CHEST TUBES AND CHEST DRAINAGE SYSTEMS

Central Nursing Orientation April 2008

Revised September 2011

2

OBJECTIVES

• Describe common tubes and indications for use at LHSC

• Review indications and contraindications, where necessary

• Nursing responsibilities associated with each tube.

• Provide hands on opportunity for each tube presented.

• Location of online LHSC resources (SONC)

3

Purpose

• Evacuate air and/or fluid from the chest cavity

• Evacuate fluid from around the heart (mediastinal)

after cardiac surgery to prevent cardiac tamponade

• Restore normal intrathoracic pressure (negative

pressure)

4

Indications for CT Insertion

• Air accumulation in pleural space

• Fluid accumulations in the pleural space

• Fluid accumulations in the mediastinal space

5

Location of Chest Tube

• Location depends on what is being drained.

• Free air in the pleural space rises tube is placed above the 2nd

intercostal space.

• Fluids gravitate to the most dependent point tubes places at the

4th to 5th intercostal space.

• Mediastinal tubes are put in place after cardiac surgery to drain

fluid from around heart.

6

7

Chest tube placement: superior tube evacuates air, inferior tube drains fluid

8

What happens when air enters pleural

space

1. Air separates visceral pleura from parietal pleura interrupting

the –(ve) pressure that prevents lungs from collapsing

2. Compresses the lung.

1. If only a small amount of air (or fluid) is present, it may be

reabsorbed without intervention.

2. If the amount of air (or fluid) is large, normal respirations are

compromised & must be evacuated from pleural space.

9

Pneumothorax

Definition: Air in the pleural space

Types: Spontaneous

Traumatic

Iatrogenic

Tension

10

Pneumothorax

11

Spontaneous Pneumothorax

Usually caused by rupture of a small bleb (enlarged air

sac) on lung’s surface.

May also result as a complication of pre-existing lung

disease that weakens lung (COPD, pulmonary disease,

CF, necrotizing pneumonia).

12

Traumatic pneumothorax

Closed pneumothorax:

Internal trauma ie.) rib fractures where rib punctures lung. No opening outside of the chest wall.

Open pneumothorax:

External trauma such as stab wound or bullet wound that penetrates chest wall may puncture lung. Also called a sucking chest wound.

13

Iatrogenic Pneumothorax

Iatrogenic pneumothorax:

Invasive procedures such as needle aspiration,

subclavian line insertion or thoracentesis may

inadvertently puncture lung. Mechanical ventilation

with high positive-end expiratory pressure (PEEP can

also result in a pneumothorax.)

14

Tension Pneumothorax

• Occurs when air accumulates in pleural space more rapidly than it

can be evacuated.

• Pressure builds up which not only causes lung to collapse but can

also shift mediastinum severely impede venous return &

cardiac output.

• In other words, it squishes the heart. Life threatening must be

dealt with STAT.

15

16

Fluid Accumulation in Pleural Space

• Pleural Effusion:

• Fluid in the pleural space

• Fluids that collect here are:

• lymph (chylothorax)

• pus (empyema)

• blood (hemothorax).

Fluid that collects in pleural space directly compresses lung tissue

& takes up space that the lung would usually fill.

17

Pleural Effusion

18

Hemothorax

19

Chest Tubes

Chest tubes may also be called thoracic catheters

Various Chest tubes are used at LHSC

Different sizes • From infants to adults

• Small for air, larger for fluid

• Different configurations • Curved or straight

• Types of plastic • PVC

• Silicone

20

Chest Tube insertion set up

•CT insertions are a medical activity

•Equipment:

¤ Atrium Oasis-Ensure underwater seal

¤ 2 Kelly clamps

¤ Sterile distilled water

¤ Cable ties/water-proof tape

¤ Wall suction set up

¤ Chest tube insertion tray

¤ Local Anesthetic

Ensure you wear proper PPE

21

22

Chest Tube Insertion

23

Making the Connection

•Once the patient is connected to the drainage system

and the suction then:

¤ cable tie the connections or use waterproof tape

¤ Kelly clamps

¤ Establish the suction

¤ Placement of the Atrium

24

Chest Tube Dressing

•Equipment:

¤Dressing tray

¤Jelonet

¤Two 4x4 guaze, two split drain gauze

¤No sting Barrier Spray

¤3” Mefix tape (aka Hypofix)

