Chest Tubes

Reason for Use Ashley Hawthorne

To Release Air, Blood, Pus, Lymph Fluid from Intrapleural Space

Connective Autoimmune Asbestos

Cancer Infection Pancreatitis
Tissue Disease Disease Exposure

Collagen Vascular Postoperative

Certain Drugs Diseases Pneumothorax Hemothorax Effusions Chest Surgery /
•Pleural Effusion Trauma

Chest Tube Locations

High
• 2nd - 3rd Intercostal
Space
• Removal of Air
• Very Little Drainage
into Collection
Chamber

Mediastinal
•Just Below the Sternum
•Drains Blood or Fluid
•Prevents Accumulation
Around the Heard
•Common After Open-
Heart

Low
•5th - 6th Intercostal
Space
•Drain Fluid in the
Intrapleural Space
•Drain Blood and Fluid
•Used After Open-Heart
and Chest Trauma
Chest Tube Safety Guidelines Ashley Hawthorne

• Get a Patient Baseline Rise and Fall of Fluid

o Vitals
• Should be Synchronous with Respirations. Fluid Rises
o Lung Sounds
with Inspiration and Falls with Expiration.
o Respiratory Status • If Patient is on a Mechanical Vetilator, Then Inspiration
• Observe the Water Seal for will Cause a Fall and Expiration will cause a rise in Fluid
o Intermittent Bubbling
o Rise and Fall of Fluid
• Sudden Stoppage of Chest Tube Activity May Notify the Provider if….
Indicate Blockage or Lung Expansion
• Sudden Decrease in the Amount of Chest Tube
o Immediate Attention and Correction Drainage
Indicated • Sudden Increase of >250mL / 1hr
• Note the Expected Amount of Drainage • Constant Bubbling in Water Seal
o Initially Q-1hr • Sudden Stoppage of Water-Seal Activity
o Then Q-4hrs
o At the End of Every Shift Mark Fluid Level
with Date/Time on the Side of the Drainage Collection Chamber
o Note Drainage Amount as Output
Bright Red
• Know the Expected Color of Drainage
o Bright Red Initially after Open-Chest Surgery Serous
o Serous Gradually after Postoperative Chest Tube
o Blood-Tinged indicates Malignancy, Drainage Blood Tinged
Pulmonary Infarction, Severe Inflammation
o Frank Blood Indicates Hemothorax
Colors Frank Blood
o Pus indicates Empyema
Pus
• Assess for Air Leaks
o If There is an Air Leak
▪ Determine if it is from the Patient or the Chest Tube System
o To Assess for Patient-Centered Air Leak
▪ Assess Respiratory Status
• This is where having a Baseline come to use
o Make sure that all tubing connections are tight
Chest Tube Drainage System Ashley Hawthorne
***All Systems Look a Little Different. Ask a Senior Nurse to Walk You Through Your Hospital’s System
Ashley Hawthorne
Types of Chest Tube Drainage Systems
System Function
Water-Seal System 2-Chamber
1-Way Valve for Chest
Drainage
Water Seal Prevents Reentry
of Air Into Lung
3-Chamber Adds a. Chamber
to Aid Evacuation of Chest
Drainage
Waterless System Also Provides chambers, But
No Water is Required to
Establish a Seal
Dry Suction System Also Provides 3 Chambers
Suction is Controlled by an
Integrated Valve
Advantage
Easy Setup and Use
Cost-Effective
Seal is Maintained by a 1-Way
Valve
Accidental Tipping of System
Does Not Compromise
Patient’s Condition
More Space Provided for
Drainage
Easy Setup
Quiet Operation
Can be Used When Higher
Levels of Suction are Required
Ashley Hawthorne
Disadvantage
System Must be Kept
Upright to Maintain Seal
Drainage Chamber May
Fill Up Quickly if Patient
Has Large Amun’s of
Drainage
Sterile Water Must Be
Added Several Times a Day
to Maitain suction and
Water Seal Because of
Evaporation
Water Must Be Added to
an Air-Leak Indicator if
Patient Requires
Evaluation of an Air Leak
Sterile Water Must Be
Added to System to
Provide a Water Seal
Insertion of Chest Tubes Ashley Hawthorne

