Eliminate the air of mystery from chest tubes
Nursing2002 June 2002 Volume 32 Number 6 Pages 36 – 43 Eliminate the air of mystery from Chest tubes Use this guide to understand when your patient may need a chest tube and how to manage the drainage system. BY DEBORAH LAZZARA, RN, APRN-BC, CCRN, MS ANXIOUS AND TACHYCARDIC, John Williams, 26, comes to the emergency department complaining of chest pain and difficulty breathing. Suffering from a bad cold, he developed the problem soon after a bout of forceful coughing. Your quick assessment reveals decreased breath sounds on his right side, and the right side of his chest barely moves on inspiration. His Spo2 reading is 88%. Suspecting that Mr. Williams is experiencing a pneumothorax, you elevate the head of his bed to 45 degrees and administer oxygen at 2 liters/minute. You titrate the flow until his Spo2 reaches 94% and page the pulmonologist. A pneumothorax is a medical emergency that calls for placement of a chest tube and use of a chest drainage unit (CDU). To help Mr. Williams through this crisis, you need to understand how chest tubes and CDUs work, how to assist during tube insertion and removal, and how to monitor his condition. I'll cover these topics below. But first, let's look at why he might need a chest tube in the first place. Removing air or fluid from the pleural space The purpose of a chest tube (also known as a thoracostomy tube or thoracic catheter) is to remove air or fluid from the pleural space. A chest tube is commonly inserted to resolve pneumothorax, hemothorax, or pleural effusion or to drain blood from the mediastinum after open-heart surgery. (See A Range of Reasons for Chest Tube Placement to learn more.) Pneumothorax is the most common reason for inserting a chest tube. Leading to partial or complete lung collapse, it's caused by external air entering the pleural space from a hole in the chest wall or by air in the lungs entering through a hole in the pleura. The collected air disrupts the normal negative pressure within the lungs--the vacuum that keeps them expanded. Loss of this vacuum causes the lung to collapse; a collapse of greater than 15% can lead to respiratory compromise, so insertion of a chest tube is necessary. Tension pneumothorax, a life-threatening emergency, occurs when the air accumulating in the pleural space increases pressure to a dangerous level, causing a mediastinal shift that pushes the heart, great vessels, trachea, and lungs toward the unaffected side. This shift severely decreases lung expansion, venous return, and cardiac output. Signs of tension pneumothorax include severe respiratory distress, tracheal deviation to the unaffected side, cyanosis, muffled heart sounds, and possibly cardiac arrest.
malignancy Posteriorly into the collection or fifth or sixth ICS transudation in the pleural space Empyema A collection of Pneumonia. bronchoscopy. surgery. and mechanical ventilation using positive endexpiratory pressure pose a risk as well. and cardiac pneumothorax output. Signs and symptoms tell the story Early on. (Its normal location is at the fifth intercostal space. that continues to midclavicular line the lung: spontaneous pneumothorax increase pressure and decreases lung * Procedures such as percutaneous needle expansion. subcutaneous emphysema (crepitus). Williams for decreased breath sounds and decreased chest expansion on the affected side. Pleural effusion An abnormal fluid Heart failure. one at the space. venous puncture or central line insertion: iatrogenic return. Monitor Mr. blunt or penetrating Two chest tubes may blood in the pleural trauma be inserted. central line insertion. invasive pulmonary Anteriorly near the space that limits lung procedures. Assess also for an increased respiratory rate and worsening pain when he tries to take a deep breath. called hemopneumothorax. Tension second intercostal pneumothorax is air * Forceful coughing or rupture of a bleb in space (ICS). such as COPD and smoking. lung abscess. surgery. bronchoscopy apex of the lung at the expansion. Chest trauma. hypotension. and a shift in the heart's point of maximal impulse. Usually it's a apex and one at the combination of both base of the lung. Hemothorax An accumulation of Open chest procedures. cardiopulmonary resuscitation.