¤Chlorhexidine 2%/70% alcohol solution

¤non sterile gloves

25

Chest Tube Dressing

• Initial dressing remains intact for the first 48 hours unless soiled,

then changed daily and prn

• Cleanse site with chlorhexidine in a circular fashion away from

insertion site

• Spray area where tape will be with Barrier Spray

• Place jelonet around tube against the skin to provide occlusive

barrier

• Place 2 4X4 dressings under chest tube to protect skin and absorb

drainage

• Place 2 4X4 dressings over chest tube

• Cover with mefix

26

Responsibilities Post Insertion

CXR within 1 hour with

Physician order

Assess:

* Respiratory status Q15min

x1hr- PRN

i.e. vital signs, oxygen

saturation, respiratory

patterns, chest sounds, patient

level of apprehension

* Water seal level for

fluctuation

Documentation

Monitor:

Vital signs

Tube location

Drainage

Subcutaneous emphysema

Air leaks

Change Atrium contained q7d

or prn

Do not strip/milk chest tube

27

Water Seal Chamber

• One way valve so air can drain out of chest cavity but not back in

• Monitor fluctuations and volume at least q shift

• Fluctuates with breathing - tidaling

• water level should be at 2 cm mark

28

Monitoring air leak

• Water seal is a window into the pleural space

• If air is leaving the chest, bubbling will be seen here

• Bubbling in water seal chamber may be present with pneumothorax

• If worsens or occurs in absence of pneumo may indicate air leak

29

Question

During your assessment, you note new bubbling in the water seal chamber. Describe what you would do to determine where this air leak is from.

30

Answer

Clamp the chest tube momentarily, beginning at the patient. Look at the chamber to see whether the bubbling has stopped.

If you clamp and the bubbling goes away, the leak is coming from the chest.

Action: reinforce dressing with Jelonet, inform physician

If you clamp at the chest and the bubbling persists, the leak is between the clamp and the water seal chamber.

Action: change tubing

31

Drainage

Record on I & O sheet, minimum q shift.

Mark level on Atrium collection devise, with date and time (if this is your

unit protocol)

Assess

• Amount of drainage

• Rate of accumulation

• Characteristics of drainage

Little drainage with pneumothorax

32

Clamping Chest Tubes

• You will only clamp for the following reasons:

• Prior to removing chest tube to determine if patient can do

without chest tube(s)

• Assessing for air leak (clamp only briefly)

• Changing the chest drainage unit (clamp only briefly)

• Performing physician-ordered procedure.

• Some instances when sudden large volumes of fluid are evacuated

33

Specimen Collection

• At time of chest tube insertion, collect drainage in sterile container

• If specimen required later:

-cleanse with alcohol/chlorhexidine swab, let dry

-crimp tubing below the port

-use 20 gauge needle, withdraw drainage from port and transfer to sterile container

-or kink tubing, cleanse, aspirate fluid with 20 gauge needle, the silicone tubing will reseal itself

Gloves should be worn when collecting specimen

34

Activity/Transport

• Patient should be able to move comfortably in their room.

• If air leak detected & depending on the size of air leak, your

patient may be required to be connected to suction at all times.

(obtain a portable suction)

• If no air leak, patients are able to leave their rooms and ambulate,

without suction, provided a doctors order is received

• You will require a support for the chest drainage unit. DO NOT

CLAMP the chest drainage system, as air needs to escape.

• Ensure Atrium is below level of chest

• If unsure of suction requirements with mobility, contact Physician

35

What to do if the Chest Tube

Mistakenly Falls out???

• Cover site with dry sterile dressing

• Call physician

• If there is air leaking from site or the patient becomes distressed,

leave one side of dressing open to allow air to escape and prevent

tension pneumothorax

• PPE

36

What to do if the chest tube becomes disconnected?

Clamp tube

Using PPE (gloves)

Cleanse connector with Chlorhexidine 2%/70% Alcohol solution

Reattach tube to system

Unclamp tube

Notify MD

37

Discontinuing Process

• Less than a total of 10ml/tube/hour for 6 hours (<10cc x 6h for paediatrics)

• Chest Xray shows re-expansion of lungs

• No air leak present

• Normal INR

• Order may indicate to remove suction or clamp the chest tube X 24 hrs, prior to removing chest tube.

• There must be an order to D/C a chest tube. (and if pt has more than one, it needs to be clearly indicated which one)

• Chest tube removal is an added nursing skill

38

Additional References

• Please refer to the LHSC intranet and visit the Nursing

Practice Manual. You will find loads of information

under the following title:

• CHEST TUBE: INITIATION, CARE AND REMOVAL OF

PLEURAL/MEDIASTINAL

• London Health Science Centre intranet, Nursing Practice Manual, Chest tube: Initiation, Care and Removal of pleural/mediastinal.

• Atrium Chest tube teaching powerpoint.