Equipment
• Prescribed Chest Drainage System
• Suction Source and Set Up
o Wall Canister or Portable
o Water-Seal System
▪ Add Sterile Water / NS Solution to Cover Lower 2cm of the Water-Seal Chamber
▪ Pour Sterile Water / NS into the Suction-Control Chamber if Suction is to be Used
o Waterless System
▪ Add Vial of 30-40mL Sterile NaCl or Water for Diagnostic air-Leak Indicator
▪ 20mL Syringe
▪ 21-gauge needle
▪ Antiseptic Swab
o Dry Suction System
• Clean Gloves
• Sterile Gauze Sponges
• Local Anesthetic
o If Not an Emergent Procedure
• Chest Tube Tray (All Items are Sterile)
o Knife Handle + Blade o Size 3-0 Silk sutures o Suture Scissors
o Scalpel No 10 o Tray Liner – Sterile Field o Hand Towels (3)
o Chest Tube Clamp o Curved 8-inch Kelly o Sterile Gloves
o Small Sponge Forceps Clamps (2)
o Needle Holder o 4X4 Sponges (10)
• Dressings
o Petrolatum / Xeroform o Split Chest-Tube o Large Gauze Dressings (2)
Gauze Dressings o 4-in Tape
o Several 4X4
• Head Cover
• Face Mask / Shield
• Sterile Gloves
• 2 Rubber Tipped Hemostasis
o For Each Chest Tube
• 2.5cm Waterproof Adhesive Tape / Plastic Zip Ties
• Stethoscope • Sphygmomanometer • Pulse Oximeter
 Process of Inserting a Chest Tube
Pre-Insertion
Written Consent
Set Up System
Pain Management
Perform “Time Out”
Hand Hygiene
Clean Chest Wall with Antiseptic
Apply Mask and Gloves
Drape the Chest with Sterile Towels
Insertion
Small Incision of the Rib Space
Thread a Clamped Chest Tube
Through the Incision
Tube Inserted into Intrapleural
Space
HCP Sutures Chest Tube into Place
Dressing
Connect to System
Sterile Water / NS Added to
Diagnostic Indicator on Waterless
System
Unclamp Chest Tube
Review Chest X-Ray Film Studies
Position Patient
Check Patency of Air Vents
Position Tubing
Keep 2 Rubber Tipped Hemostats
in Easily Accessible Positions
Purpose
Procedure
Possible Complications
Water Seal or Dry
Have Available for Before and After
Procedure
Verifies Correct Patient & Procedure
HCP Injects Local Anesthetic
Stays Clamped Until System is Connected to Water Seal
Prevents Entry of Atmospheric Air into chest
Secures Chest Tube into Place
Sterile Petrolatum Gauze is Used
Around the Tube
Sterile 4X4inand Large Dressing to
form Occlusive Dressing
Semi-Fowlers or High-Fowlers
High-Fowlers
Water-Seal Vent Must Have NO
Occulsion
Suction-Control Chamber Vent is Not
Occluded When Suction is Used
Waterless Systems have Relief Valves
Without Caps
Horizontally on Bed and Secure
Hang Straight Line from Chest Tube
to Drainage Chamber
Clamps
Ashley Hawthorne
Explain the Procedure
Improves Patient Comfort
Helps Patient to Take the Appropriate Deep
Breaths to Promote Lung Expansion and Drainage
of Fluid in Pleural Space
Unless Emergent Situation
Surgical Asepsis
Surgical Asepsis
Allow Time for Anesthetic to Take Effect
Helps to Prevent Air Leak
Holds Tube in Place
Occludes Site Around It
Helps Stabilize Chest Tube
Holds Dressing Tightly in Place
Allows for Assurance that System is Functioning
Properly
Connects Chest Tube to Drainage
For Pneumothorax to Drain Air
For Hemothorax to Drain Fluid
Allows Displaced Air to Pass into Atmosphere
Provides Safety Factor of Releasing Excess
Negative Pressure into Atmosphere
Provides Safety Factor of Releasing Excess
Negative Pressure
Prevents looping that can occlude the drainage
system
Promotes Drainage
Needed if there is an Air Leak, to Empty / Quickly
Change Disposable Systems
 Connecting the Patient to the Chest Tube System
Water-Seal System
Remove Connector Cover from Patient’s
End of Chest Drainage Tubing
Secure Drainage Tubing to Chest Tube and
Drainage System
Water-Seal Suction
Connect System to Suction or Supervise a
Nurse Connecting it to Suction if Suction is
to be used
Waterless System
Remove Connector Cover from Patient’s
End of Chest Drainage Tubing with Sterile
Technique
Secure Drainage Tubing to Chest Tube and
Drainage System
Waterless Suction
Turn on Suction Source
Set Suction Indicator to Prescribed Setting
Ashley Hawthorne
Use Sterile The HCP is Responsible for Making Certain that the
Technique System is Set Up Properly, Proper Amount of Water is in
the Water Seal, Dressing is Secure, and Chest Tube is
Connected to Drainage System Securely
HCP is Responsible for Determining and Checking
Amount of Fluid that is to be added to Suction-Control
Chamber and Prescribing Suction Setting
HCP is Responsible for Making Certain that System is Set
up Properly and Chest Tube is Securely Connected to
Drainage System
Float Ball Health Care Provider is Responsible for Prescribing Level
or Bellows Suction
Unexpected Outcomes of Chest Tube Insertion Ashley Hawthorne
Patient • Chest Pain • Notify HCP Immediately
Develops • Decrease in Breath Sounds Over Affected and Unaffected Lungs • Collect Vitals + SpO2
Respiratory • Marked Cyanosis • Prepare for Chest X-Ray
Distress • Asymmetrical chest Movements • Provide O2 as Ordered
• Presence of SQ Emphysema Around Tube Insertion Site or Neck
• Hypotension
• Tachycardia
• Mediastinal Shift
Air Leak • Determine Where the air Leak is Occurring • Check All Connection
o Assess for Location by Squeezing the Chest Drainage • Inspect the Chest Drainage Units
Tubing… for Cracks / Brakes
▪ If Bubbling Stops, then Air Leak is Inside Patient’s • Can Remove Tape without
Thorax or at Chest Insertion Site Disconnecting Tubing to Inspect
▪ If Bubbling Continues, Leak is in the Drainage Connections
System • Leaks are Corrected when.
o Connections Between Tube & Drainage device Constant Bubbling Stops
o Within Drainage Device
• Is Leak Occurring During Inspiration or Expiration
• Air Leak at Patient • Release the Pressure on the Drainage Tube
• Reinforce Chest Dressing
• Notify HCP
• Leak in the Drainage System • Change Drainage System

