1. Thoracic cavity, pleural space

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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

22. 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

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

24. 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

25. 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

26. Accidental DC of Chest Tube
N26 Chest Tubes
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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

27. 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

28. 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