. air and blood. With a tension pneumothorax. a patient with pneumothorax may complain of pleuritic chest pain and exhibit anxiety and tachycardia. the patient may develop distended neck veins.The risks for pneumothorax include factors that compromise pulmonary function. or contamination or Posteriorly into the purulent material in injury of the pleural cavity fifth or sixth ICS the pleural space Prevention of cardiac tamponade after Bleeding associated with surgery The clinician may open-heart surgery insert anterior and Blood that could cause posterior chest tubes cardiac tamponade if attached to the same not removed from the drainage device using mediastinum a Y connector or to two separate drainage devices.
A range of reasons for chest tube placement
Where the tube is placed
Pneumothorax Air in the pleural * Trauma.
Size #12 to #26 French is adequate for a pneumothorax. is needed to drain accumulated fluid. and a suction-control chamber or regulator. a water-seal chamber. as the water seal evacuates air from the chest cavity. To regulate suction. Chest tube. rate. flexible. Let's look at each component. You can use the water-seal chamber to monitor your patient's intrapleural pressure. the air passes through the column and bubbles into the bottom of the water seal. such as from a pleural effusion.) He could die of cardiovascular collapse and pulseless electrical activity as the increased intrathoracic pressure prevents his heart from pumping. All CDUs incorporate three basic components: a collection chamber. connect the CDU's vacuum line tubing to wall suction and set the CDU suction to the ordered level.midclavicular line. Think of a cup of water with a straw in it. The pulmonologist determines that Mr. nonthrombogenic catheter of vinyl or silicone. if you try to draw air in. and then into the CDU's collection chamber (which holds up to 2. but a wider tube. Fluid drains into the chest tube. air bubbles out through the water. and a bent tube is appropriate for the mediastinum. Chest drainage unit. This acts as a one-way valve so air can drain from the chest cavity but can't return to the patient. from #28 to #40 French. which rests in the pleural space.
A straight chest tube may be used to drain the pleural cavity. The water level fluctuates as the pressure changes.
. Williams needs a chest tube and CDU to restore normal intrapleural pressure. Most units also have a port for obtaining samples. In the same way. and characteristics of the drainage. Water-seal chamber. Looking at chest tubes and drainage systems A chest tube drains into a CDU or Heimlich valve. If you blow into the straw.000 ml). depending on the nature of the patient's problem. The decision to insert a chest tube is based on the amount of lung collapse. The tube's proximal end. (See How a Chest Drainage Unit Works . has several eyelets--small holes--to drain air or fluid and to prevent catheter occlusion. The distal end connects to the CDU. The diameter selected depends on the patient's condition. Water-filled or dry suction removes chest drainage and maintains the flow. A sterile. you get water.)
How a chest drainage unit works
All chest drainage units (CDUs) incorporate three basic components: Collection chamber. a chest tube measures about 20 inches (50 cm) long and has a diameter anywhere from #12 to #40 French. through a 6-foot (180-cm) connecting tube. Here you can assess the amount. Suction-control regulator.
uncomplicated pneumothorax with little or no drainage that doesn't require suction.Water-suction system
A water-filled suction chamber regulates suction by the amount of water in the chamber. suction decreases. The regulator on a dry-suction CDU is preset to -20 cm H2O. this device is essentially a water-seal chamber connected to the chest tube. his chest tube may be connected to a Heimlich valve instead of a traditional CDU.
. but the level can range from -10 to -40 cm H2O. When you set up the CDU. so regularly assess and refill the chamber to the ordered level. usually -20 cm H2O for a simple pneumothorax. If the patient has a small. Less expensive and easier to assemble and use. You'd need to adjust the regulator to change the level. Heimlich valve. fill the chamber to the appropriate level. Dry-suction system
Dry suction provides more consistent flow because the regulator automatically adjusts suction to changes in the patient's pleural pressure or fluctuations in wall suction pressure. As the water evaporates.
Williams' problem. Poor oxygenation can affect cardiac rhythm. Administer 2 to 4 liters/minute of oxygen via nasal cannula and monitor his pulse oximetry. Each model provides systematic instructions for setup and operation. Prepare the patient and the equipment When the clinician decides to insert a chest tube. gloves. do the following: Gather the equipment. and central cyanosis. so attach Mr. Most hospitals provide preassembled chest tube insertion trays with all the necessary items for the sterile field. If your patient has COPD. Initially. you have plenty to do.