No Chest Tube • Observe for Kink in Chest Drainage System

Drainage • Observe for Possible Clot in Chest Drainage System
• Observe for Mediastinal Shift or Respiratory Distress
• Notify HCP
Chest Tube is • Immediately Apply Pressure Over Site
Dislodged • Have Assistant Obtain Sterile Petroleum gauze
• Apply Dressing with Tight Seal
• Tape Over Dressing on 3 Sides
o Allows for Air to Escape
• Notify HCP
Substantial • Obtain Vitals
Increase in • Monitor Drainage
Bright Red • Assess Patient’s Cardiopulmonary Status
Drainage • Notify HCP
Water-Seal is • Add Sterile water to Water-Seal Chamber Until Distal Tip is 2cm Under Surface Level
No Longer • Most Chest Drainage Units are Marked at the 2cm Level to Indicate the Fill Line
submerged in
Sterile Fluid
due to
Evaporation
Assess for • Severe Respiratory Distress • Make sure the Chest Tubes are Patent, Remove Clamps,
Tension • Low SpO2 Eliminate Kinks, Eliminate Occlusion
Pneumothorax • Chest Pain • Notify HCP Immediately
• Absence of Breath Sounds on Affected Side • Prepare for Another Chest Tube Insertion
• Tracheal Shift to Unaffected Side • A One-Way Flutter (Heinrich) Valve or Large-Gauge
• Hypotension Needle May be Used for Short-Term Emergency Release
• Signs of Shock of Pressure in the Intrapleural Space
• Tachycardia • Have Emergency Equipment, O2, and Code Cart Available
Removal of Chest Tubes
Equipment Ashley Hawthorne

Suture Set Sterile Scissors Sterile Forceps Clean Gloves

Prepared Sterile 4-Inch Adhesive Tape or

Dressing Elastic Bandage

Sterile Gloves Face Mask / Shield o Petrolatum- o Cut into Strips

Impregnated Gauze
o 4X4 Gauze
o Large Dressings

Stethoscope Sphygmomanometer Pulse Oximeter Disposable Bed Pad

 The Process of Removing a Chest Tube Ashley Hawthorne
Identify Patient Name
Assessment
DOB
MRN
Looking for Lung Reexpansion
Perform Respiratory Assessment

