Thoracic cavity, pleural space

Conditions requiring chest drainage_1 Air between the pleurae is a pneumothorax Occurs when there is an opening on the surface of the lung or in the airways, in the chest wall — or both The opening allows air to enter the pleural space between the pleurae, creating an actual space

Conditions requiring chest drainage_2 Blood in the pleural space is a hemothorax Lateral decubitus X-Ray

Conditions requiring chest drainage_3 pleural effusion Transudate Exudate Empyema: Transudate: fluid that passes through a membrane; compared w/an exudate, has fewer cellular elements. Exudate: any fluid from the body w/a high concentration of protein, cells, or solid debris. Empyema: collection of purulent fluid in the pleural space

open vs closed pneumothorax Open pneumo Opening in the chest wall (with or without lung puncture) Closed Pneumo Chest wall is intact Rupture of the lung and visceral pleura (or airway) allows air into the pleural space Photo courtesy trauma.org

tension pneumothorax Tension pneumothorax occurs when a closed pneumothorax creates positive pressure in the pleural space that continues to build That pressure is then transmitted to the mediastinum (heart and great vessels) A tension pneumothorax can kill Chest wall is intact Air enters the pleural space from the lung or airway, and it has no way to leave There is no vent to the atmosphere as there is in an open pneumothorax Most dangerous when patient is receiving positive pressure ventilation in which air is forced into the chest under pressure

mediastinal shift from a tension pneumothorax Mediastinal shift occurs when the pressure gets so high that it pushes the heart and great vessels into the unaffected side of the chest These structures are compressed from external pressure and cannot expand to accept blood flow Mediastinal shift Mediastinal shift can quickly lead to cardiovascular collapse The vena cava and the right side of the heart cannot accept venous return With no venous return, there is no cardiac output No cardiac output = not able to sustain life

Clinical Manifestations of a collapsed lung N26 Chest Tubes 4/9/2017 Clinical Manifestations of a collapsed lung SOB Chest Pain Cough Absent or decreased breath sounds on affected side Shallow Respirations Asymmetrical chest movement Decreased O2 saturation Symptoms depend on cause, and how quickly or slowly it develops. Cyanosis – but very late sign of hypoxia Small <15% Observe patient’s CXR for further collapse Lung re-expands at a rate of 1.25% per day Moderate 15-60% Patient symptomatic, chest tube is indicated Large >60 % Chest tube is indicated Cabrillo College ADN/C. Madsen RN, MSN

Treatment for pleural conditions 1. Remove fluid & air as promptly as possible 2. Prevent drained air & fluid from returning to the pleural space Restore negative pressure in the pleural space to re-expand the lung

Remove Fluid &/or Air: chest tube insertion N26 Chest Tubes 4/9/2017 Remove Fluid &/or Air: chest tube insertion Chest tube tray with an appropriate size tube Surgical prep, sutures, sterile gloves Lidocaine, needles, syringes, alcohol preps Vaseline gauze, 4x4s & tape CDU = Chest drainage unit Suction and sterile water Cabrillo College ADN/C. Madsen RN, MSN

RN Role Educate patient and family Administer pain meds N26 Chest Tubes 4/9/2017 RN Role Educate patient and family Administer pain meds Set up chest drainage unit Obtain consent Assists with insertion PRN Verify occlusive dressing is intact Tape all connections from CT to drainage system to prevent air leaks Assess the patient and document appropriately Cabrillo College ADN/C. Madsen RN, MSN

2. 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 This system works if only air is leaving the chest If fluid is draining, it will add to the fluid in the water seal, and increase the depth As the depth increases, it becomes harder for the air to push through a higher level of water, and could result in air staying in the chest

3. Restore negative pressure in the pleural space Tube to vacuum source Tube open to atmosphere vents air Tube from patient 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 Many years ago, it was believed that suction was always required to pull air and fluid out of the pleural space and pull the lung up against the parietal pleura However, recent research has shown that suction may actually prolong air leaks from the lung by pulling air through the opening that would otherwise close on its own If suction is required, a third bottle is added Straw under 20 cmH2O Fluid drainage Suction control 2cm fluid water seal Collection bottle

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

How a chest drainage system works: summary Expiratory positive pressure from the patient helps push air and fluid out of the chest (cough, Valsalva) Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest Suction can improve the speed at which air and fluid are pulled from the chest

N26 Chest Tubes 4/9/2017 Collection Chamber This chamber allows monitoring of volume, rate and nature of the drainage Measure output per hospital policy Most systems are considered “full” at 2500ccs Cabrillo College ADN/C. Madsen RN, MSN

N26 Chest Tubes 4/9/2017 Water Seal Chamber Water creates a one-way valve that prevents air or fluid from returning to the patient’s chest Monitor this chamber for: air leaks (bubbling) tidaling (fluctuations in fluid level) increased negative pressure Fill this chamber to the 2 cm level with sterile water Cabrillo College ADN/C. Madsen RN, MSN