. so keep the head of Mr. remember that an Spo2 of less than 90% usually correlates with a Po2 of 60 mm Hg. and acidosis. but if Mr.A Heimlich valve may be included in the chest tube insertion kit. The chest X-ray is the definitive diagnostic tool. you'll note hypoxemia. orientation. Place the CDU upright and at least 1 foot (30 cm) below the patient's chest level. Promoting chest expansion and intercostal muscle use eases breathing. Consult the manufacturer's instructions and follow hospital policy. Use the attached stand to place it on the floor or hang it on the bed's footboard. Prepare the CDU . sterile masks. he may have tachycardia from activation of the sympathetic nervous system that occurs with respiratory distress and inadequate oxygenation. restlessness. Watch for changes in his level of consciousness. Williams to a cardiac monitor. hypercapnia. Williams' bed at 30 degrees or higher. Protect your patient before insertion Now that the pulmonologist has confirmed Mr. including goggles and impervious sterile gowns. You also may see new-onset premature atrial or ventricular beats. and responsiveness. Besides the chest tube and CDU. At its distal end are 'flutter' leaflets that allow air to exit but not reenter the pleural space. monitor his respirations as you increase his oxygen: A higher Po2 level could decrease his respiratory drive. The clinician will probably order a chest X-ray and arterial blood gases (ABGs) to confirm pneumothorax. Be alert to anxiety. local anesthetic (usually 1% lidocaine). Assemble the suction source and connecting tubing. Closely monitor his vital signs and breath sounds and make sure he has intravenous access. Initially. the ABGs will reveal respiratory alkalosis caused by tachypnea. which can be early signs of hypoxemia. showing black areas where the lung is collapsed. Williams' respiratory status worsens. and personal protective gear. and drapes. along with warnings and precautions. you'll need povidoneiodine solution. Adjust the FIo2 to a target Spo2 of 94%.
Adjust the CDU suction to the level the clinician specifies. Make sure a signed consent form for the procedure is in his chart. chest excursion. Secure the chest tube to the connecting tube using tape or nylon bands. such as
. Perform a baseline cardiopulmonary assessment. Assess his vital signs. Also check any pertinent lab work. With his finger. according to hospital policy. usually 20 cm H2O. add sterile water to the water-seal chamber according to the manufacturer's instructions. Wall suction must have at least 80 mm Hg of vacuum to operate the system efficiently at 20 cm H2O. attach the patientconnecting tube to the drainage device.To prepare the CDU. he'll make a skin incision about 1 inch (2. such as ABGs and coagulation profile. Avoid dependent loops in the drainage tubing. breath sounds. Spo2. Place him in high Fowler's or semi-Fowler's position. he'll create a tract for the chest tube. Assisting with chest tube insertion The clinician will drape and prepare the insertion site with povidone-iodine solution. Williams' response to treatment. and cardiac rhythm. This will help you evaluate Mr. Once the tube is inserted but before you start suction.
Keep the head of your patient's bed elevated to 30 degrees or higher. Attach the wall suction line to the suction connector on top of the CDU. Explain the procedure to the patient. If multiple drains. Then he'll clamp the tube with hemostats. Place the CDU upright and at least 1 foot (30 cm) below his chest level. so administer pain medication or sedation as ordered. He'll probably be anxious and in pain. Tell him to remain as still as possible and to breathe normally during the procedure. Answer his questions and offer reassurance. After injecting a local anesthetic. Set the wall suction pressure to 80 mm Hg or greater until the display on the suction-control chamber confirms adequate suction. and advance it so that the distal eyelet is 2 inches (5 cm) inside the pleura.5 cm) long. level of consciousness. skin color. then insert a hemostat through it to enter the pleural space. insert it.
he'll wrap petrolatum gauze around the site. Assess your patient and prevent complications The less time a patient has a chest tube in place. Assess his cardiopulmonary status at least every 4 hours. Mr. signs of
. Williams will need a portable chest X-ray to verify proper tube placement. After your patient's chest tube is functioning properly.
Never let the drainage tube dangle. However.
