Chest tube thoracostomy

Insertion of chest tube in the pleural space indications:

 A collapsed lung
 Lung infection
 Pneumothorax ( air between lung and chest cavity)
 Bleeding ( due to trauma)
 Fluid buildup/ air
 Surgery ( lung/heart)

CHEST TUBE INSERTION

 A small incision (14-17 inch) is made between the ribs
to open the chest cavity Tube is inserted into the
thoracic cavity
 Chest tube is stitched to chest wall to keep it in place
 Drainage is attached to one way drainage system
 This allows air/ fluid to flow out into the drainage
bottle
 Before a chest tube is inserted into the chest, other
end of tube is put into a drainage system and
immersed into 2 cm saline solution.

One way bottle system

 End of drainage tube from the patient's chest is
immersed in 2.5 cm NSS
 This permits drainage of air and fluid from the pleural
space but does not allow air to move back into the
chest
 Tube from patient extends 2 cm below water level
 Vent-for escape of air leaking from the lungs
 Water level fluctuates/ rise and fall (tidaling) with
patient respiration; goes up when patient inhales and
down when patient exhales.

Closed Chest Drainage( thoracostomy Tube)

Purposes
 To remove air and/ or fluids from plevral space.
 To reestablish negative pressure and reexpand the
lungs.

One - bottle system

 Immerse tip of the tube in 2-3 cm. of sterile NSS to
create water – seal
Principles of Chest Drainage
1. Water acts as a seal and permit air and fluid to drain  Keep bottle at least 2 to 3 feet below the level of the
from the chest. chest to allow drainage from the pleura by gravity. >
Never raise the bottle above the. Level of the chest to
 air cannot reenter the submerged tip of tube.
prevent reflux of air or fluid.
 The underwater seal prevents air re-entering the
 Assess for patency of the device
pleural space.
o Observe for fluctuation of fluid along the
 Usually, the distal end of the drain tube is submerged
tube.
2cm under the surface level of the water in the
o Observe for intermittent bubbling of fluid;
drainage (or collection) chamber.
continuous bubbling means presence of air-
 This creates a hydrostatic resistance of +2cmH20 in
leak.
the drainage chamber.
 Absence of fluctuation may indicate :
Types of closed drainage o obstruction of the device
1. One-- way bottle system o check for kinks along tubing, milk tubing
 Bottle serves as drainage bottle and water seal towards the bottle.
bottle.  If no obstruction, consider lung
2. Two-way bottle system expansion: validated by chest x-ray.
 Drainage bottle  should be open to air.
 Water seal bottle. Two-bottle system
3. Three-bottle system –  Not connected to suction apparatus
 Drainage bottle o First bottle = drainage bottle/ fluid collection
 Water seal bottle chamber
o Second bottle = water-seal bottle
 Suction bottle.
o Observe for fluctuation of fluid along the tube
(water-seal bottle) and intermittent bubbling
with each respiration.
  Place client in semi-fowlers position.
 Instruct client to exhale deeply and do Valsalva
maneuver as the chest tube is removed.
 Chest x-ray may be done after the tube is removed.
 Assess for complications: subcutaneous emphysema;
respiratory distress.

Pleur de vac
1. first chamber = drainage / collection chamber
2. Second chamber (middle) = water- seal chamber
3. Third chamber = suction control chamber

 Connected to suction apparatus

o First bottle is drainage and water seal bottle
o Second bottle is suction control bottle

 Continuous bubbling in the suction control bottle is

expected;
 Intermittent bubbling and fluctuation in the water-seal.
 tip of the tube in the first bottle = immersed in 2-3 cm
of sterile NSS;
 tube of the suction control bottle = immersed in 10 -
20 cm of sterile NSS to stabilize the normal negative
pressure in the lungs.
 This protects the pleura from trauma if the suction
pressure is inadvertently increased

Three-bottle system

 First bottle= is drainage bottle

 Second bottle= is water-seal bottle
 Third bottle = is suction control bottle
o Observe for intermittent bubbling and
fluctuation with respiration in water-seal
bottle, continuous bubbling in the suction
control bottle.
 The water- seal chamber =
o filled with 3 cm of sterile NS
o Fluctuation ion of fluid indicates patency of
the apparatus.
 There should be no bubbling in water-seal chamber,
bubbling indicates air leak. Check connection of
tubing.
 The suction-control chamber is filled with 20 cm of
sterile NS, to stabilize the negative pressure with in
the lungs.

