Care of the Client with Chest Tubes

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Care of the Client with Chest Tubes

• Matthew D. Byrne, RN, MS, CPAN

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Outline

• Basics
• Indications
• Insertion
• Function

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The Pleural Space

• Space between ribs and lungs
• Filled with small amount of fluid
• Air or fluid in pleural space inhibits expansion
  and breathing

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The Pleural Space

• Physiologically, intrapleural pressure is 4-5 cm
  H2O below atmospheric pressure during expiration
• Intrapleural pressure is 8-10 cm H2O below
  atmospheric pressure during inspiration
• If the intrapleural pressure equals the
  atmospheric pressure, the lung will collapse,
  causing a pneumothorax

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Chest Tubes Basics

• Used when integrity of the pleural space is lost
• Loss of normal intrapleural pressures
• Air or fluid may enter with loss of integrity

Image from Trauma.org
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Chest Tubes Indications

• Surgery
• Traumatic chest injuries
• Pneumothorax
• Hemothorax
• Pleural effusion (build up of fluid between the
  pleura)
• Infection (empyema)

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Chest Tubes Insertion

• Placed in the OR/ER/PACU or bedside
• Metal trocar used as guide
• Generally done with some sedation
• Ideally restores negative pressure and allows air
  to escape/fluid to drain
• Sutured to chest wall
• Occlusive dressing applied
• Serial chest X-Rays for progress/placement
• Free end attached to drainage system
• Connections are secured (taped/banded)
• Pre and post vital signs and pain assessment

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Chest Tubes Location

• To drain air Anterior (and laterally) through
  2nd intercostal space

• To drain fluid/blood Posterior through 8 or 9th
  intercostal space in midaxillary line

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Chest Tubes How they function

• Drainage systems
• One chamber
• Two chamber
• Three chamber
• Two types of suction control chambers
• 1) dry (valve/regulator)
• 2) wet (water chamber) control

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When you breathe

• When you inhale, negative pressure is created in
  your chest that pulls air in through your
  mouth/nose
• What would happen if there was a hole in your
  chest?
• A chest tube system can act as a one-way valve
  that can remove air/fluid
• Can also be set up to create pull in the form
  of negative pressure

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Chest tube systems

• What do we need to connect to this tube in the
  patients chest?
• How can what we connect collect drainage, allow
  air to escape and create a slight pull?
• We need a three part system to do this

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One BottleOne way valve

• Allows air out but not in
• Rise and fall of fluid with breathing (WHY?
  HOW?)- Tidaling
• Creates no pull
• Not intended for collection
• The valve is the water
• What would happen if we pulled the tube out of
  the water?

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Two BottlesValve Drainage

• Allows air out but not in
• Rise and fall of fluid with breathing
• Creates no pull
• Allows for collection

Water Seal (Valve)
Drainage
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3 BottlesValve Drainage Pull

• Allows air out but not in
• Rise and fall of fluid with breathing
• Allows for collection
• Creates a pull in the form of negative pressure

Suction (Dry or Wet)
Drainage
Water Seal (Valve)
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Commercial chest tubes
Dry Suction pressure and vacuum internally
regulated
Wet Suction actual column of water used
(usually 20cm)
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In Clinical

• The units are connected to wall suction unless
  the order is for water seal only
• Wall suction creates a vacuum, while the column
  of water creates the actual pull
• Turning up the wall suction, WILL NOT increase
  the pull
• A column of water creates pressure, much like
  when you are diving underwater
• Therefore, increasing the column of water WILL
  increase the pull

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Nursing Responsibilities

• Standard 1 Assessment
• Patency/functioning of system (kinks, clamps,
  atrium, suction, etc)
• Dressings
• Quantity and quality of drainage
• Dependency of collection system
• Coiled tubing, not hanging tubing
• Pain control
• Respiratory status and Vital signs (CDB/IS, lung
  sounds, respiratory quality/number)

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Nursing Responsibilities

• Standard 5 Implementation
• Note specific orders regarding
• Suction versus water seal
• Amount of acceptable drainage
• I O
• X-rays
• Administer pain medications regularly
• Patient should change positions frequently
  (promotes drainage, prevents complications)

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BSN Essentials

• Critical thinking and technical skills
• Having the knowledge and skill to handle
  problems!
• Always have at the ready
• Extra atrium/set-up
• Oxygen
• Suction
• Occlusive dressings
• Chest tube clamps
• Bottle of sterile normal saline

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Patient Ed Standard 5BReducing anxiety

• Teach basics of drainage system, frequent checks,
  ask for analgesics PRN
• Assure that CT is sutured in place
• Remind not to kink/compress tubing
• Drainage system to be kept below level of chest
• Fluctuations in water seal are normal
• Prepare for expected amount type of drainage
• May hear bubbling if it is a wet suction system
• Discuss ambulating and repositioning
• Plan of care

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Chest Tubes Removal

• When tidaling ceases and chest
  X-ray/assessments confirm re-expansion of lung
• Pre-medicate for pain
• Breath in hum out (have pt practice)
• CT is quickly removed
• Occlusive dressing applied over insertion site
• Pleura seals itself off
• Chest wound heals within a week