Chest Tubes Indications, Management,

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Chest TubesIndications, Management, Assessment

• Dawn Parenteau, RN, BSN, CCRN
• PN III
• Mercy Hospital CCU

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Points to Discuss

• Indications
• Brief Overview of AP and set-up
• Assessment and Care
• Trouble-shooting

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Basic Anatomy and Physiology

• Visceral pleura Covers lung segments
• Parietal pleura Lines chest wall and
  diaphragm
• Pleural Space Area between visceral
  and parietal pleura
• Surfactant Thin serous fluid that acts as a
  lubricant between the visceral and parietal
  pleura
• Negative Pressure Restores Lung Collapse

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Indications For UseChest Tube Inserted into the
Pleural Space to Remove

• Air Pneumothorax

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Pleural Effusion

• Chylothorax collection of lymphatic fluid
• Empyema collection of pus from infection
• Hemothorax collection of blood
• Hydrothorax collection of serous fluid

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Hemothorax
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Empyema
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Pleural Effusion
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Contraindications to Chest Tube Insertion

• Refractory Coagulopathy
• Diaphragmatic Hernia
• Adhesions to the pleural space
• Lack of patient cooperation
• Patient refusal

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Chest Tube Locations

• Air Pneumo anterior chest 2nd intercostal space
  in the mid clavicular line OR 4th intercostal
  space mid- axillary line
• Fluid Drainage between the 4th or 5th
  intercostal space mid-axillary line

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Atrium Set Up

• Chamber 1 or A suction control chamber
• Chamber 2 or B air leak or water seal chamber
• Chamber 3 or C collection chamber

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Demonstration of Atrium Setup
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AssessmentAlways start with the patient!

• Rate, rhythm, depth, and effort of respirations
• Chest movement symmetry, accessory muscle use,
  and/or retractions
• Palpate for lung expansion
• Percuss thorax
• Note tracheal location
• Auscultate breath sounds
• Assess for crepitus at the site
• Review CXRs

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Assessment Continued

• Observe insertion site for redness, exudate, air
  leak
• Ensure all tubing/connections are secure
• MEASURE DISTANCE FROM INSERTION SITE TO FIRST
  CONNECTOR!! Mark over tape.
• Make sure collection system is placed at least 1
  foot below chest.
• Ensure that water level is appropriate in
  suction chamber add or remove as needed
• Assess for air leak, and fluctuation
• Monitor quality and quantity of drainage.
• Check that emergency equipment is at bedside
  readily available

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Emergency Equipment

• Rubber tipped or non-toothed hemostats
• Vaseline gauze
• Sterile 4x4s

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Air Leak Good or Bad?

• Good if tube is newly inserted for pneumothorax
  (air)
• Bad if chest tube is old and suddenly develops
• If there was an air leak initially and now there
  is not, the lung may be re-expanded.
• Note The higher up on the numbered column the
  air bubble appears, the greater the degree of PTX

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Video of Air Leak Assessment

• http//www.youtube.com/watch?vHxRh3dF1BZgfeature
  player_detailpage

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Tidaling or Fluctuation

• Normal tidaling is 2 TO 6 cm H2O.
• Large fluctuations in tidalling mean that there
  is increased WOB if the patient is on a
  ventilator
• The amount of fluctuation within the tubing is
  usually directly correlated to the degree of PTX

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Water Direction During Respirations
Spontaneous Respirations Mechanically Ventilated
Inspiration Up Down
Expiration Down Up
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Please

• Always consider and treat pain. These things are
  darned uncomfortable!!!

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Dressing Changes

• Change dressing q 24-48 hrs and prn
• Take down old dressing
• Cleanse site with NS
• Apply occlusive vaseline gauze
• Apply DSD
• Foam tape
• Mark insertion location over the foam tape to aid
  with measuring
• Dont forget to measure!!!!

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Changing the Collection System

• Turn off suction if applicable
• Clamp chest tube closest to pleur-evac
• Disconnect old drainage system
• Reconnect new drainage system
• Resume suction if applicable

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Major Complications.

• Clogging can lead to pericardial tamponade,
  tension PTX, empyema in setting of infection
• Injury to liver, spleen, or diaphragm
• Pain

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Minor Complications

• Subcutaneous seroma or hematoma
• Anxiety, SOB, and Cough
• Subcutaneous emphysema

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Troubleshooting

• If CT becomes disconnected
• 1. reconnect immediately
• 2. retape connections
• If CT comes out
• 1. Cover with DSD or vaseline gauze.
• 2. LEAVE OPEN TO AIR if on MV
• In either situation Call MD and prep pt for stat
  PCXR

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Clamping the Chest Tube

• Must need MD order to do so!!
• Clamp ONLY
• If changing drainage collection system
• Is assessing for location of air leak
• If assessing patient readiness for tube removal
• Unnecessary clamping could result in tension PTX
  or arrest

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Mr G A Case Study

• 89 y.o male
• PMH Chronic Foley catheter, Stage II CKD,
  Dementia, CVA, Diastolic CHF with EF 40-45, HTN,
  Enterococcus bacteremia, MW tear, Recent UTI with
  ABX Rx, anemia, asp pna.
• Presented to ED from LTC appearing septic from
  recent UTI
• BP70/30, T 103, HR 100-160 with PSVT

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Mr. G A Case Study Contd

• Decision made in place TLC for potential pressor
  admin and place pt on BIPAP
• R SC attempted first. Catheter migrated up to
  the neck
• L SC accessed with success after the 4th attempt
  however pt developed moderate sized L
  pneumothorax
• Pt then became hypertensive, hypoxic and more
  tachycardic

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Mr. G contd

• Decision made by intensivist to insert a 20
  French chest tube at the Left mid axillary line.
  CT sutured at the 20 cms mark per MD procedure
  note.
• The CT was placed to -20 wall suction. Per MD
  note intermittent air leak that varied with
  resps.
• CXR confirmed placement.

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Mr. G contd

• Ongoing RN chest tube assessments showed that the
  chest tube measurements were increasing. No
  documentation of notification of provider of
  findings.
• Over the next several days, this chest tube had
  persistent air leak, though the lung appeared to
  be reinflated.
• Significant subcutaneous air was noted on day 7
  prompting a CT Scan which showed a large anterior
  undrained PTX

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Mr. G contd

• Decision made place a second chest tubein the
  anterior midclavicular line. This was placed
  around 4pm.
• At 1930 pt became hypotensive 70/30. MD notified
  and orders for IVF bolusing were received. BP
  was refractory.
• RN then noted approx 1200 mls of frank blood in
  collection chamber of initial chest tube.
• No tidalling or air leak noted in either system.
• Cxr showed persistent PTX with R shift of the
  mediastinum and deep sulcus.

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Mr G contd

• AM Hgb 11.4 now 7.7
• Concern was for intercostal artery bleed or chest
  wall muscle rupture
• Decision made to transfer pt to MMC while
  receiving blood and now needing vasopressive
  therapy.

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How can we all learn from this and what should we
do differently next time?
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Please click on link to view U tube video!

• http//www.youtube.com/watch?viZupWjeaHEU