Nursing alert
- Continuous, gentle bubbling in the suction control
chamber is present this ensures drainage of air or
fluids from the pleural space.
- Absence of bubbling in the suction control chamber
indicates that the pressure of suction is not enough.
There will be no drainage.
- Special precautions:
Nursing interventions o Never lift drain above chest level
- Encourage to do the following to promote drainage:
o Unit / and all tubing should be bellow
 Deep breathing and coughing exercises.
patient's chest to facilitate drainage.
 Turn to sides at regular intervals,
o No kinks/ obstructions in tubing( may inhibit
 Ambulate
o ROM exercises of arms drainage)
o All connections between chest tubes and
o Mark the amount of drainage at regular
drainage are tight and secure.
intervals.
o Never clamp a WSD while transporting a
o Avoid milking and damaging of tube to
patient.
prevent tension pneumothorax.
o Removal of chest tube-done by physician.
Pharmacologic Therapy
- Removal of chest tube-done by physician.
1. Antihistamines
o Prepare:
- Reduce histamine activity by blocking histamine
o Petrolatum gauze receptor sites.
o Suture removal kit - Act within 15-30 minutes after administration.
o Sterile gauze - suppresses histamine release in allergy indicated
o Adhesive tape during the first stage of cold.
 Adverse effects in children:
 Paradoxical excitation (increased talkativeness,
emotional release, excitement, excess movement)
Adverse effects in elderly:
 dizziness
 confusion
 sedation
 hypotension.
Anticholinergic effects: dry nose, mouth, throat, urinary
retention, constipation, tachycardia and blurred vision.
Examples of antihistamines
1. chlorpheniramine maleate ( Trimeton)
 Given PO, IM, SC, and IV
 Can increase depressant effects of taker with
alcohol/other CNS depressants.
2. Diphenhydramine HCL ( Benadryl)
 Given PO, IM, IV.
 Given deeply in large muscle mass.
3. Promethazine (Phenergan)
 Given PO, IM, and IV.
 For allergy, oral administration : before meals(Ac) and
at bedtime (HS) as a single dose.
 Monitor respiratory function esp in children drug can
suppress cough reflex and thicken bronchial
secretions
Second generation nonsedating antihistamines
- Second generation non- sedating
antihistamines (prescription drugs) Loratadine (Claritin)
Bronchodilators and corticosteroids
- Inhaled corticosteroids
- main treatment to reduce inflammation and prevent
flare-ups in asthma.
Anticholinergics
 to treat COPD, but a few can also be used for
asthma. –
 taken using an inhaler, but may be nebulised to treat
sudden and severe symptoms.
 Anticholinergics cause the airways to widen by
blocking the cholinergic nerves.
 These nerves release chemicals that can cause the
muscles lining the airways to tighten.
 used with caution in people with:
 benign prostate enlargement
o a bladder outflow obstruction -any condition
that affects the flow of urine out of the
bladder, such as bladder stones or
 prostate cancer
 glaucoma - a build-up of pressure in the eye
3. Expectorants
 Reduce the viscosity of bronchial secretions, which
allows for their removal from
 the lungs.
 Indications:
• cough associated with cold
o Bronchitis
Example : expectorants

2. Bronchodilators 1. Guaifenesin( Robitussin) .

 relaxes the muscles in the lungs and widening the  Given to children and adults
 airways (bronchi).  increase the respiratory tract fluid reducing viscosity
 Making breathing easier. of secretions.
o to treat long-term conditions where the  OTC expectorant
airways may become narrow and inflamed.  Inform clients to Increase fluid intake and add
o asthma, a common lung condition caused by humification.
inflammation of the airways  Common adverse effect:
o COPD o gastric upset, caused by its stimulatory effect
on gastric secretions

4. Antitussives
 Reduces the force and amount of coughing.
 suppresses the cough center in the brain or
peripherally to reduce the susceptibility of irritant
receptors to activity.
 May contain narcotics ( analgesia, narcosis addictive)
 Given or symptomatic relief of nonproductive cough.

1. Detromethorphan
 Most frequently used non-narcotic antitussive
 Adverse effects;
o Dizziness, drowsiness, nausea
Types of bronchodilators  Contraindicated to patients with MAO inhibitors.
1. beta-2 agonists: salbutamol, salmeterol, formoterol and
vilanterol
2. anticholinergics: as ipratropium, fiotropium, aclidinium 5. Decongestants
glycopyrronium  provide short-term relief for a blocked or stuffy nose
- theophylin (nasal congestion).
 Bronchodilators may be either:  Relief of symptoms of conditions such as colds and
o short-acting-short-term relief from sudden, flu, hay fever and other allergic reactions, catarrh and
unexpected attacks of breathlessness l sinusitis.
o ong-acting - Used regularly to help control  reduces the swelling of the blood vessels in the nose,
breathlessness in asthma and COPD, and which helps to open the airways.
increase the effectiveness of corticosteroids
in asthma Types of decongestants
- nasal sprays
 Drops
 tablets or capsules
 liquids or syrups
 flavoured powders to dissolve in hot water

