Name: Jake Yvan G.

Dizon

Course and Year: BSN III

Oxygenation

1. Chest Tube Therapy Care

 Assisting in Insertion

 Monitoring Patency

 Monitoring and Measuring Output

Introduction

A chest tube, also known as a thoracic catheter, is a sterile tube with a number of

drainage holes that is inserted into the pleural space. The pleural space is the space

between the parietal and visceral pleura, and is also known as the pleural cavity. A

patient may require a chest drainage system any time the negative pressure in the

pleural cavity is disrupted, resulting in respiratory distress. Negative pressure is

disrupted when air, or fluid and air, enters the pleural space and separates the

visceral pleura from the parietal pleura, preventing the lung from collapsing and

compressing at the end of exhalation. A small amount of fluid or air may be absorbed

by the body without a chest tube. A large amount of fluid or air cannot be absorbed

by the body and will require a drainage system (Bauman & Handley, 2011; Perry et

al., 2014).
Care and management of the thoracostomy tubes (chest tubes) are subject to

the direction and practice pattern of the responsible physician. It is, therefore,

difficult to make a “one size fits all” set of instructions about the specific

management recommendations for all chest tubes. It is recommended to

discuss specific expectations for management with the patient’s attending

physician. Facility specific Clinical Practice Guidelines (CPGs) may provide

further guidance for your practice. This activity describes the placement and

management of surgically placed thoracostomy tubes. The thorax houses all

organs bound by the thoracic vertebrae and the ribs, and the diaphragm

separates the chest from the abdomen. The pleural space encompasses both a

left and a right cavity that is separated by the mediastinum. Within each of the

two cavities are the corresponding lungs (2 lobes on the left and 3 lobes on the

right). Inspiration is accomplished by negative pressure created by the

diaphragm. As pressure within the lungs decreases, air rushes in through the

airway to maintain equilibrium. Expiration is normally a passive process driven

by the natural recoil of the chest wall. The parietal pleura lines the inner layer

of the chest wall and the visceral pleura lines the lungs. About 10 to 20 mL of

pleural fluid provides lubrication for continuous respiration. A pneumothorax

occurs when air is introduced into the pleural space. As more air is introduced,

the air within the pleural space will act as a space-occupying lesion preventing

reinflation of the lung inflation. As pressure continues to build, the lung and

mediastinal structures will start to shift to the contralateral side. A tension

pneumothorax develops when the pressure causes compression of the inferior

vena cava (IVC) inhibiting venous return.

Indications and Contraindications

Indications for Chest Tubes There are various reasons for excess air and/or

fluid in the pleural space. Specific common indications for chest tubes include:

Pneumothorax (open and closed)., Tension pneumothorax., Hemothorax.

Hemopneumothorax. Pleural effusions. Chylothorax (a type of pleural effusion

that results from lymphatic fluid (chyle) accumulating in the pleural cavity).

Penetrating chest trauma. Pleural empyema (collection of purulent material in

the lungs). (Durai, Hoque, & Davies, 2010)

Contraindications to Chest Tube Insertion There are no definite

contraindications to a chest tube especially when a patient is experiencing

respiratory distress. If multiple adhesions, giant blebs, or coagulopathies are

present and the patient is relatively stable, the benefit of chest tube therapy

can be carefully weighed against the higher risks of complications for these

patients (Doelken, 2010).

 Assisting in Insertion
Placement of the appropriately sized chest tube is performed on the affected

side. The typical landmark for placement is the 4th or 5th intercostal space

(nipple line for males, inframammary fold for females) at the anterior axillary

line. The space above the 5th intercostal space and below the base of the axilla
that is bordered posteriorly by the trapezius and anteriorly by the pectoralis

muscle has recently been described as the "safe triangle." Tubes are

positioned anteriorly for pneumothoraces and posteriorly for fluid processes

Often a #10 scalpel is used to make the initial incision through the skin. Some

providers teach to cut directly on top of the 5th rib to use it as a "cutting

board" to prevent injury to deeper structures. Subsequent blunt dissection is

carried through the subcutaneous fat and superior to the rib to avoid the

neurovascular bundle that travels along the inferior rib margin. Blunt entry

through the pleura is then made with either a Peon or Kelly clamp with

gradually increasing steady pressure to prevent uncontrolled entry into the

chest damaging underlying organs. Once the pleural space has been entered,

the instrument is opened widely to bluntly dissect the intercostal muscles and

pleural off the rib edge and create a tract for the chest tube. This is the most

painful part of the procedure. A "rush of air" or "rush of blood" is typically

noted after entry and the initial spread. A finger sweep is performed to confirm

entry into the thorax and break-up any immediate adhesions that would

interfere with tube placement. The length of the tube to enter the chest is

measured from the thoracostomy site to the apex of the thoracic cavity. The

tube is then inserted along the chest wall to the prespecified depth, ensuring

that the sentinel port (the last hole on the tube which divides the radioopaque

line) is completely within the chest wall.

