Chest Tubes

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Chest Tubes

• by Charlotte Cooper RN, MSN, CNS
• modified by Kelle Howard RN, MSN
• Modified by Darlene Cookie Wilson, RN, MSN

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Thoracic Cavity

• Lungs
• Mediastinum
• Heart
• Aorta and great vessels
• Esophagus
• Trachea

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Breathing Inspiration

• Diaphragm contracts
• Moves down
• Increasing the volume of the thoracic cavity
• When the volume increases, the pressure inside
  ________.
• aka?
• Pressure within the lungs is called
  intrapulmonary pressure

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Breathing Exhalation

• Phrenic nerve stimulus stops
• Diaphragm relaxes
• This ______ the volume of the thoracic cavity
• Lung volume decreases, intrapulmonary pressure
  _____

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Physics of Gases

• If two areas of different pressure communicate,
  gas will move from the area of higher pressure to
  the area of lower pressure

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Pleural Anatomy

• Parietal pleura
• lines the chest wall
• Visceral pleura (pulmonary)
• covers the lung

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Pleural Anatomy
Parietal pleura
Visceral pleura
Lung
Ribs
Intercostal muscles
Normal Pleural Fluid Quantity Approx. 10-20 mL
per lung
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Pleural Physiology

• The area between the pleura is called the pleural
  space (sometimes referred to as potential
  space)
• Normally, vacuum (negative pressure) in the
  pleural space keeps the two pleura together and
  allows the lung to expand and contract
• It is also what holds the 2 pleuras together.

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Review Questions

• AP of chest (You tube http//www.youtube.com/watc
  h?vwKhldyCC6wg)

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What happened?
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What is this?
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What is this?
archive.student.bmj.com/.../02/education/52.php
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What is this?What is this movement called?
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Flail Chest
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What do you do when a Pleural Injuryoccurs?

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Pleural Injury Therapeutic Interventions

• Diagnostic tests
• Client position
• Treatment depends on severity
• Chest tube
• Heimlich valve on chest tube

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Chest Tubes

• Also called thoracic catheters
• Different sizes
• From infants to adults
• Small for air, larger for fluid
• Different configurations
• Curved or straight
• Types of plastic
• PVC
• Silicone
• Coated/Non-Coated
• Heparin
• Decrease friction

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Chest Tube Placement

• In what setting/environment is a chest tube
  placed?
• A. Operating Room
• B. Bedside
• C. Emergency Room
• D. All of the above
• E. None of the above

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Chest Tube Placement
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Chest Tube Placement
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Chest Tube Placement Procedure

• Sterile technique
• Small incision
• Tube is sutured
• Dressing applied
• What type?
• Can the client have 2 chest tubes?
• When the tube is placed, is it clamped or
  unclamped?
• why or why not?

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Chest tube insertion
Choose site
Suture tube to chest
Explore with finger
Place tube with clamp
Photos courtesy trauma.org\
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Chest tubes in place
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Heimlich Valve
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Heimlich ValveWhat are some problems with this
valve?
http//www.scielo.br/img/revistas/jbpneu/v34n8/en_
a04fig01.gif
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Prevent air fluid from returning to the pleural
space

• Chest tube is attached to a drainage device
• Allows air and fluid to leave the chest
• Contains a one-way valve to prevent air fluid
  returning to the chest
• Designed so that the device is below the level of
  the chest tube for gravity drainage

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Treatment goal for pleural injuries

• 1. Remove fluid air as promptly as possible
• 2. Prevent drained air fluid from returning to
  the pleural space
• 3. Restore negative pressure in the pleural space
  to re-expand the lung

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Interventions

• Dressing changes
• When?
• No dependent loops
• What is this?
• Why?
• Oxygen therapy
• Record output
• How often?
• Analgesics
• IS and turn, cough, deep breathe

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What about dependent loops?
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Nursing assessment and pertinent nursing
problems/interventions

• Health history-respiratory disease, injury,
  smoking, progression of symptoms
• Physical exam- degree of apparent resp distress,
  lung sounds, O2 sat, VS, LOC, neck vein
  distention, position of trachea
• All require observation for respiratory symptoms
• Pertinent nursing problems
• Acute pain
• Ineffective airway clearance
• Impaired gas exchange
• Home care

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• How a
• chest drainage system
• works

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• Purpose of Chamber One
• Correct any fluid comingback from the patient.
• Purpose of Chamber Two
• Water seal, one-way valveallows air out of the
  patientbut not back into the patient.
• Purpose of Chamber Three
• Suction control. Manual or Fluid filled (most
  hospital systems)

