1. by Charlotte Cooper RN, MSN, CNS modified by Kelle Howard RN, MSN
Chest Tubes
by Charlotte Cooper RN, MSN, CNS
modified by Kelle Howard RN, MSN

2. Thoracic Cavity Lungs Mediastinum Heart Aorta and great vessels
Esophagus
Trachea

3. Breathing: Inspiration
Diaphragm contracts
Moves down
Increasing the volume of the thoracic cavity
When the volume increases, the pressure inside ________.
Pressure within the lungs is called intrapulmonary pressure

4. Breathing: Exhalation
Phrenic nerve stimulus stops
Diaphragm relaxes
This ______ the volume of the thoracic cavity
Lung volume decreases, intrapulmonary pressure _____

5. Pleural Anatomy Parietal pleura lines the chest wall
Visceral pleura (pulmonary)
covers the lung

6. Normal Pleural Fluid Quantity: Approx. 20 - 25mL per lung
Pleural Anatomy
Visceral pleura
Parietal pleura
Lung
Intercostal muscles
Ribs
Normal Pleural Fluid Quantity: Approx mL per lung

7. Pleural Physiology Area between pleura “potential space”
Normally, negative pressure between pleura
During inspiration, the intrapleural pressure is approximately -8cmH20 (below atmospheric pressure)
During expiration, intrapleural pressure is approximately cmH20 (below atmospheric pressure)

8. What happened?

9. What is this?

10. What is this?
archive.student.bmj.com/.../02/education/52.php

11. What is this?

12. Flail Chest

13. Pleural Injury Occurs

14. Pleural Injury: Therapeutic Interventions
Diagnostic tests
Client position
Treatment depends on severity
Chest tube
Heimlich valve on chest tube

15. Chest Tube Placement
In what setting/environment is a chest tube placed?

16. Chest Tube Placement

17. Chest Tube Placement

18. Chest Tube Placement Procedure
Sterile Tech
Small incision
Tube is sutured
Dressing applied

19. Heimlich Valve

20. Heimlich Valve

21. 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

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

23. Interventions Dressing changes No dependent loops Oxygen therapy
Record output
Analgesics
IS and turn, cough, deep breathe

24. Nursing assessment and pertinent nursing problems/interventions
Health history-respiratory disease, injury, smoking, progression of symptoms
Physical exam- degree of apparent resp distress, lung sounds, O2 sat, VS, LOC, neck vein distention, position of trachea
All require observation for respiratory symptoms
Pertinent nursing problems
Acute pain
Ineffective airway clearance
Impaired gas exchange
Home care

25. How a
chest drainage system
works

26. Prevent Air and Fluid Backflow
Tube open to atmosphere vents air
Tube from patient

27. Prevent Air and Fluid Backflow
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

28. 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

29. How a chest drainage system works
Expiratory positive pressure
Gravity
Suction

31. Atrium Chest Tube System
Chamber A
Suction control chamber
Chamber B
Water seal chamber
Chamber C
Air leak monitor
Chamber D
Collection chamber
Be sure you under stand how to set up the system, the function of each chamber and how to troubleshoot issues with each chamber.

32. Monitoring Water seal is a window into the pleural space
Not only for pressure
If air is leaving the chest through an air leak, bubbling will be seen here
Air meter (1-5) provides a way to “measure” the air leaving and monitor over time – getting better or worse? 32

33. Assessment Focused respiratory assessment Breath sounds
Respiratory rate
Respiratory depth
SpO2
ABG
CXR

34. Assessment Cardiovascular assessment Level of consciousness Pain
Chest tube

35. Interventions r/t chest tubes
System position
Tubing position
Connections to patient and system
Assessing the system
Monitoring output

36. Complications
What are some common complications?

37. Complications & Troubleshooting
Chest tube malposition (most common)
Subcutaneous emphysema
High Fluid in Water Seal Chamber
Chest system may need to be vented
Air leak
Others
pleural effusion, inc. pneumo, pulmonary edema
mediastinal shift ?

38. If chest tube comes out?

39. Review Check fluid level in suction chamber
Observe water seal chamber fluid level
Assess for tidaling in water seal chamber
Assess for tubing – non dependent
Determine if the unit been knocked over
Note the amount, color and consistency of drainage
Above all

40. What is most important? Monitor your client Notify MD STAT if
Significant drainage
Increasing shortness of breath
Pain
Absence of breath sounds

41. Management Do not remove suction without an order Manage pain
When full - place in biohazard container
Do not change collection device on client with an air leak without an order
When suction discontinued, must disconnect from suction, not just turn off

42. Questions
What is the progression of events for discontinuing a chest tube?
Can a patient ambulate with a chest tube?

43. Removing the Chest Tube