 Monitoring Patency
A chest tube drainage system is a sterile, disposable system that consists of a

compartment system that has a one-way valve, with one or multiple chambers,

to remove air or fluid and prevent return of the air or fluid back into the patient

(see Figures 10.5 and 10.6). The traditional chest drainage system typically has

three chambers (Bauman & Handley, 2011; Rajan, 2013). Always review what

type of system is used in your agency, and follow the agency’s and the

manufacturer’s directions for setup, monitoring, and use. In general, a

traditional chest tube drainage system will have these three chambers:

Collection chamber: The chest tube connects directly to the collection chamber,

which collects drainage from the pleural cavity. The chamber is calibrated to

measure the drainage. The outer surface of the chamber has a “write-on”

surface to document the date, time, and amount of fluid. This chamber is

typically on the far right side of the system (Teleflex Medical Incorporated,

2009).

Water-seal chamber: This chamber has a one-way valve that allows air to exit

the pleural cavity during exhalation but does not allow it to re-enter during

inhalation due to the pressure in the chamber. The water-seal chamber must

be filled with sterile water and maintained at the 2 cm mark to ensure proper

operation, and should be checked regularly. Fill with additional sterile water as

required. The water in the water-seal chamber should rise with inhalation and

fall with exhalation (this is called tidaling), which demonstrates that the chest

tube is patent. Continuous bubbling may indicate an air leak, and newer
systems have a measurement system for leaks — the higher the number, the

greater the air leak. The water-seal chamber can also monitor intrathoracic

pressure (Teleflex Medical Incorporated, 2009).

Wet or dry suction control chamber: Not all patients require suction. If a

patient is ordered suction, a wet suction system is typically controlled by the

level of water in the suction control chamber and is typically set at -20 cm on

the suction control chamber for adults. If there is less water, there is less

suction. The amount of suction may vary depending on the patient and is

controlled by the chest drainage system, not the suction source. Monitor the

fluid level to ensure there is gentle bubbling in the chamber. A dry suction

system uses a self-controlled regulator that adjusts the amount of suction and

responds to air leaks to deliver consistent suction for the patient. If suction is

discontinued, the suction port on the chest drainage system must remain

unobstructed and open to air to allow air to exit and minimize the development

of a tension pneumothorax (Teleflex Medical Incorporated, 2009).

 Monitoring and Measuring Outputs

Fluid Collection In a traditional water seal operating system, fluids drain

from the patient directly into a large collection chamber via a 6-foot patient

tube. As drainage fluids collect in this chamber, the nurse records the

amount of fluid that collects on a specified schedule. Water Seal The second

chamber functions as an underwater seal (UWS), which is a one way valve

that allows air to exit the chest and prevents air returning to the patient. Air
bubbling through the water seal chamber intermittently is normal when the

patient coughs or exhales, but if there is continuous air bubbling in the

chamber, it can indicate a leak that should be evaluated. The water seal

chamber is connected in series to the collection chamber, and allows air to

pass down through a narrow channel and bubble out through the bottom of

the water seal. Since air cannot return to the patient, an UWS is considered

one of the safest ways of protecting the patient, in addition to being a very

useful diagnostic tool. The UWS column is calibrated and acts as a water

manometer for measuring intrathoracic pressure. As changes in

intrathoracic pressure occur, fluctuation in the water level can be observed

in this calibrated column. Such fluctuations provide the clinician an

indication of how the patient is progressing. Suction Control The use of

suction helps overcome an air leak by improving the rate of air and fluid

flow out of the patient. The simplest and most cost effective means of

controlling suction is by using a suction control chamber, which is an

atmospherically vented section containing water and is connected in series

with the water seal chamber and collection chamber. By adding or removing

water in the suction control chamber, the chest drain effectively controls the

amount of suction imposed on the patient. The lower the water content, the

lower the imposed suction. The higher the water level, the higher the

imposed suction. Types of Chest Drainage Units In addition to the 3

chamber drainage device previously discussed, there are now newer

drainage devices available that eliminate the UWS by using a mechanical

 check-valve, or a mechanical regulator to regulate the suction pressure.