Provide HCP with Results of CXR Shows Position of Lung Tissue

Note Trend in Water-Seal Fluctuation Over Last 24hrs
Determine if Bubbling is Present
Confirm that Drainage has Decreased to Less than
100 – 150 mL/day
Percuss Lung for Resonance
Auscultate Lung Sounds
Assess the Patients Level of Comfort
Determine when Analgesic Last Given
Determine Patient’s Understanding of Chest Tube Removal
Procedure
Do Not Clamp Chest Tube Before Removal
Assess for Changes in Vital Signs, Chest Pain, Apprehension,
Symptoms of Tension Pneumothorax
Administer Prescribed Analgesic 30mins Prior
Implementation
Pleura of Expanded Lungs Seals Holes on Internal Tip of
Chest Tube – Stopping Fluctuation in Water Seal.
Halt in Fluctuation for 24hrs Indicates that Lung is
Expanded
When Bubbling is Present, this Indicates that the Lung is
Not Fully Expanded
Pleural Drainage was Removed, Allowing Lung to
Reexpand
Normal Resonance Occurs with Reexpansion
Normal Breath Sounds are Heard Bilaterally with
Reexpansion
Chest Tube Removal is Painful
Additional Analgesia and Breathing exercises are often
Needed
Encourage Cooperation
Minimize Anxiety
Clamping Chest Tube Before Removal to Assess
Patient’s Tolerance is No Longer Recommended Due to
No Benefit.
If a Chest Tube That was Continuing to Bubble Is
Clamped, Tension Pneumothorax May Occur
Patient May Reporst Sensations Ranging from Pain to

Pulling When Chest Tube Is Removed

Perform “Time Out” Verify Patient, Planned Procedure, Correct Tubes,
Patient Position, Chest Tube is Visible
Perform Hand Hygiene
Apply Clean Gloves
Face Shield
Put Patient into Sitting Position on Edge of Bed, Supine, or HCP Decides Patient’s Position
on Side Without Chest Tube
Place Pad Under Chest Tube Site
HCP Prepares an Occlusive Dressing of Petrolatum-
Impregnated Gauze on Pressure Dressing – Sterile
Applies Sterile Gloves
Support Patient Physically and Emotionally Reduce Anxiety and Pain
Patient is told to Exhale Completely and Hold it While This Prevents Air from Being Sucked into Chest as Tube
Bearing Down is Removed.
If not performed then Pneumothorax can occur.
HCP Quickly Pulls Out Chest Tube and Tightens and Ties
Purse-String Sutures
Patient can now breathe normal
HCP Applies Sterile Occlusive Dressing Over Wound
Secures in place with Wide Tape
Chest Tube Inspected to Ensure Entire Removal
Help Patient into Upright Position Supported by Pillows
Remove Used Equipment and Dispose
Remove Gloves + Hand Hygiene
 Auscultate Lung Sounds
Evaluation Palpate Skin Over Area Where Tube Wat Inserted for SQ This is Air in the SQ
Emphysema
Evaluate for Signs of Respiratory Distress Immediately After Chest Tube May Need to Be Re-Inserted
Tube Removal and During First Few Hours Post Removal
Evaluate Vital Signs, Pulmonary Status, and Psychological Detects Early S/S of Complications
Status
Review CXR if Ordered May Also Have Ultrasound or CT
Pain / Comfort Level
Assess Dressing for Drainage and Patency Ensures Occlusion and Proper Healing of Chest Wound
Note Signs of Healing During Dressing Changes
Patient Education
Ashley Hawthorne

Unexpected Outcomes of Chest Tube Removal

Dyspnea & Labored Respirations Infection Noted at Insertion Site
• Potential Recurrence of Pneumothorax, • Prepare for Possible Chest Tube Re-Insertion
Hemothorax, Effusion • Assess Vitals for
• Notify HCP • Fever
• Obtain Vitals • Tachypnea
• Stay With Patient • Tachycardia
• Assess Wound for
• Drainage
• Odor
• Erythema
• Increased Pain

1. B
2. A
Practice Questions!

1. A nurse has just received report on 4 clients who all have chest tubes in place. Which client
is the priority to see first?
a. The client whose drainage system is standing on the floor
b. The client with continuous bubbling in the drainage chamber
c. The client with tidaling in the drainage tubing
d. The client with suction pressure set at -20cmH2O

2. A nurse is assisting a provider with the removal of a chest tube. Which of the following
nursing interventions is the priority once the provider removes the tube from the chest?
a. Applying an occlusive dressing
b. Assessing lung sounds
c. Cleaning the wound with soap and water
d. Culturing the insertion site