1. Chest Tube Management Kristin Eckland, RN, MSN, ACNP-BC, RNFA-I Acute Care Nurse Practitioner, Cardiothoracic & Vascular Surgery Duke University

2. Cardiothoracic and Vascular Surgery Who we are: Who we are: Dr. McCann, Cardiothoracic and Vascular Surgeon K. Eckland, Acute Care Nurse Practitioner Surgical Team: OR staff – nurses, perfusionists, RNFA, surgical techs Extended CVT team: Unit/ step-down, telemetry, and floor nurses caring for our patients.

3. CVT Surgery

4. - Not just ‘open heart.’ - Major lung resection; lobectomies, pneumonectomies, chest wall resection. - Major/ Minor Vascular: carotid endartarectomies, aneurysmal disease, Peripheral vascular disease including revascularization/ amputation -Traumatic injury to chest/ vascular / cardiac -Disease / injury to the esophagus -Diseases of the mediastinum (lymphoma, thymus, etc.) -Any time CPB is needed.

5. The Wonderful World of Thoracics The Wonderful World of Thoracics Always a team effort!

7. Indications for Chest Tube Placement Air or fluid in chest/ pleural cavity Chest tube size determined by chest contents (pigtail versus 40 french) Chest tubes as treatment/ or after surgery Used when integrity of chest cavity is interrupted.

8. Pneumothorax Aka – air in the chest causing lung collapse. Aka – air in the chest causing lung collapse. Spontaneous versus otherwise acquired Spontaneous versus otherwise acquired Tension pneumothorax Tension pneumothorax

9. Pneumothorax If very small/ asymptomatic may treat medically: -100% NRB -Monitor for development of symptoms – Pneumothorax may enlarge and require surgical treatment/ chest tube placement.

10. Fluid in the chest Pleural effusion Pleural effusion Hemothorax Hemothorax Empyema Empyema Require larger chest tubes (32 – 40 fr.) Require larger chest tubes (32 – 40 fr.)

11. Fluid in the chest

12. Pleural Effusion Causes: CHF, noncardiogenic pulmonary edema - Fluid is usually serosanguinous - Can be malignant – if suspicious presentation/ history; send for cytopathology and cytology - Can perform pleurodesis following drainage.

13. Hemothorax Blood in the chest Blood in the chest May be secondary to chest trauma or post surgical May be secondary to chest trauma or post surgical

14. Malignant Effusion Fluid collection associated with metastatic disease Fluid collection associated with metastatic disease Poor prognostic sign Poor prognostic sign Pleurodesis may be performed for palliative treatment. Pleurodesis may be performed for palliative treatment. Have large volume containers for specimens – 1 liter suction containers. Have large volume containers for specimens – 1 liter suction containers. Must get to lab in a timely fashion – degrades quickly. Must get to lab in a timely fashion – degrades quickly. Specimens important for disease staging – may be new diagnosis – first disease presentation. Specimens important for disease staging – may be new diagnosis – first disease presentation.

15. Empyema Pus in the chest cavity ‘empyema thoracis’ Pus in the chest cavity ‘empyema thoracis’ Patients often critically ill: high mortality related to sepsis and respiratory failure. Patients often critically ill: high mortality related to sepsis and respiratory failure. Mortality 20 – 30% (statistics from multiple sources) Mortality 20 – 30% (statistics from multiple sources) Always requires multi-modality approach, sometimes surgical evacuation and decortication. Always requires multi-modality approach, sometimes surgical evacuation and decortication. Often caused by pneumonia, pleural effusion that becomes infected. Often caused by pneumonia, pleural effusion that becomes infected.