Dress the insertion site by placing one sterile split-drain sponge over the top of the chest tube and one underneath. Document the following: your cardiopulmonary assessments before and after the procedure chest tube size and insertion site the insertion date and time who inserted the tube whether drainage was present and the amount. Dress the site with sterile split-drain sponges covered by sterile 4*4 gauze pads and secure the gauze with 2-inch (5-cm) tape. color. are connected to a single suction source. such as infection. so these products shouldn't be used routinely. the clinician will suture it in place. continued use of petrolatum gauze or ointments can macerate the skin. the smaller his chance for complications. Here's what you can do to protect him while he's in your unit: Assessments. Then place sterile 4x4 gauze pads over the drain sponges and secure with 2-inch (5-cm) tape. As part of your routine care.two mediastinal tubes. and type your patient's tolerance to the procedure medications he received during the procedure results of his postinsertion chest X-ray your patient and family teaching. you'll need more vacuum. Examine the chest tube insertion site every 8 hours for inflammation. If he notes an air leak. make sure it's coiled on the bed.
However. Promoting drainage and lung expansion. don't 'strip' the chest tube. Change the dressing on the insertion site as ordered or according to your facility's policy. not fluid. Pay close attention to tidaling. try milking the tube: Starting at the proximal end.
Pinpointing subcutaneous emphysema
A collection of air or gas under the skin.
To milk the tube. In this case. a lack of drainage may indicate a clot obstructing the tube. If he has a hemothorax. But if he has a hemothorax. or empyema and he's been supine for a while. stripping the tube causes a dangerous increase in intrathoracic pressure and doesn't lead to any significant increase in output. pleural effusion. and negative pressure. start at the proximal end and gently squeeze and release along its length betweenyour fingers. Notify the clinician of excessive output. you probably won't change it until the third day after insertion. expect little if any output because the tube is draining air.
. However. Encourage your patient to cough and breathe deeply. air may move from the insertion site into the neck. chest. gently squeeze and release it between your fingers along the length of the tubing. If he's well enough to walk in the hall. ) Get daily chest X-rays as ordered to check for lung reexpansion. Teach him how to splint the insertion site and make sure you administer pain medications as needed. which means squeezing the length of the tube without releasing it. ask the clinician if you can interrupt suction and encourage him to ambulate as desired. Monitoring output. this is old drainage coming out of the pleural space. so don't be alarmed if you note a sudden gush of output the first time he sits up. if the tube is improperly placed or has an air leak. and face and cause pain. (See Pinpointing Subcutaneous Emphysema. or subcutaneous emphysema. When your patient has a pneumothorax. If it's dry and you don't see evidence of infection. bubbling. Once a common practice. usually every 2 to 4 hours. notify the clinician. If that occurs. The patient's position influences drainage.
Encourage him to change position at least every 2 hours. Small amounts of subcutaneous emphysema around the tube insertion site are commonly absorbed. He can lie on the side with the chest tube if he can keep the tubing free of kinks. Coil the tube on the bed if you notice it dangling. subcutaneous emphysema--crepitus--is usually painless and feels spongy on palpation.infection. Monitor and record the amount and characteristics of the chest tube drainage as ordered or according to your unit's policy. Monitoring the water-seal chamber.
