Chest Tubes Charlotte Cooper RN, MSN, CNS

Thoracic Cavity Lungs Mediastinum – Heart – Aorta and great vessels – Esophagus – Trachea

Breathing: Inspiration Diaphragm contracts Moves down Increasing the volume of the thoracic cavity When the volume increases, the pressure inside ________. Pressure within the lungs is called intrapulmonary pressure

Breathing: Exhalation Phrenic nerve stimulus stops Diaphragm relaxes This ______ the volume of the thoracic cavity Lung volume decreases, intrapulmonary pressure _____ Atmospheric pressure

– Parietal pleura – lines the chest wall – Visceral pleura (pulmonary) – covers the lung Pleural Anatomy

Parietal pleura Visceral pleura Normal Pleural Fluid Quantity: Approx. 25mL per lung Lung RibsIntercostal muscles

Pleural Physiology Area between pleura “potential space” Normally, negative pressure between pleura During inspiration, the intrapleural pressure is approximately - 8cmH 2 0 During exhalation, intrapleural pressure is approximately - 4cmH 2 0

What happened?

What is this?

Flail Chest

Pleural Injury Blood in pleural space Caused by Like pneumothorax Manifestations

Pleural Injury: Therapeutic Interventions Diagnostic tests Client position Treatment depends on severity Chest tube Heimlich valve on chest tube

Chest Tube Placement

Heimlich Valve

Prevent air & fluid from returning to the pleural space Chest tube is attached to a drainage device – Allows air and fluid to leave the chest – Contains a one-way valve to prevent air & fluid returning to the chest – Designed so that the device is below the level of the chest tube for gravity drainage – What happens if you clamp the chest tube?

Treatment goal for pleural injuries 1. Remove fluid & air as promptly as possible 2. Prevent drained air & fluid from returning to the pleural space 3. Restore negative pressure in the pleural space to re-expand the lung

Interventions Dressing changes No dependent loops Oxygen therapy Analgesics IS and turn, cough, deep breathe

Nursing assessment and pertinent nursing problems/interventions Health history-respiratory disease, injury, smoking, progression of symptoms Physical exam- degree of apparent resp distress, lung sounds, O2 sat, VS, LOC, neck vein distention, position of trachea All require observation for lung symptoms Pertinent nursing problems – Acute pain – Ineffective airway clearance – Impaired gas exchange – Home care

Prevent Air and Fluid Backflow Tube open to atmosphere vents air Tube from patient

Prevent Air and fluid backflow For drainage, a second bottle was added The first bottle collects the drainage The second bottle is the water seal With an extra bottle for drainage, the water seal will then remain at 2cm

Restore negative pressure in the pleural space The depth of the water in the suction bottle determines the amount of negative pressure that can be transmitted to the chest, NOT the reading on the vacuum regulator

How a chest drainage system works Expiratory positive pressure Gravity Suction

Chest Tube Set Up Stop cock control Placement of unit Disposal Air leaks

Assessment Focused respiratory assessment Breath sounds Respiratory rate Respiratory depth Chest excursion SpO2 ABG CXR

Assessment Respiratory assessment Heart rate Level of consciousness Pain Chest tube

If chest tube comes out?

Pleural Effusion

Pleural effusion- S & S and therapeutic interventions Common manifestations Diagnostic tests Treatment

Mediastinal shift High pressure Displaced to unaffected side Structures compressed External pressure Decrease blood flow

Review Check fluid level in suction chamber Observe water seal chamber fluid level Assess for tidaling in water seal chamber Assess for tubing – non dependent Determine if the unit been knocked over Note the amount, color and consistency of drainage Above all

What is most important? Monitor your client Notify MD STAT if Significant drainage Increasing shortness of breath Pain Absence of breath sounds

Management Do not remove suction without an order Manage pain When full place in biohazard container Do not change collection device on client with an air leak without an order When suction discontinued, must disconnect from suction, not just turn off