2. Chest Tube
Prepeared By
Dr: Manal Moussa

3. Definition:
*Use of tubes and suction to return negative
pressure to the intrapleural space.
*To drain air from the intrapleural space, the
chest tube is placed in the second or third
intercostals space, to drain blood or fluid, the
catheter would be placed at a lower site, usually
the eighth or ninth intercostals space.

5. *Chest tubes also can administer
therapy. Chest tubes are sometimes
used to instill fluids into the pleural
space as well. For example, your
patient may receive cancer
chemotherapy through a chest tube.

6. Chest tube indications:
* Pneumothorax
* Hemothorax
* Pleural effusion
*Chylothorax, or accumulation of
lymphatic fluid in the pleural space.
* Empyema

7. * A traditional chest drainage unit
(CDU) consists of:
1- a collection chamber,
2- a water seal chamber,
3- and a suction control chamber.
This unit can drain both fluid and air.

9. *Nursing Care:
-Preparing for chest tube insertion depending
on circumstances, the practitioner may insert
a chest tube at the bedside or send the
patient to the operating room.

10. *Pre-insertion:
-patient consent.
-explanation of the procedure with him and his family.
-Explain that his breathing will be easier once the tube is inserted and his lung starts to reexpand.
-Tell them he'll receive a local anesthetic to reduce discomfort.

11. *prepare for the procedure:
*obtain tray, which typically includes:
-injectable lidocaine,
-an antiseptic,
-sterile gloves,
-a scalpel,
-hemostats,
-sutures,
-dressing material.
-obtain the appropriate CDU
-sterile water
-and suction control chambers.

12. Setting up a CDU:
*Before the patient's skin is prepared for chest tube insertion,
set up the CDU according to the manufacturer's instructions.
A traditional water seal system is set up by filling the water
seal chamber to the level specified by the manufacturer
(usually the 2-cm mark).
*Fill the suction control chamber with
sterile water to the -20 cm H2O level, or as prescribed.

13. *connect the tubing on the suction control chamber to
a suction source and turn up the pressure until you see
Gentle bubbling in the chamber.
*Avoid higher suction, which causes more vigorous bubbling
and faster evaporation.
*Monitor the CDU water levels and add sterile water as
necessary.
*Momentarily turn off the suction to add water because
bubbling makes the water level appear artificially high.

14. *Inserting the chest tube:
help position the patient for the procedure. Patient
positioning depends on the site of the air or fluid to be
drained and the patient's clinical status.
The practitioner cleans the patient's skin with povidone-iodine
or another antiseptic solution,
drapes the area,
and anesthetizes the skin.

15. After inserting the chest tube:
-She connects its distal end to the CDU.
-She uses suture to fix the tube at the insertion site and prevent displacement.
-She applies a 4x4-inch piece of sterile gauze with a slit over the tube,
and places an occlusive dressing over the gauze on the chest wall.
-She tapes the chest tube to the patient's chest to prevent traction on it when he moves.
-All tube connections, from the insertion site to the drainage container, must also be securely taped to prevent air leaks or disconnections.
-A chest X-ray confirms tube position and lung expansion.

16. Risks and complications:
Bleeding is a potential complication of chest tube
insertion if a vessel is nicked accidentally during the
procedure. Usually it's minor and resolves on its own,
but bleeding into or around the lung may require surgery.

17. Infection, another risk, becomes more likely
the longer the chest tube stays in place.
Subcutaneous emphysema can occur if air
leaks from the pleural space into
subcutaneous tissues. Notify the practitioner
if you notice subcutaneous emphysema,
which is characterized by tissue swelling in
the neck, face, and chest and a crackling
sound when the area is palpated.

18. Other rare but potential complications include lung
trauma and bronchopleural fistula.
In both of these complications, you'll notice
respiratory distress, decreased oxygen saturation,
altered level of consciousness, tachypnea, and
signs and symptoms of infection.
A patient with lung trauma also will have bloody
chest tube drainage. In both these conditions,
the chest tube remains in place until the patient
heals.

19. Problems? Check your patient first:
Now that your patient's chest tube is in place,
your goals are to restore adequate
oxygenation, promote lung reexpansion,
and prevent complications.
Whether giving routine care or managing
a complication, always assess the patient
before the equipment.

20. Monitor his vital signs—especially rate, pattern,
depth, and ease of respirations—and Spo2 level
every 2 hours or as necessary.
Assess his breath sounds bilaterally, especially
checking for symmetry of breathe sounds.
Assess the insertion site for subcutaneous
emphysema.

21. taped and that the chest tube is secured to your patient's chest wall.
Encourage the patient to cough and coach him in
deep breathing to promote drainage and lung
expansion.
*Teach him to support a thoracic incision if indicated.
Keep all tubing free from kinks.
Make sure that the connections are securely
taped and that the chest tube is secured to
your patient's chest wall.

22. * Keep the collection apparatus below the patient's chest level.
*Frequently check the water seal and suction control chambers.
*Keep in mind that the water in either chamber can evaporate, so
you may need to add water to maintain the manufacturer's
recommended level.
*The water seal level should fluctuate with respiratory effort; this is
called tidaling. If it doesn't, the tubing may be kinked or clamped or
the patient may be lying on it.

23. *The lack of tidaling may be a good sign indicating
that no more air is leaking into the pleural space.
*Assess the color of drainage in the drainage tubing
as well as the collection chamber.

24. Measure drainage every 8 hours, or more
frequently depending on your patient's clinical
status.
*At regular intervals, mark the date and time at
the current fluid level on the drainage chamber.
*The chamber isn't replaced until almost full,
unless the unit is accidentally broken.

25. *Document the amount of drainage and its
characteristics in your patient's medical record and
fluid intake/output record.
*Immediately report more than 70 ml/hour of bright
red blood or red free-flowing drainage, which could
indicate hemorrhage.
*Frequently reposition the patient and help him
ambulate or sit in a chair as ordered.

26. Clamping: *As a rule, avoid clamping your patient's chest tube.
Clamping prevents the escape of air or fluid, which increases
the risk of tension pneumothorax.
*You can clamp the tube momentarily to replace the CDU or to
locate the source of an air leak, but never clamp it when
transporting the patient or for any extended period, except as
directed by the practitioner.

27. *For example, she may want to clamp the tube
to assess the patient's ability to do without it
before removing it.
*While it's clamped, observe him for any signs
of respiratory distress (such as chest pain and
tachypnea) that could indicate the
development of a tension pneumothorax.
*If this happens, remove the clamp immediately
to let air escape.

28. Removing the tube:
The practitioner will remove your patient's chest tube
according to these criteria:
* The drainage has decreased to little or none.
* The air leak has disappeared.
* The patient is breathing normally without respiratory distress.
* Breath sounds are at baseline.
* Fluctuations in the water seal chamber have stopped.
*A chest X-ray shows lung reexpansion with no residual air or
fluid in the pleural space.

29. *Gather the necessary equipment and supplies,
including a suture removal kit,
-petroleum gauze dressing,
-4x4 dressings, and occlusive tape.
-Explain the procedure to the patient and
answer his questions.
-Administer premedication as ordered to
prevent pain and anxiety.

30. The practitioner will remove the insertion site
dressing, clean the area, and remove the sutures.
Then, during peak exhalation, she'll remove the tube
in one quick movement.
Immediately apply sterile occlusive petroleum gauze
to the wound to prevent air from entering the pleural
space.

31. Arrange for your patient to have a chest X-ray
to assess for lung reexpansion.
Monitor his respiratory status and Spo2 for 1
to 2 hours after removal, or longer if necessary.

32. THANK YOU