Chest Tubes

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Chest Tubes

• by Charlotte Cooper RN, MSN, CNS
• modified by Kelle Howard RN, MSN

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Thoracic Cavity

• Lungs
• Mediastinum
• Heart
• Aorta and great vessels
• Esophagus
• Trachea

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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

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Breathing Exhalation

• Phrenic nerve stimulus stops
• Diaphragm relaxes
• This ______ the volume of the thoracic cavity
• Lung volume decreases, intrapulmonary pressure
  _____

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Physics of Gases

• If two areas of different pressure communicate,
  gas will move from the area of higher pressure to
  the area of lower pressure

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Pleural Anatomy

• Parietal pleura
• lines the chest wall
• Visceral pleura (pulmonary)
• covers the lung

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Pleural Anatomy
Visceral pleura
Parietal pleura
Lung
Ribs
Intercostal muscles
Normal Pleural Fluid Quantity Approx. 20 -
25mL per lung
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Pleural Physiology

• Area between pleura ----potential space
• Normally, negative pressure between pleura

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What happened?
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What is this?
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What is this?
archive.student.bmj.com/.../02/education/52.php
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What is this?
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Flail Chest
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Pleural InjuryOccurs
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Pleural Injury Therapeutic Interventions

• Diagnostic tests
• Client position
• Treatment depends on severity
• Chest tube
• Heimlich valve on chest tube

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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

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Chest Tube Placement

• In what setting/environment is a chest tube
  placed?

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Chest Tube Placement
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Chest Tube Placement
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Chest Tube Placement Procedure

• Sterile Tech
• Small incision
• Tube is sutured
• Dressing applied

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Chest tubes in place
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Heimlich Valve
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Heimlich Valve
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a04fig01.gif
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Prevent air fluid from returning to the pleural
space

• Chest tube is attached to a drainage device
• Allows air and fluid to leave the chest
• Contains a one-way valve to prevent air fluid
  returning to the chest
• Designed so that the device is below the level of
  the chest tube for gravity drainage

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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

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Interventions

• Dressing changes
• No dependent loops
• Oxygen therapy
• Record output
• Analgesics
• IS and turn, cough, deep breathe

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Nursing assessment and pertinent nursing
problems/interventions

• Health history-respiratory disease, injury,
  smoking, progression of symptoms
• Physical exam- degree of apparent resp distress,
  lung sounds, O2 sat, VS, LOC, neck vein
  distention, position of trachea
• All require observation for respiratory symptoms
• Pertinent nursing problems
• Acute pain
• Ineffective airway clearance
• Impaired gas exchange
• Home care

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• How a
• chest drainage system
• works

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Prevent Air and Fluid Backflow
Tube open to atmosphere vents air
Tube from patient
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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

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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

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How a chest drainage system works

• Expiratory positive pressure
• Gravity
• Suction

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What is different about this system?
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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.

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Monitoring

• 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?

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Assessment

• Focused respiratory assessment
• Breath sounds
• Respiratory rate
• Respiratory depth
• SpO2
• ABG
• CXR

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Assessment

• Cardiovascular assessment
• Level of consciousness
• Pain
• Chest tube

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Interventions r/t chest tubes

• System position
• Tubing position
• Connections to patient and system
• Assessing the system
• Monitoring output

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Complications

• What are some common complications?

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Complications Troubleshooting

• Chest tube malposition (most common)
• Subcutaneous emphysema
• High Fluid in Water Seal Chamber
• Chest system may need to be vented
• Air leak
• Others
• pleural effusion, inc. pneumo, pulmonary edema
• mediastinal shift
• ?

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If chest tube comes out?
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Review

• Check fluid level in suction chamber
• Observe water seal chamber fluid level
• Assess for tidaling in water seal chamber
• Assess for tubing non dependent
• Determine if the unit has been knocked over
• Note the amount, color and consistency of
  drainage

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What is most important?

• Monitor your client
• Notify MD STAT if
• Significant drainage
• Increasing shortness of breath
• Pain
• Absence of breath sounds

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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

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Questions

• What is the progression of events for
  discontinuing a chest tube?
• Can a patient ambulate with a chest tube?