you may not see any fluctuations. such as a loose connection or a nonocclusive dressing. If you've clamped along the tube's entire length and still can't find the source. Using rubber-tipped hemostats. If bubbling in the waterseal chamber is continuous. Bubbling will stop when you clamp between the air leak and the water seal.* Tidaling indicates fluctuations in the water-seal chamber's fluid level that correspond with respiration. a water level 2 cm above the water-seal chamber is a sign that the pneumothorax is resolving. Spotting signs of improvement As your patient's pneumothorax begins to resolve. Removing his chest tube is appropriate when a chest X-ray shows that his lungs have reexpanded. watch the pattern. Before deciding to remove the tube. decreased pleural pressure decreases the water level. Closely observe for deterioration in his respiratory status while his chest tube is on water seal: His lung may not remain inflated or he could develop another pneumothorax. On expiration. You may notice a small amount of bubbling right after chest tube insertion or when the patient exhales or coughs. try clamping the tubing momentarily at various points along its length. the water level decreases during inspiration and increases during expiration. suspect a leak in the system. To do this. Explain the procedure to the patient and premedicate him for pain at least 15 minutes
. This should resolve as his lung reexpands. You won't see them with a mediastinal chest tube either. On inspiration. If the patient's pleural space is leaking air. he'll have less dyspnea on exertion and less chest pain on inspiration (unless the tube itself causes discomfort). Tidaling fluctuations reverse when the patient's breathing is assisted by positivepressure mechanical ventilation. To locate the source. When bubbling is present. the CDU might be cracked and need to be replaced. Don't clamp the chest tube before discontinuing suction because it could cause your patient's lung to collapse. caused most commonly by poor tubing connections. Shallow breathing causes less fluctuation and labored breathing causes more. * Negative pressure in the water-seal column indicates negative pressure in the pleural space--the goal of chest tube therapy. If your patient's lung fully expands or the tubing becomes obstructed. start at the proximal end and work your way down. * Bubbling in the bottom of the water-seal chamber indicates an air leak. detach the wall suction tubing from the CDU. usually corresponding to his respirations. the clinician may order it placed on 'water seal. If you're having trouble finding an air leak. Because the respiratory pressures are reversed. gather the necessary supplies. generally 24 hours before the anticipated removal. To assist with chest tube removal. including personal protective equipment because blood splattering is likely. breathing doesn't affect a tube that's outside the pleural space. you'll notice intermittent bubbling. assess from the insertion site to the CDU. his respiratory status has returned to normal. increased negative pressure in the pleural cavity increases the water level. Normally.' This simply means discontinuing suction. and the drainage over the previous 24 hours is less than 100 ml.
Quickly connect the new CDU. you've protected your patient and helped him recover from a serious pulmonary problem. Pa. June 2001. Philadelphia. By learning about their components and the techniques needed to use them. Hudson. and Carelson.5 cm) of sterile 0.org/pneumo..) Hospitals. dress the site with a sterile occlusive dressing and dispose of the tube and CDU in the appropriate receptacle.pneumothorax. April 1999. Lazzara. Resume suction and assess the CDU chambers for normal function.' Nursing99.H..: 'Taking the Tension Out of Traumatic Pneumothoraxes.. D. Deborah Lazzara is a cardiology clinical nurse specialist in the cardiac care center at the University of Chicago (Ill. unclamp the tube. Mastering techniques Using chest tubes and CDUs is a complex and critical nursing function. Once the chest tube is removed. Observe your patient for any changes in respiratory status and make sure he has a portable chest X-ray to ensure that his lung has expanded.9% sodium chloride solution or water in a sterile container. eds: AACN Procedure Manual for Critical Care. If you hear air leaking from the site.. 31(6):5863.' Nursing2001. Saunders Co.B. 29(4):41-46. 1999. C.nsf
. D. Q: What if the chest tube becomes disconnected from the chest drainage unit (CDU) or the CDU breaks? A: Submerge the chest tube's distal end in 1 inch (2.
Frequently asked questions about chest drainage units
Q: What if the chest tube becomes dislodged? A: Immediately cover the site with a dry sterile dressing and call the clinician. and secure all connections according to your unit's policy. Securing the tube connections and properly positioning the CDU help prevent disconnection or breakage. P. Q: When should I change the CDU? A: Change it if it breaks or it's full: Prepare the new CDU according to the manufacturer's instructions. This will create a liquid seal until you prepare and attach a new CDU.org http://www. N. Atrium Medical Corp.. Remove the current CDU from suction. Tell him that he'll need to take a deep breath and hold it when instructed. Lynn-McHale. tape the dressing on only two or three sides to allow air to escape and prevent a tension pneumothorax. 4th edition.. 2001.. K. and Reid. warn him to expect some pain as the tube is removed.: 'Respiratory Distress: Loosening the Grip. W. Closely monitor the patient and prepare for insertion of a new chest tube. clamp the chest tube with a rubber-tipped hemostat.
SELECTED REFERENCES A Personal Guide to Managing Dry Suction Chest Drainage. Photos by Gary Donnelly SELECTED WEB SITES Pneumothorax.beforehand. Blank-Reid. and disconnect the connecting tube from the CDU.
Yale University School of Medicine.yale. 2002.edu/intmed/cardio/imaging/cases/pneumothorax _tension/ Last accessed on May 2.med.
. cardiothoracic imaging: tension pneumothorax http://info.