CHEST TUBE THORACOSTOMY

 Insertion of a tube (chest tube) into the pleural cavity to drain air, blood, bile, pus, or other fluids
 Whether the accumulation of air or fluid is the result of trauma, or an insidious malignant
exudative fluid, placement of a chest tube allows for continuous, large volume drainage until the
underlying pathology can be more formally addressed

ANATOMY

o The lungs are covered by a thin tissue layer called the pleura.
o A thin layer of fluid acts as a lubricant allowing the lungs to slip smoothly as they expand and
contract with each breath.
o Parietal fluid separate parietal and visceral pleural surfaces.
o Amount of pleural fluid secretion is 0.3 ml/kg or 25 ml/24 hrs.
o Natural tendency of lung to recoil v/s adherence of pleura
o Negative intra plural pressure keeps the lung expanded
-During inspiration: -8cmH20
-During expiration: -4cmH20
o Air, Fluid, or Blood in pleural cavity create disruption of negative intra-pleural pressure that leads
to Lung Collapse

INDICATIONS

 Pneumothorax
>in any ventilated px
>tension pneumothorax after initial relief
>persistent/recurrent pneumothorax after simple aspiration
>large secondary spontaneous pneumothorax in patients over 50 y/o
 Malignant pleural effusion
 Empyema and complicated parapneumonic pleural effusion
 Traumatic hemopneumothorax
 Postoperative---for example, thoracotomy, esophagectomy, cardiac surgery

CONTRAINDICATIONS

Coagulopathy
Pulmonary bullae
Pulmonary, pleural, or thoracic adhesions
Skin infection over the chest tube insertion site

MATERIALS/EQUIPMENT

 Chest tube types

 Suction
 Drainage
 Two Bottle System
 Three Bottle System
 Plastic Multi-chamber system- commercially available; incorporates the 3 bottle system into 1 unit

SUPPLIES TO BE PREPARED
  Chest tube tray
-Kelly clamps x2
-forceps x1
 Sterile gloves, gown, hair covering, drapes, and towels
 Chest tube
-Adults:
36-38 F (large pneumothorax or hempthorax)
24-32 F (simple/nontraumatic pneumothorax)
-Pediatrics: Based on Broselow tape but ranges 12-28 F for children and 12-18 F for infants
 Pleurivac system (or alternative suction device with reservoir) & connection tubing
 Betadine or chlorhexidine skin cleansing preparation
 Scalpel #10 blade & handle
 Nonabsorbable suture (e.g. 1-0 or 2-0 silk)
 Xeroform or Vaseline gauze dressing
 Sterile 4”x4” bandages with slits
 Elastoplast dressing roll
 Adhesive tape
 20-gauge and 25-gauge needle with 10 ml syringe
 Local anesthetic (e.g. 1-2% lidocaine with or without epinephrine)
 Parenteral analgesia and/or sedative hypnotic

PRE-PROCEDURE CONSIDERATIONS

 Risk of hemorrhage---any coagulopathy or platelet defect should be corrected prior to chest drain
insertion
 Following differential diagnosis requires careful radiological assessment such as pneumothorax,
bullous disease, lung collapse and a pleural effusion
 Lung densely adherent to the chest wall throughout the hemithorax
 The drainage of a post pneumonectomy space should only be carried out by or after consultation
with a cardiothoracic surgeon

ANATOMICAL REPLACEMENT

 5th intercostal space at the midaxillary line

 Considerations & Special Circumstances:
-avoid placement directly over an area of infected soft tissue
-avoid going below or through the diaphragm, which can extend up as high as the nipple during
full expiration
-consider going into the 4th intercostal space at the midaxillary line in patients who are pregnant,
have ascites from cirrhosis, or large hemoperitenum where the increases intraabdominal contents
and pressure can further elevate the diaphragm

PRE-PROCEDURE

 Explain the procedure to the patient and obtain informed consent if not emergent
 Place the patient on the cardiac monitor, pulse oximetry & supplemental oxygen
 Ensure 2 points of functioning IV access with 2 large bore (16-18 G) catheters
  Determine the right position for the patient:
-Lying in the supine position: (Least preferred) used when patient is hemodynamically unstable
-Sitting in the supine position: (Preferred if stable) head of bead elevated to 30 degrees
-patient’s arm on the side of the chest tube placement should be abducted & flexed at the elbow
with hand up above the head to expose the area of insertion
 Identify the anatomical landmark
 Set up the Pleurivac system
 Verify all supplies
 Initiate procedural sedation

POSITIONING

 Supine, slightly rotated w/ arm on side of lesion behind patient’s head to expose the axillary
 Sitting upright while leaning towards a table or pillow
 Lateral decubitus position

NURSING RESPONSIBILITIES

 Wash hands and don sterile gloves before coming in contact with the patient.
 The chest tube should contain approx. 6 ft. of tubing that connects to a collection device located
several feet below the patient’s chest. Instruct the patient not to rest the body on the tubing. The
nurse should take this time to check the patient’s tubing for twists and kinks in the tubing line. The
nurse should also tape the tubing connections to prevent air from leaking out of the tube.
 The drainage system has a water seal that operates as a one-way valve. The nurse must add the
required amount of saline into the patient’s separate water chamber while ensuring the end of the
patient’s tubing remains in the fluid.
 Add suctioning to the chest drainage system if necessary, but remember that the amount of
suctioning depends on the saline solution’s depth
 The nurse should make a note of the level of drainage at the end of his or her shift. Also,
document the color and amount of drainage in the patient’s notes.
 The respiratory status of the patient requires frequent assessment to maintain the patient’s
health. Note of decreased breathing sounds near the side of the patient’s tube
 Maintain care of the chest tube; encourage px to perform deep-breathing exercises or coughing

NURSING CARE PLAN

Nursing diagnosis: Ineffective Breathing Pattern

May be related to:

 Decreased lung expansion (air/fluid accumulation)

 Musculoskeletal impairment
 Pain/anxiety
 Inflammatory process

Possibly evidenced by:

 Dyspnea, tachypnea
 Changes in depth/equality of respirations; altered chest excursion
 Use of accessory muscles, nasal flaring
  Cyanosis, abnormal ABGs

Desired Outcomes

 Establish a normal/effective respiratory pattern with ABGs within patient’s normal range.
 Be free of cyanosis and other signs/symptoms of hypoxia

Nursing diagnosis: Risk for trauma

Risk factors may include:

 Concurrent disease/injury process

 Dependence on external device (chest drainage system)
 Lack of safety education/precautions

Desired Outcomes:

 Recognize need for/seek assistance to prevent complications.

 Correct/avoid environmental and physical hazards.