with or in need of chest tube placement.

CHEST ANATOMY
Negative pressure is present
within the pleural space and
creates a vacuum or suction
called intrapleural pressure.
This vacuum keeps the lungs
against the chest wall, allowing
for expansion of the lungs and
thorax during inhalation.
Intrapleural pressure is always
slightly negative compared to
atmospheric pressure. When
this intrapleural pressure is lost
or disrupted, the lung collapses.

Indications For Tube Placement

Chest tubes are indicated for the following patient
conditions:
1. Pneumothorax
2. Hemothorax
3. Hemopneumothorax
4. Tension pneumothorax
5. Empyema
6. Chylothorax
7. Pleural effusion
8. Post-operative cardiothoracic surgery

Pneumothorax
A pneumothorax is
defined as air within
the pleural space. This
air can cause partial or
complete lung
collapse.

Pneumothorax Symptoms
Symptoms of the patient with a pneumothorax may
include any or all of the following:

1. Shortness of breath
2. Increased respirations (tachypnea)
3. Falling pulse oximetry (decreased or falling SaO2)
4. Loss of breath sounds on the affected side
5. Palpable subcutaneous (SQ) emphysema or
crepitus
6. Hyperresonance to percussion (late sign)
7. Lack of movement on the affected side

Pneumothorax Radiography

Tension Pneumothorax
A tension pneumothorax is "an
injurious condition which occurs
when air is allowed to escape into
the pleural space during inspiration
but cannot escape during
expiration".
As this increases with each
inspiration, the positive pressure
rises and forces a "shift" of the
mediastinum, trachea, and larynx
to the opposite side of the
collapsed lung

Tension Pneumothorax
Tension pneumothorax is a life threatening situation.
Blood pressure drops (compression of vessels), neck
veins distend, respiratory status becomes impaired
and arrhythmias ensue.

Untreated or unrecognized tension pneumothorax may

lead to arrest and ultimately death, as the other lung
becomes compressed

Hemothorax
A hemothorax is defined as blood
within the pleural space.

The most common cause is trauma

such as motor vehicle accidents,
industrial injury, fractured ribs,
gunshot, or stab wounds,
anticoagulant therapy after surgery or
cardiothoracic surgery.
Hemothorax is confirmed by chest
radiography and placement of a
chest tube

Hemothorax Radiography

Pleural Effusion

Accumulation of fluid within the pleural space that

compresses lung tissue is called a pleural effusion.
Symptoms include decreased or absent breath
sounds, less defined intercostal spaces on the
affected side and respiratory difficulties.

Pleural Effusion Radiography

Before

After

66-year-old woman with malignant pleural effusion from metastatic breast

carcinoma shows large left-sided pleural effusion with compressive
atelectasis of most of left lung. Film on right is 24 hrs later after 2100cc
fluid collection.

Cardiothorasic Surgery
During cardiothoracic surgery, the chest is opened through the
median sternotomy or thoracotomy approach.
A patient undergoing coronary artery bypass grafting using
saphenous vein grafts or internal mammary artery grafting may
experience disruption of the pleural cavity and lose negative
pressure.

During surgery, thoracic catheters are routinely placed within the

mediastinal and pleural spaces to evacuate drainage and clots.
Mediastinal chest tubes are placed beneath the sternum to
evacuate drainage from the chest and to prevent cardiac
tamponade, a life-threatening complication.

Chest Tube Placement

Chest Tube Placement

Chest Tube Placement

Air Rises - Fluid Sinks

Water Seal Drainage System

3 main compartments
The first compartment collects
fluid and air from the chest
cavity.
The second is compartment is
sealed with water to keep air
from being sucked back into
the chest.
The third compartment is used
to supply suction to the system.

Collection Chamber
Collects drainage
Amount should decrease
and lighten
Generally greater than
200cc/hr should be reported
Expect temporary dump of
drainage with position
changes

Water Seal Compartment

2cm Water
One way valve
Air can exit but not re-enter lung
Bubbles in the water seal = Air
Leak
-Air leak with expiration is good in the
event of a pneumothorax. It is evidence
that extra air is leaving the lung.
-Continuous air bubbles indicate a leak
in the system.

Suction Control Chamber

Suction is regulated by the
height of the fluid
Fluid level is standard at 20cm
H2O unless otherwise ordered by
MD
May use sterile H2O or NS
Apply wall suction to achieve
gentle bubbling

Stopcock is to remain open even

if the patient is just on water seal

Nursing Assessment
At least every four hours more frequently if changes are noted
Patients pain or comfort level
Breath Sounds, Heart Rate , Respiratory Rate & Rhythm, O2
Saturation, B/P and Temperature.
Chest Wall - for subcutaneous emphysema
Dressing - for signs of bleeding, inflammation or infection
Tubing - for signs of clot formation, secure connection of tube to
drainage container and position of tube to promote adequate drainage
Container- for amount and color of drainage, presence of air leak,
suction level or water evaporation, open stopcock if on water seal,
adequate bubbling if on suction

Clamping Chest Tubes

Clamping a chest tube can cause a

tension pneumothorax!
Chest tubes should only be clamped momentarily when
changing the drainage collection system or checking the
system for air leaks.

Accidental Dislodgement
What do you do if the chest tube becomes disconnected from the
Atrium?

Dont Panic!
There should always be a sterile liter bottle of H2O or saline in the
room of a patient that has a chest tube.
In case of total disconnect from the Atrium:
Clamp the chest tube temporarily, you can do this with your hand

Open the sterile NS or H2O and put the open end of the chest tube
down into the bottle. You have just created a water seal. This
gives you time to prepare a new Atrium as the other is now
contaminated without having to clamp the chest tube.
Prepare the Atrium and reconnect.

Accidental Dislodgement
Now if you have an agitated, confused or combative patient
that just decides to rip that tube out of their chest. What do you
do?

Dont Panic
Put on some gloves and place you hand over the site and hold
pressure. Use some Bacitracin ointment on some sterile gauze
and apply a pressure dressing. Assess breath sounds and the
patients hemodynamic status. Notify the MD. Consider a
chest x-ray.

Documentation
Example of appropriate documentation for a patient with a
chest tube would be:

Right pleural and mediastinal chest

tube to 20cm water seal suction draining
scant, thin, dk. red secretions. Drsg. dry
and intact. Sm. Air leak noted in water
seal chamber.

Criteria For Removing Chest Tubes

Drainage diminishes in volume

(usually less than 100cc for the past 12 hours)

and/or
Air Leak disappears
Patient can breath easily
Audible breath sounds bilaterally
CXR confirms re-expansion of the lungs

Chest Tube Removal Procedure

Once physician notifies you of plan to DC chest tube do the
following:
Consider analgesia prior to removal.
Make sure #11sterile scalpel blade, 4x4s 3 tape, and 2 chest tube
clamps are at the bedside.
Instruct and educate patient regarding removal procedure.
Wash hands and don gloves.

Chest Tube Removal Procedure

Place disposable chux pad underneath chest tube at level of
insertion site.
Gently remove dressings and any anchoring tape.

Notify physician patient is ready for chest tube removal.

Physician will remove tubes.
Once insertion site is sutured, secure 4X4 dressing over
site.
Assess frequently for any change in lung sounds or
respiratory distress.

References
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