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Prevent Air and Fluid Backflow
Tube open to atmosphere vents air
Tube from patient
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Restore negative pressure in the pleural space

• The depth of the water in the suction bottle
  determines the amount of negative pressure that
  can be transmitted to the chest, NOT the reading
  on the vacuum regulator

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How a chest drainage system works

• Expiratory positive pressure
• Gravity
• Suction

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How a chest drainage system works

• Expiratory positive pressure from the patient
  helps push air and fluid out of the chest (cough,
  Valsalva)
• Gravity helps fluid drainage as long as the chest
  drainage system is below the level of the chest
• Suction can improve the speed at which air and
  fluid are pulled from the chest

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From bottles to a box
From patient
To suction
from patient
Suction control bottle
Water seal bottle
Collection bottle
Suction control chamber
Collection chamber
Water seal chamber
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From box to bedside
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Water suction on left Dry suction on
rightLewis p. 589 Fig 28-8
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Atrium Chest Tube System

• Chamber A
• Suction control chamber
• How do you know what level the water should be
  at?
• Chamber B
• Water seal chamber
• How do you know what level the water should be
  at?
• Should the ball be fluctuating in this chamber?
• What if it isnt?
• Chamber C
• Air leak monitor
• What does bubbling mean?
• Chamber D
• Collection chamber
• When do you record output?

Be sure you under stand how to set up the system,
the function of each chamber and how to
troubleshoot issues with each chamber.
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Monitoring

• Water seal is a window into the pleural space
• Not only for pressure
• If air is leaving the chest through an air leak,
  bubbling will be seen here
• Air meter (1-5) provides a way to measure the
  air leaving and monitor over time getting
  better or worse?

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Assessment

• Focused respiratory assessment
• Breath sounds
• Respiratory rate
• Respiratory depth
• SpO2
• ABG
• CXR

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Assessment

• Cardiovascular assessment
• Level of consciousness
• Pain
• Chest tube
• Amount of drainage
• Insertion site dressing

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Interventions r/t chest tubes

• System position
• Tubing position
• What happens when the patient lays on it?
• Connections to patient and system
• Assessing the system
• Monitoring output

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Complications

• What are some common complications?

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Complications Troubleshooting

• Chest tube malposition (most common)
• Subcutaneous emphysema
• What is this?
• What are some nursing interventions related to
  this complication?
• High Fluid in Water Seal Chamber
• Chest system may need to be vented
• Air leak
• How do you know?
• What do you do?
• Others
• pleural effusion, inc. pneumo
• mediastinal shift
• Do chest tubes get clotted off?
• What can happen when fluid is removed too fast?

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If chest tube comes out?
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Review

• Check fluid level in suction chamber
• Observe water seal chamber fluid level
• Assess for tidaling in water seal chamber
• Assess for tubing non dependent
• Determine if the unit has been knocked over
• Note the amount, color and consistency of
  drainage

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Review

• http//www.youtube.com/watch?vw65OgC3mVBk
  (Atriums Set Up part 2, 247)
• http//www.youtube.com/watch?vWVHelcIIee8 (set
  up part 3 to 5 mins)
• http//www.youtube.com/watch?v74H6N-Qxm34playnex
  t1listPLFCFEACCE12F1D1E0index26 (dry
  suction start at 510)

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What is most important?

• Monitor your client
• Notify MD STAT if
• Significant drainage
• Increasing shortness of breath
• Pain
• Absence of breath sounds

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Management

• Do not remove suction without an order
• Manage pain
• When full - place in biohazard container
• Do not change collection device on client with an
  air leak without an order
• When suction discontinued, must disconnect from
  suction, not just turn off

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Questions

• What is the progression of events for
  discontinuing a chest tube?
• Can a patient ambulate with a chest tube?

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Portable chest drainage system
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PleurX Catheter
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Removing the Chest Tube

• http//www.medicalive.net/186_chest_tube_insertion
  
• If time permits
• http//www.atriummed.com/Products/Chest_Drains/
  edu-ocean.asp
• Oasis dry suction set up
• http//www.google.com/imgres?imgurlhttp//www.at
  riummed.com/Common/Images/help-oasis.jpgimgrefurl
  http//www.atriummed.com/products/chest_drains/ed
  ucation.aspusg__iFwkxjbty1SgU2UOxzHu7gyeorMh1
  00w100sz6hlenstart2zoom1um1itbs1tbn
  idbjQxSvGWg2AsiMtbnh82tbnw82prev/images3F
  q3Doasis2Bdry2Bsuction2Bchest2Btube2Bsystem
  26um3D126hl3Den26tbs3Disch1

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The END

• Thank you, Thank you, Thank you, Thank you, etc.