Suction Control Chamber N26 Chest Tubes 4/9/2017 Suction Control Chamber regulates the suction level acceptable for thoracic drainage Suction increases drainage rate Suction is controlled by water level Regulate wall suction until gentle bubbles appear suction level acceptable for thoracic drainage ( 5-40cm) Suction is controlled by water level [usually -20 cm H2O (MD will order)] Cabrillo College ADN/C. Madsen RN, MSN

Monitoring air leak Water seal is a window into the pleural space Not only for pressure If air is leaving the chest, bubbling will be seen here Air leak meter (1-5) provides a way to “measure” the leak and monitor over time – getting better or worse? Continuous bubbling in the water seal chamber after initial out rush of air when tube is inserted indicates an air leak. You should only see bubbling when pt coughs or exhales. Check all obvious sites for a leak.

Air Leaks Continuous bubbling initially - OK N26 Chest Tubes 4/9/2017 Air Leaks Continuous bubbling initially - OK Bubbling when pt coughs or exhales. How to troubleshoot: Crepitus (subcutaneous emphysema) Troubleshooting: First briefly clamp the tube near the insertion site. If bubbling stops the leak is in the patient Next remove the dressing and pinch the skin around the insertion site if you are able to seal off leak then apply Vaseline gauze around the tube and redress If leak doesn’t stop inch clamp down tube until bubbling stops. The air leak will stop when the clamp is between leak and drainage system. Tape the tubing or replace system Cabrillo College ADN/C. Madsen RN, MSN

Tubing from chest drainage system N26 Chest Tubes 4/9/2017 Tubing from chest drainage system Make sure connections are tight and taped No Dependant loops Milking or Stripping- only done if clot is suspected Controversial : may cause damage to lung tissue as increased negative pressure is exerted Short tubing to suction 6 foot long tubing connects to chest tube & patient No Dependant loops Allow for clotted material to block drainage Assure there are no dependant loops by coiling the tubing on the patient’s bed Cabrillo College ADN/C. Madsen RN, MSN

Transporting a patient with a chest tube N26 Chest Tubes 4/9/2017 Transporting a patient with a chest tube Keep the drainage system lower than the patients chest May open suction end to air which equals a water seal Mayo clamps (rubber tipped hemostats) should be kept at the bedside Cabrillo College ADN/C. Madsen RN, MSN

Assess the patient N26 Chest Tubes 4/9/2017 Cabrillo College ADN/C. Madsen RN, MSN

Then: Assess the CDU Check the dressing Check tubing - dependent loops N26 Chest Tubes 4/9/2017 Then: Assess the CDU Check the dressing Check tubing - dependent loops Check drainage in tubing & collection chamber Check water seal chamber Bubbling tidaling Check level of water Water seal chamber suction control chamber Check tubing CDU to wall suction: open? Cabrillo College ADN C. Madsen RN, MSN

Accidental disconnection of tube and drainage system N26 Chest Tubes 4/9/2017 Accidental disconnection of tube and drainage system Reconnect ASAP or Place end of tube in a sterile water bottle until new system arrives Monitor patient for s/s of resp distress Notify physician Reconnect if, for example, CDU cracked or broken – tubing sterile. Place end of connecting tubing in 2 cm (about an inch) of sterile Sodium Chloride or Sterile Water. Get a new system. Cabrillo College ADN/C. Madsen RN, MSN

Accidental DC of Chest Tube N26 Chest Tubes 4/9/2017 Accidental DC of Chest Tube Seal off insertion site – dry, sterile dressing or, petroleum gauze dressing secure on 3 sides Notify physician Assess patient prepare to assist with reinsertion Watch for tension pneumothorax If resp distress after dressing applied, tension pneumo may occur if pt. still has internal air leak. Cabrillo College ADN/C. Madsen RN, MSN

Termination of Chest Tube N26 Chest Tubes 4/9/2017 Termination of Chest Tube Assess for signs of re-expansion Minimal drainage Minimal bubbling / fluctuations in water seal chamber Chest x-ray shows re-expansion MD may leave to gravity 24° When suction turned off, want to make sure you disconnect tubing Provide way for air to escape Cabrillo College ADN/C. Madsen RN, MSN

Termination of Chest Tube N26 Chest Tubes 4/9/2017 Termination of Chest Tube Explain procedure to patient Equipment Suture removal kit, gloves, Vaseline gauze, 4x4s, tape, towels Tube should be pulled at the end of full inspiration. Some physicians prefer coughing or holding breath to increase intrathoracic pressure Occlusive dressing Tube should be pulled at the end of full inspiration. (this prevents air from sucking back into chest) Cabrillo College ADN/C. Madsen RN, MSN