16. Empyema Always nutritionally deficit – Always nutritionally deficit – Pre-albumin usually less than 10, albumin less than 2. Requires nutritional / dietician consult May need enteral/ parenteral nutrition. -Poor wound healing / high caloric needs -Usually multiple co-morbidities

17. Empyema

18. Empyema

19. Pleurodesis Mechanical / Chemical or combination. Mechanical / Chemical or combination. Surgical or bedside Surgical or bedside Mechanical: by pleural cavity irritation from either chest tube (bedside) or surgically induced. Mechanical: by pleural cavity irritation from either chest tube (bedside) or surgically induced. Chemical (sterile talc – placed into chest cavity) Chemical (sterile talc – placed into chest cavity) Causes lung to adhere to chest wall Causes lung to adhere to chest wall

20. Why pleurodesis? To prevent a reaccummulation of fluid To prevent a reaccummulation of fluid To increase likelihood of adherence of lung to chest wall – prevent repeat pneumothorax To increase likelihood of adherence of lung to chest wall – prevent repeat pneumothorax

21. Management: Key Points -All of these patients are at high risk for respiratory distress! - Need aggressive pulmonary toileting: -cough / deep breathing -cough / deep breathing -incentive spirometry -incentive spirometry -frequent ambulation -frequent ambulation -Nebulizer treatments -Nebulizer treatments -Chest PT -Chest PT -All patients with Chest tubes need a daily chest x- ray – before 8 am, EVERY day.

22. Suction? Length of suction depends on purpose o chest tube (air versus fluid) Length of suction depends on purpose o chest tube (air versus fluid) All patients at least 24 hours of continuous suction. All patients at least 24 hours of continuous suction. Need to ambulate while on suction – either in room, or with portable suction. Need to ambulate while on suction – either in room, or with portable suction. Water seal trials: before AM film – check for pneumothorax. Water seal trials: before AM film – check for pneumothorax.

23. High level Suction Aka “High and dry” Aka “High and dry” Special pleurovacs or modified atrium Special pleurovacs or modified atrium Silent suction – no bubbling in chest tube Silent suction – no bubbling in chest tube Suction controlled by wall suction Suction controlled by wall suction Not to exceed -40cm! Check wall settings. Not to exceed -40cm! Check wall settings.

24. Chest Tube Disasters Usually preventable (i.e. Atrium taped to floor) Usually preventable (i.e. Atrium taped to floor) We are here to help you (so call us!) We are here to help you (so call us!) Printed chest tube emergency sheets on all of our patients – use them. Printed chest tube emergency sheets on all of our patients – use them. Chest tube dislodgement can cause life- threatening complications such as tension pneumothorax. Chest tube dislodgement can cause life- threatening complications such as tension pneumothorax.

25. Chest Tube Disasters Immediate steps after chest tube is dislodged: DO STAT! 1. 3 cornered dressing using Vaseline gauze. 2. 100% NRB 3. Page service*** 4. STAT chest x-ray !Even if patient appears okay – do ALL of the above!!

26. Chest Tube Toolbox Contains everything needed for STAT chest tube placement Contains everything needed for STAT chest tube placement Should have a toolbox on every floor Should have a toolbox on every floor Arrow AK-1000 for STAT thoracentesis. Arrow AK-1000 for STAT thoracentesis.

27. Chest Tube Disasters/ Mishaps and Mismanagement: Scenes from DRMC

28. Scenes from DRMC

29. Chest tube mishaps Other things I never want to see: Other things I never want to see: (no photographic evidence – don’t give me a chance to get any.) - Hemostats / clamps on the chest tube (only exception when placed by CT surgery) - Closed valve

30. Care of patients with chest tubes Mark chest tubes: every shift with date and time. Mark date pleurovac changed. Mark chest tubes: every shift with date and time. Mark date pleurovac changed. Changing the pleurovac: a sterile procedure – chest tube open to chest cavity. Changing the pleurovac: a sterile procedure – chest tube open to chest cavity. Check fluid level frequently – this is what maintains proper amount of suction in standard pleurovacs. Check fluid level frequently – this is what maintains proper amount of suction in standard pleurovacs.

31. Chest Tube Management Amy, ICU – one of our dedicated CVT nurses

32. Thank you! To Rebecca Rinn – for presenting this session. To Rebecca Rinn – for presenting this session. To everyone here for listening To everyone here for listening To everyone caring for our patients To everyone caring for our patients