Systems which employ a mechanical check-valve and a mechanical

regulator are known as dry systems, whereas systems that retain a UWS

but use a mechanical regulator are called wet-dry systems. Systems which

use a water seal and water column regulator are called wet systems .

2. Postural Drainage

Introduction

Postural drainage allows the force of gravity to assist in the removal of

bronchial secretions. The secretions drain from the affected bronchioles into

the bronchi and trachea and are removed by coughing or suctioning. Postural

drainage is used to prevent or relieve bronchial obstruction caused by

accumulation of secretions. Because the patient usually sits in an upright

position, secretions are likely to accumulate in the lower parts of the lungs.

Several other positions are used so that the force of gravity helps move

secretions from the smaller bronchial airways to the main bronchi and trachea.

Each position contributes to effective drainage of a different lobe of the lungs;

lower and middle lobe bronchi drain more effectively when the head is down,

whereas the upper lobe bronchi drain more effectively when the head is up.

The secretions then are removed by coughing. The nurse instructs the patient

to inhale bronchodilators and mucolytic agents, if prescribed, before postural

drainage, because these medications improve drainage of the bronchial tree.

 Assisting
he nurse should keep in mind the medical diagnosis, the lung lobes and

segments involved, the cardiac status, and any structural deformities of the

chest wall and spine. Auscultation of the chest before and after the procedure

is used to identify the areas that need drainage and assess the effectiveness of

treat ment. The nurse educates family members who will assist the patient at

home to evaluate breath sounds before and after treatment. The nurse explores

strategies that will enable the patient to assume the indicated positions at

home. This may require the creative use of objects readily available at home,

such as pillows, cushions, or cardboard boxes. Postural drainage is usually

performed two to four times daily, before meals (to prevent nausea, vomiting,

and aspira tion) and at bedtime. Prescribed bronchodilators, water, or saline

may be nebulized and inhaled before postural drainage to dilate the

bronchioles, reduce bronchospasm, decrease the thickness of mucus and

sputum, and combat edema of the bronchial walls. The recommended

sequence starts with positions to drain the lower lobes, followed by positions to

drain the upper lobes. The nurse makes the patient as comfortable as possible

in each position and provides an emesis basin, sputum cup. and paper tissues.

The nurse instructs the patient to remain in each position for 10 to 15 minutes

and to breathe in slowly through the nose and out slowly through pursed lips

to help keep the airways open so that secretions can drain. If a position cannot

be tolerated, the nurse helps the patient assume a modified position. When the

patient changes position, the nurse explains how to cough and remove
secretions.If the patient cannot cough, the nurse may need to suction the

secretions mechanically. It also may be necessary to use chest percussion and

vibration or a high-frequency chest wall oscillation (HFCWO) vest to loosen

bronchial secretions and mucus plugs that adhere to the bronchioles and

bronchi and to propel sputum in the direction of gravity drainage (see later

discussion). If suctioning is required at home, the nurse instructs caregivers in

safe suctioning technique and care of the suctioning equipment.

 Monitoring and Measuring Outputs

After the procedure, the nurse or family caregivers note the amount, color,

viscosity, and character of the expelled sputum. The nurse evaluates the

patient's skin color and Thick secretions that are difficult to cough up may be

loosened by tapping (percussing) and vibration the chest or through the use of

an HFCWO vest. Chest percussion and vibration help dislodge mucus adhering

to the bronchioles and bronchi. A scheduled program of coughing and clearing

sputum, together with hydration, reduces the amount of sputum in most

patients.

