Chest TubesSamantha Soto BSN, RN-BC

University of Central Florida

MSN Candidate

Objectives

After participating in this class the learner will be able to…Describe the anatomy and

physiology of the lung Identify potential conditions

requiring need for a chest tubeList equipment and supplies

used to place, maintain, and remove chest tubes

Outline the process of insertion, maintenance, and removal of chest tubes

Anatomy & PhysiologyThoracic CavityR Lung: 3 lobesL Lung: 2 lobesMediastinum: heart, aorta,

esophagus, & tracheaDiaphram: separates

thoracic cavity from abdomen

Visceral Pleura: covers the lungs

Parietal Pleura: lines the chest wall

Right Lung Left Lung

Parietal Pleura

Mediastinum

Diaphragm

Visceral Pleura

Pleura Anatomy

area between the pleura is called the pleural space

the pressure between the pleural space is always negative

negative pressure is suctionNormal pleural fluid quantity is

small. There is no set number or calculation, and it is based on size.

Inhalation Exhalation

Breathing

DownUp

Conditions that require Chest TubesPneumothoraxA collapsed lung is the collection of air in the space

around the lungs. This buildup of air puts pressure on the lung so it cannot expand.

Conditions that require Chest Tubes

Open Pneumothoraxstab wound, gun shot

wound, surgery where air would leak in to the thoracic cavity from the outside; also known as a “sucking chest wound”

Conditions that require Chest Tubes

Closed Pneumothorax disruption of lung and

visceral pleura results when air leaks from

a ruptured bronchus or a perforated esophagus and eventually ruptures into the pleural space.

Can progress to a tension pneumothorax

Hemothorax Large Plueral Effusions

Conditions that require Chest Tubes

blood in the pleural spacetransudate or exudate in the pleural space usually from CHF and Cancer

Conditions that require Chest Tubes

Tension Pneumothoraxair can get in, but not OUT there is an obstruction and

an accumulation of air under pressure in the pleural space. This condition develops when injured tissue forms a 1-way valve, allowing air to enter the pleural space and preventing the air from escaping naturally

Conditions that require Chest TubesMediastinal Shifta shifting or moving of the

tissues and organs that comprise the mediastinum (heart, great vessels, trachea and esophagus) to one side of the chest cavity. The condition occurs when a severe injury to the chest causes the entrapment of air in the pleural space

Very serious condition and requires attention immediately; can lead to cardiac arrest

Worsening closed/tension pneumothorax

Conditions that require Chest TubesThoracic surgeryCoronary Artery Bypass Graft

(CABG) and Valve replacements

Chest tubes are used to drain the chest cavity of fluid and blood (which is temporary and normal) after surgery.

Occasional placement of tubes in the left or right pleurae are used for collapsed lung during and post procedure

Signs & SymptomsDyspneaTachypneaTachycardiaChest painCrepitusDecreased breath

sounds on the side where the pneumothorax is

CoughFatigueCyanosis

Diagnostic Tools

Pulse oximetryAusculatationChest x-rayCT scan

Equipment for Chest Tube placement

Chest tube cartClampsPleur EvacVaseline guazeTrocarChloraprepChest tubeSuction set upSuture with needlesDry sterile 4x4sSome medications will

be pulled from pyxis

Drainage Systems

Heimlich Valve• used primarily to

release air• MobilePleur Evac• used for both fluid

and air drainagePluerX• used for effusions

that rapidly reaccumulate

Insertion Diagram

Insertion Diagram

Maintenance of the Chest Tube

Vital Signs with O2 sats as per hospital policy q 15min x4, q 30min x2, q 1hr x4,

then q 4hr until removed

Site tape securely check for bleeding, crepitus

around insertion site, mark it with a marker, if its

growing…that’s could be a problem

assess color at insertion and for swelling or bruising

Maintenance of the Chest TubeTubing Start at the insertion site and

move down towards drainage system

You should never see any holes

Remove any loops Check for patency/clots Check color of fluid DO NOT CLAMP a chest

tube unless you have been instructed to or you are changing the drainage box

Do not strip or milk your chest tube

Maintenance of the Chest TubePleur Evac/Drainage SystemDo not touch sterile tip, you will

hand this to the physician during insertion

Fill in the H2O chamber with sterile water

If air is leaking then you will see it in this chamber as shown. It is numbered 1-5 to indicate the grade of the air leak.

you will almost always have an air leak when the tube is inserted, but is resolves

Hang drainage box at the foot of the bed

Maintenance of the Chest TubeSuction You will set the suction dial on

the Pleur Evac as ordered by the physician

The wall suction is increased until the orange buoy floats

Output What does it look like? Check for stop cocks How much is ok, or not

enough? Mark the Pleur Evac at the

beginning of your shift Check the amount of

drainage at least every 2 hrs.

Maintenance of the Chest Tube

What is water seal?Water seal acts as a one way valveFluid and air can go out, but not back in.

What if your water seal is low?You can refill it with a syringe and a bottle of sterile

water

How often does the dressing need to be changed?Daily unless it is saturated and needs to be

changed sooner Is this a sterile procedure?No, but should be as clean a technique as possible

Patient EducationDescription of procedure IS and cough/deep

breathAmbulation/sitting up in

chair(pts can do these things even with a chest tube!)

Pain managementThe pt can expect to

have chest x-rays performed daily until the tube is removed

When to call for HELP!My patient’s having trouble breathingMy patient’s sats are below 90% and staying thereMy patient’s chest tube is making whistling noisesMy patient pulled out their chest tube

Chest Tube Removal A chest x-ray has confirmed that the

patient’s problem has resolved or well enough to remove their chest tube

Your patient should have breath sounds over the affected area now

Drainage has also decreased significantly.

Sometimes a physician will ask that the chest tube be clamped for a few hours prior to removal

Usually a physician will order for a chest tube to be removed from wall suction and placed to water seal for a day prior to tube removal.

Chest Tube Removal

What will you need?Kelly Clamps to clamp the chest tubeChloraprep or betadine swab to clean the site

before you remove the chest tubeSuture removal kit-to remove the suturesVaseline gauze or Adaptic-to help create a seal Dry sterile 4x4, that will go over the Vaseline

dressingTegaderm or Occlusive Dressing (at first you

want a dressing that will help make a seal)Red Bag for disposal of the chest tube and Pleur

Evac

Chest Tube Removal

Proceduremake sure you have an order firstExplain what your going to do to the patient.The patient must be in bed, alwaysPre-medicate: some physicians will pre-medicate for

large bore chest tubes 15-30min prior to pull.Practice breathing deep. Explain to the pt that on the

third breath they will hold it until you say so, at that time you will pull the chest tube quickly

Get your red bag ready and place the Pleur Evac in the bag prior to pulling the chest tube

Clamp the chest tube with the Kelly Clamps

Chest Tube RemovalProcedure continued…Remove old dressingCleanse the area with chloraprep or betadine prior to

pull and make sure it is dry.Remove suturesAs you pull the chest tube you will place the Vaseline

gauze and dry sterile 4x4s. Remind your patient to breath and that IT’S OVER!Place Tegaderm over the gauze. Time and date the

dressing. Instruct your patient on when to call for helpDispose of your waste in the red bin