1. Chest Tube

2. Out line Introduction Definition Indications
WHERE IS THE CHEST TUBE INSERTED?
Nursing skills.
Problem solving.
Removal of a chest tube

3. Introduction
Trauma, disease, or surgery can interrupt the closed negative-pressure system of the lungs, causing the lung to collapse. 
Air or fluid may leak into the pleural cavity.  A chest tube is inserted and a closed chest drainage system  is attached to promote drainage of air and fluid.
Chest tubes are used after chest surgery and chest trauma and for pnuemothorax or hemothorax to promote lung re-expansion

4. Definition:
A chest tube insertion involves the surgical placement of a hollow, flexible drainage tube into the chest.
Chest tubes are inserted to drain blood, fluid, or air and to allow the lungs to fully expand.
The tube is placed between the ribs and into the space between the inner lining and the outer lining of the lung (pleural space).

5. a chest tubes is a catheter inserted through the thorax to remove air and fluids from the pleural space and to reestablish normal intrapleural and intrapulmonic pressures.

6. Indications Air leaks from the lung into the chest (pneumothorax)
Bleeding into the chest (hemothorax)
After surgery or trauma in the chest (pneumothorax or hemothorax)
Lung abscesses or pus in the chest (empyema).

7. WHERE IS THE CHEST TUBE INSERTED?
Two sites: anterior and lateral.
ANTERIOR CHEST TUBES: Landmarks- Second (2nd) intercostal space in the mid clavicular line.
LATERAL CHEST TUBES: Landmarks - between the mid - axillary line, the anterior axillary fold and the level of the nipple / 5th intercostal space.

11. There are different sizes of chest tube

12. Nursing skills and observation

13. DRESSINGS
A piece of gauze around the tube entry site into the skin is sufficient.
Cover the tube and gauze with an opsite or tegaderm dressing.

14. CHEST XRAY
Ordered post insertion of the chest tube and daily thereafter.
The nurse must ensure that chest x-rays is available to assess the position of the chest tube on the chest x-ray.

15. Position the patient to permit optimal drainage
(1)   High Flower’s position to drain fluid (hemothorax)
(2) Semi-Flower’s position to evacuate air (pneumothorax)

16. ASSESS AND REPORT ANY OF THE FOLLOWING
Sudden drop of Sa 02 < 90%
increased restlessness and anxiety of the patient.
tympany or hollow sound on chest percussion.
Report immediately chest drainage of >200mls of blood in a 1 to 2 hour time frame.

17. Strip or milk chest tube by orders only.
Chest drainage system, which should be upright and below level of tube insertion.
 Maintain tube connection between chest and drainage tubes and drainage bottle intact and taped.
(1)   Water-seal vent must be without occlusion
(2)   Suction-control chamber vent must be without occlusion when suction is used

18. Documentation If chest tube is draining fluid, indicate time
(e.g., 0900) that drainage was begun on drainage bottle’s adhesive tape or on write-on surface of disposable commercial system.
Monitor and record character of drainage .
Document and report immediately chest drainage of >200mls of blood in a 1 to 2 hour time frame.
Continuous Sa 02 monitoring. to keep 02 Sa > 96%.

19. Observe the swings of fluid in the chest tube bottle.
With inspiration water will rise up into the chest tube.
with expiration, water will fall.
if the swing is less than 2 cm, the lung is not likely to be fully expanded and therefore suction may need to be increased.

20. NEVER CLAMP the chest TUBE: WHY??
Because somebody may forget to remove the clamp and a tension pneumothorax may develop.
Two tubing clamps should be left at the patients bedside to clamp the tube in the event of emergency action being required if the tubing became dislodged from the chest tube bottle and air is at risk of entering the chest cavity.

21. Chest tubes are only clamped under specific circumstances
To assess air leak.
To change disposable systems; have new system ready to be connected before clamping tube so that transfer can be rapid and drainage system reestablished.
To change a broken water-seal bottle in the event that no sterile solution container is available.
To assess if patient is ready to have chest tube removed

22. Contents of the chest bottle
The contents of the chest bottle should be sterile solution that is not toxic to the lungs should the fluid inadvertently enter the chest. Therfore, water, saline or dextrose

23. Problem solving situations

24. Problem:  Air leak
Continuous bubbling is seen in water-seal bottle/chamber, indicating that leak is between patient and water seal.
Locate leak.
Tighten loose connection between patient and water seal because Loose connections cause air to enter system.
Leaks are corrected when constant bubbling stops

25. Cross-clamp chest tube close to patient’s chest, if bubbling stops, air leak is inside the patient’s thorax or at chest tube insertion site.
Unclamp tube and notify physician immediately!
Warning:         Leaving chest tube clamped caused a tension pneumothorax
(c)        Reinforce chest dressing.

26. Problem: Tension pneumothorax
Severe respiratory distress or chest pain
Determine that chest tubes are not clamped, kinked, or occluded. Locate leak.
Obstructed chest tubes trap air in intrapleural space when air leak originates within patient.
Absence of breath sounds on affected side
Notify physician immediately

27. Mediastinal shift to unaffected side, tracheal shift to unaffected side, hypotenstion or tachycardia
Immediately prepare for another chest tube insertion.
Obtain a large-guage needle for short-term emergency release or air in intrapleural space.
Have emergency equipment (oxygen and code cart) near patient.

28. Problem: Water seal is disconnected
Connect water seal
Tape connection
Problem:  Water-seal bottle is broken
Insert distal end of water-seal tube into sterile solution so that tip is 2 cm below surface
Set up new water-seal bottle
If no sterile solution is available, double clamp chest tube while preparing new bottle

29. Removal of a chest tube
Explain procedure to patient and place in a position of comfort.
Remove sterile dressing.
Cut suture and …. Ask patient to take a deep breath and hold it - then remove the tube and place a sterile piece of gauze and airtight over the site.

30. Thank You