Managing complications

The primary goal of closed-chest drainage is to optimize ventilation and gas exchange by
draining the air or fluid from the pleural cavity. When the closed-chest drainage system is not
working properly, patients may show early signs of altered oxygenation, such as restlessness,
hyperventilation, and tachycardia. They may also report increased pain on the affected side. At
this point, it is essential to troubleshoot the equipment, quickly identify the problem, and provide
effective interventions.

Start by checking the patency of the chest tube and

looking for loose connections between the patient and
drainage system. Determine if the chest tube is clamped,
kinked, or occluded by following the length of the entire
tubing. If the tubing has disconnected from the drainage
unit, instruct the patient to exhale and cough. This rids
the pleural space of as much air as possible. Submerge
the end of the chest tube in 1 inch of sterile water until
you can cleanse the tips of the tubing and reconnect them
quickly. Tighten any loose connections and tape them
securely or use a locking plastic tie.

Next,
determine
whether or
not there is
an air leak.
If you see
excessive and continuous bubbling in the water-seal
chamber or the air-leak meter, especially if the
system is connected to a suction source, look for a
leak in the drainage system. Using rubber-tipped
clamps, try to locate the leak by clamping the tube
momentarily at various points along its length.
Begin at the tube’s proximal end, near the dressing.
Look at the water-seal/air-leak meter chamber. If
the bubbling stops, the air leak is at the chest-tube
insertion site or inside the chest. Examine the
chest-tube insertion site quickly to see if the
dressing is loose or the tube is dislodged. If the
dressing is loose, air may be entering around the
tube as the patient inhales. Palpate around the chest tube site and listen for a crackling sound
indicating subcutaneous emphysema, which can result from a poor seal at the chest-tube
insertion site. Ask the patient to cough to rid the pleural space of as much air as possible, apply
an occlusive dressing or reinforce the dressing if it is intact, and monitor the patient to see if
oxygenation improves. The sound of hissing air, a large amount of new drainage at the insertion
site, or visibility of the drainage holes at the proximal end of the chest tube suggest that the
tube has dislodged. Notify the physician immediately and prepare for another chest-tube
insertion. Have emergency equipment (oxygen, resuscitation cart, chest- tube insertion kit)
nearby including a flutter (Heimlich) valve or a large-gauge needle for an emergency
thoracostomy.

If the bubbling continues after you clamp the tube momentarily near the insertion site, place
another clamp a little further down the tube about 20 to 30 cm (8 to 12 inches) toward the
drainage system and remove the first clamp. Each time you clamp at the more distal location,
check the water-seal/air-leak meter chamber. When you place a clamp between the source of
the air leak and the water-seal/air-leak meter, the bubbling will stop. That indicates a leak in the
tubing distal to the clamp. Replace the tubing or secure the connection and release the clamp. If
you clamp along the tube’s entire length and the bubbling doesn’t stop, the drainage unit might
be cracked and you will have to replace it.

When a chest tube disconnects from

a closed-chest drainage system,
quickly clamp the tube as long as
there is no bubbling in the water-
seal/air-leak meter. Use a
disinfectant to clean the end of the
chest tube and the reattachment site
and re-establish the connection. If
there is bubbling in the water-
seal/air-leak meter and your
assessment has determined that
there is an air leak from the chest,
do not clamp the chest tube as this
will cause air to accumulate in the
pleural cavity with no means of
escape. This can rapidly lead to a
collapsed lung and tension
pneumothorax, a potentially life-
threatening event. Instead of
clamping the tube, submerge the distal end of the tube in
1 inch of sterile water to create a temporary water seal
while you prepare the system for reattachment or
replacement.

If the drainage system has tipped over or is disrupted or

damaged, or the drainage collection chamber is filled to
its maximum capacity, replace it. Prepare a new closed-
chest drainage system so that you can attach it as quickly
as possible. Clamp the chest tube but only for the brief
time it takes to re-establish drainage.

If a chest tube is completely dislodged, cover the site

immediately with a sterile gauze dressing. If you can hear
air leaking out of the site, make sure the dressing is not
occlusive. If it is, it can cause a tension pneumothorax.
Stay with the patient and monitor his vital signs while
another staff member notifies the physician. Observe for signs of a tension pneumothorax,
hypotension, distended jugular veins, absent or decreased breath sounds, tracheal shift,
hypoxemia, weak and rapid pulse, dyspnea, tachypnea, diaphoresis, and chest pain. Make sure
the equipment for chest-tube insertion and emergency equipment are nearby.

When a patient has a recurrent pneumothorax, the

physician may perform pleurodesis, a procedure that
involves instilling a chemical agent, such as talc, into the
pleural space. The subsequent inflammatory response
creates scar tissue and adhesion between the pleural
layers and reduces the risk of recurrent pneumothorax.
However, it may also make subsequent surgery more
difficult. For this procedure, the physician will instill the
chemical agent or talc slurry into the chest tube and allow
it to flow into the pleural cavity. The chest tube must
remain clamped for a period of time to allow the
chemicals to work. Closely monitor the patient during this
time to detect any changes that could indicate a tension
pneumothorax. If you see them, notify the physician
immediately and unclamp the tubing.

MECHANISM:

In normal situations, the pressure between the pleura of the lungs is below atmospheric
pressure.

When air or fluid enters the intra pleural space, the pressure is altered, and this can cause
collapse of a portion of the lung

Even with adequate oxygenation and open airway, a patient with a collapsed portion of the lung
will not have adequate oxygen= carbon dioxide exchange

The only treatment for this altered condition is to restore the negative pressure to the
intrapleural space. This is accomplished through the use of chest tube.