1. Chest Tubes by Charlotte Cooper RN, MSN, CNS modified by Kelle Howard RN, MSN

2. 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

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

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

5. Pleural Anatomy Parietal pleura Visceral pleura Normal Pleural Fluid Quantity: Approx. 20 - 25mL per lung Lung RibsIntercostal muscles

6. Pleural Physiology Area between pleura ----“potential space” Normally, negative pressure between pleura

7. What do you do when pleural injury occurs

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

9. Chest Tubes Also called “thoracic catheters” Different sizes – From infants to adults – Small for air, larger for fluid Different configurations – Curved or straight Types of plastic – PVC – Silicone Coated/Non-Coated – Heparin – Decrease friction

10. Chest Tube Placement In what setting/environment is a chest tube placed?

11. Chest Tube Placement

12. Chest Tube Placement Procedure Sterile technique Small incision Tube is sutured Dressing applied

13. Chest tubes in place

14. Heimlich Valve

15. http://www.scielo.br/img/revistas/jbpneu/v34n8/en_a04fig01.gif

16. 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

17. How a chest drainage system works

18. How a chest drainage system works Expiratory positive pressure One way valve Gravity Suction

19. Goal: Prevent Air and Fluid Backflow Tube open to atmosphere vents air Tube from patient

20. Goal: 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

21. From bottles to a box Collection chamber Water seal chamber Suction control chamber from patient Suction control bottle Water seal bottle Collection bottle From patient To suction

22. From box to bedside

23. Water suction (A) Dry suction (B) Lewis p. 570 Fig 28-8

25. Atrium Chest Tube System Chamber A – Suction control chamber Chamber B – Water seal chamber Chamber C – Air leak monitor Chamber D – Collection chamber Be sure you under stand how to set up the system, the function of each chamber and how to troubleshoot issues with each chamber.

26. 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

27. Air Leak Water seal is a window into the pleural space Not only for pressure If air is leaving the chest through an air leak, bubbling will be seen here Air meter (1-5) provides a way to “measure” the air leaving and monitor over time – getting better or worse?

28. Assessment Focused respiratory assessment – Breath sounds – Respiratory rate – Respiratory depth – SpO2 – ABG – CXR

29. Assessment Cardiovascular assessment Level of consciousness Pain Chest tube & Chest tube system – Be sure you know what is to be assessed

30. Interventions System position Tubing position Connections to patient and system Monitoring & recording & reporting output

31. Interventions Dressing changes Oxygen therapy Analgesics IS and turn, cough, deep breathe

32. Complications What are some common complications?

33. Complications & Troubleshooting Chest tube malposition (most common) Subcutaneous emphysema High Fluid in Water Seal Chamber – Chest system may need to be vented – But only if the suction is on Air leak Others pleural effusion, inc. pneumo, mediastinal shift ?

34. If chest tube comes out?

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

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

37. 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

38. Questions What is the progression of events for discontinuing a chest tube? Can a patient ambulate with a chest tube?

39. Portable chest drainage system

40. PleurX Catheter