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

2. Outline
Basics
Indications
Insertion
Function
9/19/2018

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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