Chest Tubes and Drainage Systems Deb Updegraff RN, CNS PICU LPCH

Chest Tubes Correct life threatening conditions caused by excess of fluid and/or air in the intrapleural space

Tension-Pneumothorax A collection of air in the pleural space. Can occur with Central line placement Chest surgery, Trauma to the chest wall Traumatic intubation Mechanical ventilation Tension-Pneumothorax If air continues to collect in the chest, the pressure can rise and push the whole mediastinum over to the other side

“Intra” pleural Space There are 2 pleural membranes involved in respiration visceral pleura parietal pleura The Parietal pleura lines the inside of the thoracic cavity. The visceral Pleura adheres to the outside of the lung.

Pneumothorax

Hemothorax A collection of blood in the pleural space Can occur with: Chest surgery Central line placement Chest trauma

Hemothorax

Pleural Effusion The accumulation of pathologic quantities of fluid in the intrapleural space. Maybe caused by: Liver and kidney failure Congestive heart failure Infection Malignancy blocking the lymphatic system

Empyema Inflammatory fluid and debris within the intrapleural space. Usually results from an untreated bacterial pneumonia. Other causes: Thoracic trauma Rupture of lung abscess into the pleural space Extension of mediastinal or abdominal infection Iatrogenic at time of thoracic surgery

Insertion Sites for Chest tubes Patient Positioning Insertion Sites for Chest tubes Pneumothorax: (AIR) The best position is supine or with head elevated anywhere from low to high fowler’s. The chest tube will be inserted into the 2nd or 3rd intercostal space anterior chest at the mid-clavicular line Effusions: (FLUID) If patient able, best position is sitting on the side of the bed leaning over a pillow placed on a bedside table. The chest tube is inserted between the 4th to 6th intercostal space mid-axillary line

Insertion sites

How 3 chamber drainage system works

First Chamber The Water Seal chamber Fresh chest tube inserted, patient could suck air directly into chest. The distal end must be controlled. The water seal chamber acts as A one way valve. Air can get out and as long as the tube is long Enough, water can not be sucked in. Bubbles moving through This chamber means the patient has an air leak.

Second Chamber Single chambers are fine if all you want to drain in air. When there is fluid it’s time for a second chamber. 2 1

Third Chamber Here’s an idea! What if the fluid is thick or just needs extra help to drain? What if we could add suction? Time for a 3rd chamber. 2 1 3 1 water seal chamber 2 drainage chamber 3 suction chamber

Water seal chamber Drainage chamber Suction Chamber 3 1 2

Third Chamber –Suction Chamber The strength of suction is directly affected by the level of water. The MD will order this. In Pediatrics the amount is usually 15cm. You need regulated wall suction. The weight of the water acts as the suction limiter. No matter how Hard the wall suctions pulls, the actual suction delivered to the patient is 15cm.

Now back to Air Leaks First Chamber-Water seal chamber This chamber shows an air leak. This is a Good thing if you have just placed the tube For a pneumothorax. It means the air is Getting out of the patient. This does not automatically mean that air is Coming out of the chest. The leak can be coming from anywhere in the System and this can be bad. 1 1

If the chest tube is pulled and dislodged, the drainage holes can actually be “outside of the patient” sucking air. Air can dangerously accumulate. In addition to the bubbles in the air leak chamber you should be able to hear this with a stethoscope. What to do: Take dressing down wrap hole with Vaseline gauze Call for a stat CXR.

Clamping a Chest tube Clamping a chest tube is a very big deal Only clamp if you are: Changing a full pleurovac Or if you are Trying to determine if the system is leaking.

It means to disconnect from wall suction Water Seal Usually this is ordered when the air/fluid draining from the patient is assumed to be pretty much over and done with. What carefully for signs of re-accumulation It means to disconnect from wall suction