Chest Tubes: Indication to Removal Chest Tube Care and Monitoring

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Chest Tubes Indication to RemovalChest Tube
Care and Monitoring

• 
  Hayek . M
• Chest tube
  related to some indications
• NSG Collage ,
  Medical complex \ Najah university

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Assessment of Respiratory System

• Presenting illness
• Past medical history
• Physical assessment
• Inspection
• Palpation
• Percussion
• Auscultation of breath
• sounds and quality of voice

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The Patient in Respiratory Distress

• Abdominal/Accessory muscles use.
• Abnormal breath sounds
• Asymmetrical chest wall motion
• Decreased oxygen saturation
• Decreased urine output
• ECG changes
• Hyper/hypoventilation
• Jugular venous distention
• Nasal flaring
• Restlessness/confusion/agitation
• Shortness of breath
• Skin color changes
• Tachycardia and hypertension
• Tracheal shift

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Indication for Chest Tube Placement

• Pneumothorax
• Hemothorax
• Symptomatic pleural effusion
• Empyema
• Complicated parapneumonic effusion ect

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Normal Chest Roentgenogram (X-ray)

• Based on systematic evaluation
• Soft tissues of neck, shoulders, breasts,
  axillae, diaphragms, and upper abdomen
• Skeletal structures such as clavicles, ribs,
  vertebrae, scapulae, and sternum
• Trachea, bronchi, pleural spaces, and lung
  parenchyma
• Tubes, lines, and monitoring devices

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Comparison of Chest Radiographs(Pneumothorax)

• Simple Pneumothorax

• Normal Chest X-ray

Collapsed lung
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How Does a Chest Tube Function?

• Collection Bottle collects fluid and debris
  delivered by chest tube. Connected to water seal
  chamber
• Water Seal Bottle One way valve for air to
  escape from the pleural space, measures negative
  pressure in chest, and determines degree of air
  leak
• Suction Control Bottle Volume of water
  determines amount of negative pressure in pleural
  space

Goal is to remove fluid or air from the pleural
space, prevent re-accumulation, and allow for
lung re-expansion.
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Chest Tubes

• French sizing refers to the diameter of the tube
  in millimeters from 8-40 Fr
• Tube is sterile, flexible, nonthrombogenic
  composed of vinyl or silicone
• Typically packaged with aluminum trocar
• Measures 20 inches in length (50 cm)
• Proximal end is fenestrated
• Indications and patient size dictates size
• Pneumothorax 20-24 Fr
• Fluid 28 Fr
• Average adult/teen male 28-32 Fr
• Average adult/teen female 28 Fr

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Common Complications of Chest Tube Insertion

• Allergic reaction
• Bronchopleural fistula
• Cardiac injury
• Hemorrhage
• Hepatic injury
• Infection
• Intercostal nerve, artery, or vein injury
• Lung laceration
• Re-expansion pulmonary edema
• Splenic injury
• Subcutaneous emphysema

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• Chest tube inserting

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Nursing Responsibilities (care)

• Conduct routine patient assessment
• Frequently assess the insertion site, tube,
  tubing, and drainage unit
• Monitor amount, color, and consistency of the
  drainage
• Encourage positioning with head of bed up to 30
  degrees
• Educate about the benefits of coughing, deep
  breathing, use of the incentive spirometer,
  and/or flutter valve every two hours
• Advocate ambulation and position changes

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Amount, Color, and Consistency

• Sudden drainage increases could be indicative of
  hemorrhage
• Changes in drainage from pure liquid to red could
  indicate hemorrhage
• Consistency changes from thin, clear fluid to
  milky could be evidence of evolving infection
• Decreased drainage may be a sign of tube
  displacement, kinked tubing, or a clot may be
  obstructing the lumen of the tube

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Care of patients with chest tube
A . Assess patient for respiratory distress and
chest pain, breath sounds over affected lung
area, and stable vital signs.B . Observe for
increase respiratory distress C . Observe the
following Chest tube dressing, ensure tubing
is patent. Tubing kinks, dependent loops or
clots. Chest drainage system, which should be
upright and below level of tube insertion.
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Care of patients with chest tube

• D. Provide two shodded hemostats for each chest
  tube, attached to top of patients bed with
  adhesive tape. Chest tube are only clamped under
  specific circumstances To assess air leak
  To quickly empty or change collection bottle or
  chamber To change disposable systems have
  new system ready to be connected before
  clamping tube so that transfer can be rapid
  and drainage system reestablished To
  change a broken water-seal bottle in the event
  that no sterile solution container is
  available.

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Care of patients with chest tube
F. Maintain tube connection between chest and
drainage tube intact and taped Water-seal vent
must be without occlusion Suction-control
chamber vent must be without occlusion when
suction is used G. Coil excess tubing on
mattress next to patient. Secure with rubber band
and safety pin or systems clamp
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Care of patients with chest tube

• H. Adjust tubing to hang in straight line from
  top of mattress to drainage chamber. If chest
  tube is draining fluid, indicate time (e.g.,
  0900) that drainage was begun on drainage
  bottles adhesive tape or on write-on surface of
  disposable commercial system. Strip or milk
  chest tube only per MD/PA orders only Follow
  local policy for this procedure
• To assess if patient is ready to have
  chest tube removed (which is done
  by physicians order

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Care of patients with chest tube

• E. Position the patient to permit optimal
  drainage.
• Semi-Flowers position to evacuate air
  (pneumothorax) High Flowers position to drain
  fluid (hemothorax)

