CHEST TUBES / PLEURAL DRAINAGE ● Purpose ○ To remove the air and fluid from the pleural space and to restore normal intrapleural pressure so that the lungs can re-expand. ● Insertion ○ Setting ■ In the operating room, the chest tube is inserted via the thoracotomy incision. ■ In the emergency department or at the bedside, the patient is placed in a sitting position or is lying down with the affected side elevated. ○ Steps ■ Make sure airway, oxygen, suction and defibrillation are in working condition ■ The area is prepared with an antiseptic solution, and the site is infiltrated with a local anesthetic agent. ■ After a small incision is made, one or two chest tubes are inserted into the pleural space. ■ One catheter is placed anteriorly through the second intercostal space to remove air ■ The other is placed posteriorly through the eighth or ninth intercostal space to drain fluid and blood. ■ The tubes are sutured to the chest wall, and the puncture wound is covered with an airtight dressing. ■ During insertion, the tubes are kept clamped. ■ After the tubes are in place in the pleural space, they are connected to drainage tubing and pleural drainage, and the clamp is removed. E ■ Each tube may be connected to a separate drainage system and suction. ● Y-connector is used to attach both chest tubes to the same system ● Pleural Drainage ○ The first compartment, the collection chamber ■ Receives fluid and air from the chest cavity. ■ Bright red blood over 100 mL/h after the first hour= notify HCP ■ Dark Red Blood= Normal(Document and monitor) ○ The second compartment, called the water-seal chamber ■ Contains 2 cm of water, which acts as a one-way valve. ■ Initial bubbling ss seen in this chamber when a pneumothorax is evacuated ■ Steady rise and fall with breathing (Tidalling)= good(Lung has not re-expanding) ■ Reduced Tidaling= Lung expansion; or kink in system ■ Continuous bubbling= Bad (air leak in the system) ■ No fluctuation= Blockage (kink, blood clot) ○ A third compartment, the suction control chamber ■ Applies controlled suction to the chest drainage system. ■ The suction Pressure is usually ordered to be -20 cm H2O. ● Water evaporates in this chamber, and water must be added periodically. ■ Dry suction: Will give visual alert if suction is not working ■ Continuous bubbling= Normal ● ● ● ● ■ Vigorous/violent bubbling= Suction to high ■ No bubbling= Suction too low or dysfunctional ■ Intermittent bubbling: Normal due to cough, etc Heimlich valves ○ The valve opens whenever the pressure is greater than the atmospheric pressure and closes when the reverse occurs. ○ should be used with caution in patients on mechanical ventilators because there is a potential for rapid accumulation of air and a tension pneumothorax. Nursing Management ○ Dont do routine milking or stripping of chest tubes to maintain patency ○ If a chest tube becomes disconnected, the most important intervention is immediate re-establishment of the water-seal system and attachment of a new drainage system ASAP ○ Clamping for more than a few moments is indicated only for assessing how the patient will tolerate chest tube removal. ○ Keep tubing below chest/heart level Complications ○ Chest tube malposition is the most common complication. ○ A vasovagal response with symptomatic hypotension can occur from too rapid removal of fluid ○ Infection at the skin site ○ Pneumonia ○ Shoulder disuse from lack of ROM exercises Chest tube removal ○ Chest tubes are removed when the lungs are re-expanded and fluid drainage has ceased. ○ Have the patient take a deep breath, exhale, and bear down (Valsalva manoeuvre); ■ A chest radiograph is obtained after chest tube removal to evaluate for pneumothorax, reaccumulation of fluid, or both. ○ A patient should be observed for respiratory distress, which may signify a recurrent or new pneumothorax.
