Chest Tubes
Kindred Hospital Louisville
Education Module
Learning Objectives
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Identify indicators for placement of a chest tube.
Identify nursing assessment findings of a patient with an
alteration in status requiring a chest tube placement.
Identify proper procedure for chest tube setup.
Identify proper procedure for maintaining chest tubes.
Identify key aspects of nursing assessment of patients with a
chest tube in place.
Identify ways to troubleshoot the chest drainage system.
Identify safety concerns for patients with chest tube collection
systems.
Identify required documentation regarding chest tubes.
Meet Mr. Williams
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Mr. Williams is a 44 year old gentleman admitted with
a diagnosis of respiratory failure. He has a history of
tobacco abuse, NIDDM, Peripheral Neuropathy, and
Atrial Fibrillation which is now controlled medically.
He is admitted for ventilatory support, and attempts
to wean. He was initially seen at an E.D. two months
ago following a MVA where he was a pedestrian
struck by a car. He sustained a right ulnar fracture,
right radial fracture, right hip fracture, as well as a
right sided hemothorax.
He has been stable for 2 weeks since admission, and
is tolerating his vent settings of IMV 8-750-.40-+5.
What do you know?
What do you know about Mr. Williams that
puts him at a higher risk for pneumothorax?
 What components of your nursing
assessment are critical for Mr. Williams?
 What abnormal findings in your respiratory
assessment of Mr. Williams would cause you
to suspect a pneumothorax?
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The Mechanics of Breathing
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In normal situations, the pressure between the
pleura of the lungs is below atmospheric pressure.
When air or fluid enters the intrapleural space, the
pressure is altered, and this can cause collapse of a
portion of the lung.
Even with adequate oxygenation and an open airway,
a patient with a collapsed portion of the lung will not
have adequate oxygen - carbon dioxide exchange.
The only treatment for this altered condition is to
restore the negative pressure to the intrapleural
space. This is accomplished through the use of a
chest tube and collection chamber.
Normal Chest Anatomy
Alterations in Normal Status
Indicators for Chest Tube Placement
Condition
Possible Causes
Pneumothorax
 Trauma, surgery,
invasive
pulmonary
procedures,
bronchoscopy,
 Forceful coughing
or rupture of a
bleb on the lung:
spontaneous
pneumothorax
 Procedures such as
central line
insertion:
iatrogenic
pneumothorax
Tube Placement
Location
Anteriorly near the
apex of the affected
lung at the second
intercostal space,
mid-clavicular line
Indicators for Chest Tube Placement
Condition
Possible Causes
Tube Placement
Location
Hemothorax
 Open chest
procedures
 Blunt or
penetrating
trauma
Two chest tubes may
be inserted, one at
the apex and one at
the base of the lung
Pleural Effusion
 Heart failure,
surgery,
malignancy
Posteriorly into the
fifth or sixth ICS
Mr. Williams
 It’s
time for Mr. Williams’ dressing
change to his right leg surgical site.
When you enter the room you notice
that he is breathing more rapidly than
he was earlier. Mr. Williams seems
more anxious, but denies any pain.
While performing the dressing change,
the ventilator alarm begins to sound
with the “High Pressure” alarm.
Mr. Williams
 He
appears to be getting restless, and
when suctioned, the catheter passes
easily and does obtains only a small
amount of sputum. The ventilator
continues to alarm “High Pressure”.
 What should be your next series of
nursing actions for Mr. Williams?
Nursing Assessment Findings
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Diminished or absent
breath sounds on
affected side.
Decreased chest wall
movement on affected
side.
Difficulty breathing.
Tachycardia
Anxiety
Restlessness
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Decreased oxygen
saturation
Increased Peak Airway
Pressures
Cyanosis
Complaints of pleuritictype chest pain
Increased respiratory
rate
Pain may worsen when
attempting to breathe
deeply
Mr. Williams
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After performing a thorough cardiovascular
assessment and documenting Mr. Williams
vital signs, you have discovered that he has
diminished breath sounds in the right upper
lobe, and absent breath sounds in the the
right lower lobe. His vital signs show an
increased heart rate, increased blood
pressure, and am increased respiratory rate.
You suspect that Mr. Williams has a
pneumothorax. You notify his physician right
away.
Mr. Williams
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The M.D. orders a STAT
portable chest X-ray, a
STAT ABG, and to
increase the patient’s
FiO2. He is on his way
in to see the patient
right now, and wants
you to have the supplies
for a chest tube
insertion ready when he
arrives.
Equipment needed for Chest
Tube Setup
Chest tube insertion
tray
 Tube (size per M.D.)
 Local Anesthetic
(Xylocaine)
 Betadine (or other
antiseptic)
 Suturing supplies
 Sterile gloves
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2 1000cc bottles of
sterile water
 4 x 4’s
 Suction setup
 Suction tubing
 Chest tube collection
system
 Vaseline Gauze
 Silk Tape
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Mr. Williams
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The Physician
diagnoses Mr.
Williams with a
pneumothorax. He
is going to insert a
chest tube. Which
of the sites that you
see on the left do
you think he will
use? Why?
Components of the Chest
Tube Drainage System
Suction control
chamber
 Water Seal Chamber
 Collection chamber
 The next slide will
look at each
chamber more
closely.
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Suction Control Chamber
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The use of suction helps overcome
an air leak by improving the rate of
air and fluid flow out of the patient.
The simplest and most cost
effective means of controlling
suction is by a calibrated water
chamber. This is axxomplished
with a suction control chamber. By
addiing or removing water from
the suction control chamber, the
chest drain controls the amount of
suction imposed on the patient.