Contraindications:
People taking other medications with the following disorders:
- Diabetes mellitus
- high blood pressure
- hyperthyroidism
- enlarged prostate
 - liver, kidney, heart or circulation problems
- glaucoma
3. Pneumonectomy
Babies and children  Removal of an entire lung
- should not be given to children under 6. Children  Treatment for bronchogenic carcinoma
aged 6 to 12
- should take them for no longer than 5 days. Ask a
pharmacist for advice about this.
Pregnant and breastfeeding women
- Possible side effects can include:
 feeling sleepy (look for non-drowsy medicines)
 irritation of the lining of your nose
 headaches
 feeling or being sick
 a dry mouth
 feeling restless or agitated
 a rash 4. Segmental resection
6. Mucolytics • Removal of one or more segments of lung.
 Action : reduces the viscosity of mucus in the • Treatment for bronchiectasis.
bronchial tree
 Use: cystic fibrosis, acute' chronic bronchopulmonary
diseases: pneumonia, bronchitis and emphysema.
 Acetylcysteine antidote for acetaminophen
(Tylenol) overdose
 May cause bronchospasm in asthmatic clients and
should be discontinued; stomatitis, nausea, vomiting

NURSING IMPLICATIONS
a) Suction equipment should be readily available.
b) Has a foul odor of "rotten eggs"
c) Rinse mouth after treatment.

 Mucolytic alter the chemical characteristics of mucus

to decrease its viscosity and facilitate its removal by
ciliary action
 Commonly used mucolytics include acetyl cysteine,
carbocysteine, bromhexine, ambroxol and dornase-
afa.

I. Types
a. Exploratory Thoracostomy
 Anterior or posterolateral incision through the
fourth, fifth or seventh intercostal spaces to
expose and examine the pleura and lung.
b. Lobectomy
 Removal of one lobe of a lung
 to treat bronchiectasis, bronchogenic
carcinoma, emphysematous blebs, lung
abscesses. Wedge Resection
c. Pneumonectomy  removal of lung cancer along with a wedge-shaped
 Removal of an entire lung section of tissue surrounding the tumor.
 Treatment for bronchogenic carcinoma  Removal of less lung tissue
d. Segmental resection Lobectomy:
 Removal of one or more segments of lung.  most common type of lung resection.
 Treatment for bronchiectasis.  one or multiple lobes are removed from the lungs.

Nursing interventions : preoperative

Types
1. Exploratory Thoracostomy
• Anterior or posterolateral incision through the
fourth, fifth or seventh intercostal spaces to
expose and examine the pleura and lung.
2. Lobectomy
 Removal of one lobe of a lung
 bronchiectasis, bronchogenic carcinoma,
emphysematous blebs lung abscesses
Provide pre-op care.
 Complete physical assessment of the lungs
 Explain expected post-op measures:
o care of incision site,
o oxygen,
o Suctioning,
o chest tubes (except if pneumonectomy
performed)
 Teach adequate splinting of incision with hands or
pillow for turning, coughing or pillow for turning.
 Demonstrate ROM exercises for affected side.
 Provide chest physical therapy to help remove
secretions.
Nursing interventions : postoperative
1. Provide routine post-op care.
2. Promote adequate ventilation.
a. Perform complete physical assessment of lungs and
compare pre-op findings.
b. Auscultate lung fields every 1-2 hours
c. Encourage turning, coughing, and deep breathing
every 1-2 hours after pain relief obtained.
d. Perform tracheobronchial suctioning if needed.
 e. Assess for proper maintenance of chest drainage
system (except after pneumonectomy)
f. Monitor ABGs and report significant changes.
g. Place client in semi-fowler's position (if
pneumonectomy performed, follow surgeon's orders
about positioning, often on back or operative but not
turned to un operative side).

3. Provide pain relief.

narcotics/ analgesics prior to turning, coughing, and deep
breathing.
Assist with splinting while turning, coughing, deep breathing.
Prevent impaired mobility of the upper extremities by doing
ROM exercises; passive day of surgery, then active.
provide client teaching and discharge planning concerning.
a. Need to continue coughing/ deep breathing for 6-8 weeks
post-op and to continue ROM exercise
b. b. Importance of adequate rest with gradual increases in
activity.
c. High-protein diet with adequate fluid intake ( 1-2 liters /
day)

C
hest physical therapy.
 Good oral hygiene.
 Avoid persons with known URTI.
 Adverse sign and symptoms - (Recurrent fever,
anorexia; weight loss dyspnea; increased pain;
difficulty
 swallowing: SOB; changes in color, characteristics of
sputum) and importance of reporting to physician.
 Avoidance of crowd and poorly ventilated areas.