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Problems solving with chest tube

• A. Problem Air leak Continuous bubbling is
  seen in water-seal bottle/chamber, indicating
  that leak is between patient and water seal(a)
  Locate leak(b) Tighten loose connection between
  patient and water seal(c) Loose connections
  cause air to enter system.(d) Leaks are
  corrected when constant bubbling stops

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Problems solving with chest tube

• Problem Bubbling continues, indicating that
  air leak has not been corrected (a) Cross-clamp
  chest tube close to patients chest, if bubbling
  stops, air leak is inside the patients thorax or
  at chest tube insertion site(b) Unclamp tube and
  notify physician immediately!(c) Reinforce chest
  dressing
• Warning Leaving chest tube clamped caused a
  tension pneumothorax and mediastinal shift

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Problems solving with chest tube

• Problem Bubbling continues, indicating that
  leak is not in the patients chest or at the
  insertion site(a) Gradually move clamps down
  drainage tubing away from patient and toward
  suction-control chamber, moving one clamp at a
  time(b) When bubbling stops, leak is in section
  of tubing or connection distal to the clamp(c)
  Replace tubing or secure connection and release
  clamp

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Problems solving with chest tube

• Problem Bubbling continues, indicating that
  leak is not in tubing(a) Leak is in drainage
  system (b) Change drainage system
• Problem Tension pneumothorax is present(1)
  Problems Severe respiratory distress or chest
  pain(a) Determine that chest tube are not
  clamped, kinked, or occluded. Locate leak(b)
  Obstructed chest tube trap air in intrapleural
  space when air leak originates within patient

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Problems solving with chest tube

• Problem Absence of breath sounds on affected
  side (a) Notify physician immediately
• Problems Hyper resonance on affected side,
  mediastinal shift to unaffected side, tracheal
  shift to unaffected side, hypotension or
  tachycardia(a) Immediately prepare for another
  chest tube insertion (b) Obtain a flutter
  (Heimlich) valve or large-guage needle for
  short-term emergency release or air in
  intrapleural space(c) Have emergency equipment
  (oxygen and code cart) near patient

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Problems solving with chest tube

• Problem Dependent loops of drainage tubing
  have trapped fluid(a) Drain tubing contents into
  drainage bottle(b) Coil excess tubing on
  mattress and secure in place
• Problem Water seal is disconnected(a) Connect
  water seal(b) Tape connection( may mistake
  happens)

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Problems solving with chest tube

• Problem Water-seal tube is no longer submerged
  in sterile fluid(a) Add sterile solution to
  water-seal bottle until distal tip is 2 cm under
  surface
• Problem Water-seal bottle is broken(a)
  Insert distal end of water-seal tube into sterile
  solution so that tip is 2 cm below surface
• (b) Set up new water-seal bottle(c) If no
  sterile solution is available, double clamp chest
  tube while preparing new bottle

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Assessing Air Leaks (RE)

• What is it? Bubbling seen in the water
  seal pressure scale. Usually will have some rise
  and fall with each breath, but constant bubbling
  is a clue that there could be a problem in
• Chest tube drainage system
• Poorly positioned chest tube
• Injury to bronchus/esophagus
• Continued air leak in the lung

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Assessing Air Leaks

• To help determine the location of an air
  leak, the chest tube may be clamped near the
  chest wall
• If the air leak disappears, then the
  leak is coming
• from the patient (i.e. persistent lung
  injury)
• If the air leak continues, the leak is
  coming from a location distal
• to the clamp.i.e. hole in chest tube,
  loose connection, leak in
• the tubing, faulty pleuravac system,
  etc
• Dont forget to release the clamp!!!

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Bad Things Happen to Good People

• .

• Chest tube gets dislodged If you
• hear air leaking, cover site with three sided
  dressing. If no air is heard, cover with sterile
  dressing and notify the physician.
• Chest drainage unit breaks change the unit,
  assess, and notify physician
• In emergent situations, tubing could be placed in
  sterile water/saline at a depth of 2-4 cm to
  re-establish the water seal

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When is it Time to Come Out?

• When indication for insertion is no longer
  present (i.e. resolution of pneumothorax,
  hemothorax, etc)
• No air leak evident the day before considering
  chest tube removal
• Drainage less than 50cc/8 hours or 150cc/day
• Patient able to tolerate chest drainage system
  being brought to water seal from suction
• Chest x-ray shows complete re-expansion of the
  lung

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Discontinuing the Chest Tube

• Procedure is explained and appropriate
  pre-medication is performed
• Assumes supine position with arm above head on
  side of tube
• Chest drainage unit brought to water seal and the
  dressing is removed
• deep inspiration or exhalation ,the tube is
  removed with one steady movement
• Site is dressed and x-ray obtained 24 hours later
• Dressing the insertion site after removing it

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SUMMARY

• Caring for a patient with a chest tube requires
  problem solving and knowledge application.
  Remember, a chest tubeis a catheter inserted
  through the thorax to remove air and fluids from
  the pleural space and to reestablish normal
  intrapleural and intrapulmonic pressures. When
  caring for and maintaining a patient with a chest
  tube, it is important to note the patency of
  chest tube, presence of drainage, presence of
  fluctuations, patient's vital signs, chest
  dressing status, type of suction, and level of
  comfort.

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?

• 1- What are chest tubes used for?
• 2- Where exactly is a chest placed?
• 3- How does the three-chamber system work?
• 4- Can suction be bad for the patient?
• 5- Can you make care for pt who have chest tube?

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Questions