Care of the Client with Chest Tubes Matthew D. Byrne, RN, MS, CPAN 9/19/2018

Outline Basics Indications Insertion Function 9/19/2018

The Pleural Space Space between ribs and lungs Filled with small amount of fluid Air or fluid in pleural space inhibits expansion and breathing 9/19/2018

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 9/19/2018

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 9/19/2018 Image from Trauma.org

Chest Tubes: Indications Surgery Traumatic chest injuries Pneumothorax Hemothorax Pleural effusion (build up of fluid between the pleura) Infection (empyema) 9/19/2018

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 9/19/2018

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 9/19/2018

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 9/19/2018

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 9/19/2018

Chest tube systems What do we need to connect to this tube in the patient’s 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… 9/19/2018

One Bottle=One 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? Ascend with inspiration; descend with expiration in the water seal tube 9/19/2018

Two Bottles=Valve + Drainage Allows air out but not in Rise and fall of fluid with breathing Creates no “pull” Allows for collection Water Seal (Valve) Drainage 9/19/2018

3 Bottles=Valve + 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) Water Seal (Valve) Drainage 9/19/2018

Commercial chest tubes Dry Suction = pressure and vacuum internally regulated Wet Suction = actual column of water used (usually 20cm) 9/19/2018

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 9/19/2018

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) 9/19/2018

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) 9/19/2018

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 9/19/2018

Patient Ed: Standard 5B Reducing 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 9/19/2018

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 9/19/2018