3. Thoracentesis

Introduction

Thoracentesis is a procedure that is performed to remove fluid from the

thoracic cavity for both diagnostic and/or therapeutic purposes. A potential

space exists in the left and right side of the chest cavity between the inner

chest wall and lung. A trace amount of fluid is found in this space as part of
healthy lymphatic drainage, providing lubrication between the lung

parenchyma and musculoskeletal structures of the rib-cage during expansion

(inhalation) and recoil (exhale).Excess fluid is pathological. The volume of

excessive fluid, the rate of accumulation, the cellular content of the fluid, and

the chemical composition of the fluid are all used to guide the management

and the differential diagnosis of the underlying etiology.Thoracentesis is done

in either a supine or sitting position depending on patient comfort, underlying

condition, and the clinical indication

 Assissting in Insertion

The patient should have a history and physical examination obtained prior to

initiating the procedure. Consent should be obtained. The side and site should

be marked in compliance with the invasive procedures policies of the local

facility. Gather all required equipment before starting the procedure. Place the

patient on a pulse oximeter. Blood pressure and heart rate should be

monitored throughout the procedure. The preferred site for the procedure is on

the affected side in either the midaxillary line if the procedure is being

performed in the supine position or the posterior midscapular line if the

procedure is being performed in the upright or seated position. Bedside

ultrasound should be used to identify an appropriate location for the

procedure. Placing the patient in the upright seated position and using bedside

ultrasound can aid in identifying fluid pockets in patients with lower fluid

volumes.
Prep and drape the patient in a sterile fashion. Cleanse the skin with an

antiseptic solution. Administer local anesthesia to the skin (25 gauge needle to

make a wheal at the surface of the skin) and soft tissue. After the local

anesthetic is administered use a larger 20 or 22 gauge needle to infiltrate the

tissue around the rib, marching the needle tip just above the rib margin. Insert

the needle, or catheter attached to a syringe, or the prepackaged catheter

directly perpendicular to the skin. If using a catheter kit, it may be helpful to

make a small nick in the skin using an 11-blade scalpel to be able to advance

the catheter through the skin and soft tissue smoothly. Apply negative

pressure to the syringe during needle or catheter insertion until a loss of

resistance is felt and a steady flow of fluid is obtained. This is paramount to

detect unwanted entry into a vessel or other structure. Advance the catheter

over the needle into the thoracic cavity. After you collect sufficient fluid in the

syringe for fluid analysis, either remove the needle (if performing a diagnostic

tap) or connect the collecting tubing to either the needle or the catheter's

stopcock. Drain larger volumes of fluid into a plastic drainage bag using gravity

feed or serial syringe draw with a three-way stop-cock. After you have drained

the desired amount of fluid, remove the catheter and hold pressure to stop any

bleeding from the insertion site.

 Monitoring Patency

Confirm site by counting the ribs based on chest x-ray and percussing out

the fluid level. Mark the top of the dullness by washable ink mark or
indenting the skin. Anesthetize the skin over the insertion site with

1% lidocaine using the 5 cc syringe with 25 or 27-gauge needle. Next

anesthetize the superior surface of the rib and the pleura. The needle is

inserted over the top of rib (superior margin) to avoid the

intercostals nerves and blood vessels that run on the underside of the rib

(the intercostals nerve and the blood supply are located near the inferior

margin). As the needle is inserted, aspirate back on the syringe to check for

pleural fluid. Once fluid returns, note the depth of the needle and mark it

with a hemostat. This gives an approximate depth for insertion of the

angiocatheter or thoracentesis needle. Remove the anesthetizing needle. Use

a hemostat to measure the same depth on the thoracentesis needle or

angiocath as the first needle. While exerting steady pressure on the patient’s

back with the nondominant hand, use a hemostat to measure the 15- to 18-

gauge thoracentesis needle to the same depth as the first needle. While

exerting steady pressure on the patient’s back with the nondominant hand,

insert the needle through the anesthetized area with the thoracentesis

needle. Advance the needle until it encounters the superior aspect of the rib.

Continue advancing the needle over the top of the rib and through the

pleura, maintaining constant gentle suction on the syringe. Make sure you

march over the top of the rib to avoid the neurovascular bundle that runs

below the rib. Attach the three way stopcock and tubing, and aspirate the

amount needed. Turn the stopcock and evacuate the fluid through the

tubing.
  Monitoring and Measuring Outputs
the sizes of the chest cavity can be quantified to estimate the fluid-filled

volumes and can be divided into three levels of small, moderate, and large

effusion sizes as follows:

small effusion size: approximately 20% of the fluid-

filled volume corresponding to < 500 mL;

moderate effusion size: approximately 20%–50% of the

fluid-filled volume, corresponding to 500–1,000 mL;

large effusion size: approximately > 50% of the fluid-

filled volume, corresponding to > 1,000 mL.