Lower the water content, lower the
suction. Raise the water level,
raise the amount of suction.
Water Seal Chamber
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The water seal chamber which is
connected to the collection
chamber, allows air to pass down
through a narrow channel and
bubble out through the bottom of
the water seal. Since air must not
return to the patient, a water seal
is considered one of the safest and
most cost effective ways for
protecting the patient. Also a
patient air leak can be rapidly
assessed when bubbles go from
right to levt in this chamber.
Continuous bubbling confirms a
persistent air leak.
Collection Chamber
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Fluids drain diirectly from
patient into the collection
chamber via a 6’ patient
tube. As drainage fluids
collect, the nurse must
record the amount of fluid
that collects on each shift.
This amount must be
marked on the unit itself,
and documented in
ProTouch, along with the
characteristics of the fluid
being collected.
Preparing for Insertion
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Gather supplies.
Prepare patient.
Open chest drainage
system. As seen at
right.
Swing out floor stand to
stabilize the unit.
Close suction control
stopcock.
Adding Sterile Water to the Unit
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First, position the funnel as
shown on the right, and fill to
the top of the funnel. Raise
funnel to empty water into
water seal to 2cm line marking.
NOTE: IF THE TUBING IS NOT
‘CRIMPED’ AS IT SHOWS IN
THE PICTURE, YOU WILL
OVERFILL THE CHAMBER.
Remove the the vent-plug, pour
sterile water in to ordered level,
and replace vent-plug. As seen
at the bottom right.
Insertion
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The patient will need to be positioned according to where the
chest tube will be placed. Typically having the patient’s arms
over their head assists the physician.
Pre-medicate the patient with sedation & pain medicine as per
Physician’s order. This is a scary & painful procedure for the
patient.
The Physician will prep and numb the area, then make a small
incision with a scalpel, then using a trocar (a sharp, pointed rod
that fits inside a tube) will insert the chest tube. The patient
will feel pressure. Once the chest tube is inserted it may be
either clamped or connected to the prepared drainage system,
while the M.D. is suturing the chest tube in place.
Connect tube to drainage system if not done previously, and
apply an occlusive vaseline gauze dressing topped with sterile
4x4’s to the insertion site. Securely tape all connections.
Post-Insertion Documentation
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Reason for chest tube
placement.
Patient vital signs.
Any medications given.
Location & size of chest
tube.
Patient’s tolerance of
procedure.
Drainage received (if
any): color,
characteristics, volume,
etc.
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Dressing type applied.
Connections securely
taped.
Vital signs during/post
procedure.
Water level ordered &
set for suction control
chamber.
Post-insertion chest xray taken.
Maintenance of Chest Tubes
Cardiovascular assessments must be
performed every 4 hours at least for all
patients with chest tubes.
 Encourage patient to cough & deep breathe.
 Check insertion site every morning at 0800
and replace dressing at that time.
 Assess water levels in drainage unit each shift
and correct fluid levels if not as ordered.
 Report to Physician immediately any change
or complication with the chest tube.
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Dressing Change
Maintenance of Chest Tubes
 Check
all tubing connections and retape as needed EVERY FOUR HOURS.
 I & O to be completed (and marked on
collection chamber at 0600; 1400; and
2200.
 Monitor for air leaks, chest x-ray results,
oxygen saturations, and peak airway
pressures. Report any alterations
immediately to M.D.
Maintenance of Chest Tubes
 Keep
tubing coiled on bed, NEVER allow
tubing to dangle.
 Ensure that bedside collection unit
NEVER goes above chest level.
Tubing Placement
Mr. Williams
 Mr.
Williams has had his chest tube
placed in his right anterior lung. The
post-insertion x-ray showed the tube in
good position. The M.D. orders a chest
x-ray to be done again in the morning.
The patient’s peak pressures are down,
and his oxygenation has improved, his
restlessness and anxiety are also
decreased.
Mr. Williams
 It
is essential for what chest-tube
specific things to become a part of Mr.
Williams routine care now that he has a
chest tube in place?
 How will you know if Mr. Williams
develops an air leak?
 Is an air leak a serious development?
Potential Complications with
Chest Tubes
 Subcutaneous
emphysema - a collection
of free air or gas in the tissue under the
skin. Can be mild or severe. Needs to
be measured, reported to M.D., and
documented.
 Air leak - noted by constant bubbling in
the bottom of the water-seal chamber.
Potential causes listed on next page.
Potential Sources of Air Leaks
Poor tubing connections.
 Tube dislodgement from pleural space.
 Cracked bedside collection unit.
 To locate air leak, clamp the tubing
momentarily at various points along tubing
length. When bubbling stops, the clamp is
between the air leak and the water seal. If
you’ve clamped the whole length of tubing, it
may be a cracked collection chamber.
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Safety Concerns
 Sealed,
taped tubing connections
 Chest tube maintained in pleural space
 Infection at site
 Tubing not disconnected or pulled
 Constant water levels in unit & constant
suction (if ordered)
 Sterile 1000cc bottle of saline and
tubing clamps at bedside continuously.
What to do if...
 Chest
tube becomes dislodged: cover
open insertion site with vaseline gauze at
peak of patient inspiration. Cover with
4x4’s, tape on three sides only, notify M.D.
STAT, chart event.
 Drainage system breaks: insert the
uncontaminated end of tubing into a bottle
of sterile water 2cm deep until new unit
can be setup. Notify M.D. & document.
Mr. Williams!
Make sure to review the Chest
Tube Policies that are attached,
and return your completed answer
sheet to your nursing manager.