Chest Tubes
by Charlotte Cooper RN, MSN, CNS
modified by Kelle Howard RN, MSN
Breathing: Inspiration
• Diaphragm contracts
• Moves down
• Increasing the volume of the
thoracic cavity
• When the volume increases, the
pressure inside ________.
• Pressure within the lungs is called
intrapulmonary pressure
Breathing: Exhalation
• Phrenic nerve stimulus stops
• Diaphragm relaxes
• This ______ the volume of the
thoracic cavity
• Lung volume decreases,
intrapulmonary pressure _____
Pleural Anatomy
– Parietal pleura
– lines the chest wall
– Visceral pleura (pulmonary)
– covers the lung
Visceral pleura
Parietal pleura
Lung
Pleural Anatomy
Intercostal
muscles
Ribs
Normal Pleural Fluid Quantity:
Approx. 20 - 25mL per lung
Pleural Physiology
• Area between pleura ----“potential space”
• Normally, negative pressure between pleura
What do you do when pleural injury occurs
Pleural Injury:
Therapeutic Interventions
• Diagnostic tests
• Client position
• Treatment depends on severity
– Chest tube
– Heimlich valve on chest tube
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
Chest Tube Placement
• In what setting/environment is a chest tube
placed?
Chest Tube Placement
Chest Tube Placement
Procedure
•
•
•
•
Sterile technique
Small incision
Tube is sutured
Dressing applied
Chest tubes in place
Heimlich Valve
Heimlich Valve
http://www.scielo.br/img/revistas/jbpneu/v34n8/en_a04fig01.gif
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
How a
chest drainage system
works
How a chest drainage system works
• Expiratory positive pressure
• One way valve
• Gravity
• Suction
Goal:
Tube open to
atmosphere
vents air
Prevent Air and Fluid
Backflow
Tube from patient
Goal:
Prevent Air and Fluid
Backflow
• For drainage, a second
bottle was added
• The first bottle collects the
drainage
• The second bottle is the
water seal
• With an extra bottle for
drainage, the water seal will
then remain at 2cm
From bottles to a box
To suction
From patient
from
patient
Suction
control
bottle
Water seal
bottle
Collection
bottle
Suction
control
chamber
Water seal
chamber
Collection
chamber
From box to bedside
Water suction (A)
Dry suction (B)
Lewis p. 570 Fig 28-8
Atrium Chest Tube System
• Chamber A
– Suction control chamber
• Chamber B
– Water seal chamber
• Chamber C
– Air leak monitor
• Chamber D
– Collection chamber
Be sure you under stand how to set up the system, the
function of each chamber and how to troubleshoot issues
with each chamber.
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
Air Leak
• 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?
Assessment
• Focused respiratory assessment
– Breath sounds
– Respiratory rate
– Respiratory depth
– SpO2
– ABG
– CXR
Assessment
•
•
•
•
Cardiovascular assessment
Level of consciousness
Pain
Chest tube & Chest tube system
– Be sure you know what is to be assessed
Interventions
• System position
• Tubing position
• Connections to patient and system
• Monitoring & recording & reporting output
Interventions
• Dressing changes
• Oxygen therapy
• Analgesics
• IS and turn, cough, deep breathe
Complications
What are some common complications?
Complications & Troubleshooting
• Chest tube malposition (most common)
• Subcutaneous emphysema
• High Fluid in Water Seal Chamber
– Chest system may need to be vented
– But only if the suction is on
• Air leak
Others
pleural effusion, inc. pneumo,
mediastinal shift
?
If chest tube comes out?
Review
•
•
•
•
•
•
Check fluid level in suction chamber
Observe water seal chamber fluid level
Assess for tidaling in water seal chamber
Assess tubing – non dependent
Determine if the unit has been knocked over
Note the amount, color and consistency of drainage
What is most important?
• Monitor your client
• Notify MD STAT if
– Significant drainage
– Increasing shortness of breath
– Pain
– Absence of breath sounds
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
Questions
• What is the progression of events for
discontinuing a chest tube?
• Can a patient ambulate with a chest tube?
Portable chest drainage system
PleurX Catheter