1. CHEST TUBES

2. Objectives:
Discuss the anatomy of the chest and the mechanism of respirations
Discuss the indications for a chest tube
Discuss the structure and function of the chest bottle (drainage system)
Troubleshoot the problems with/maintain chest tubes and chest tube bottles

3. Inspiration: Expiration: Lung expansion Ribs move outwards and upwards
Diaphragm moves downwards
Expiration:
Decreased lung volume
Ribs move inwards and downwards
Diaphragm moves upwards

4. Pleura:
Lungs are surrounded by two thin layers (films) called the pleurae They function as lubricant, preventing the lungs from rubbing with the rib cage during inspiration and expiration
Visceral:
Outside the lungs
Parietal:
Inside the ribcage
The area between the two pleurae is filled with a fluid called the pleural fluid (that fills a pleural space)
The pleural fluid acts as a lubricant so the two films don’t rub each other

5. THE PLEURAL SPACE HAS ALWAYS A NEGATIVE PRESSURE. OTHERWISE,
THE LUNGS WILL COLLAPSE

6. Pleural Pressure:
The degree of negativity changes throughout the respiratory cycle
Intrapleural pressure normally ranges from –(4) to –(10) cm of water
Inspiration pressure drops to –(10) cm water
Expiration pressure rises up to –(4) cm water
It is the pressure variance that allows the air to move in and out easily

7. Definition of the chest drainage
Is the insertion of a tube into the pleural and/or mediastenal space and a physician order required for the type of evacuation force: a-normally 20cm for adult
b-10-15cm for pediatric
The drainage must be kept always lower than the patient to prevent backflow of fluid into the pleural or mediastinal space.

8. Indications of a Chest Tube:
Pneumothorax
Hemothorax
Hemopneumothorax
Pleural Effusion
Empyema
Drainage

9. Chest tube location
For evacuation of air: 2,3,4 intercostals space are commonly used sites.
To drain fluid : 5,6 intercostals space are commonly used sites.

10. CHEST DRAINAGE SYSTEM UN
DEUX
TROIS

11. Fluid Collection Chamber:
Collects fluid as it drains from the pleural space or mediastinal space
Water Seal Chamber:
Acts as a one way valve, allowing air to escape from the patient and never return back. Always 2 cm of water.
Suction Control Chamber:
Controls the amount of suction applied directly to the patient. It improves the rate and flow of drainage.

13. Subcutaneous Emphysema:
When the lungs or the air passages are injured, air may enter the tissue planes and pass for some distance under the skin.
The tissues give a crackling sensation when palpated, and the subcutaneous air produces an alarming appearance as body becomes misshapen.
It is not a serious complication if the air is spontaneously absorbed or stopped, or if the leak is treated.

14. Chest Tube Assessment: STOP
S=SITE
T=TUBING
O=OUTPUT
P=PATENCY

15. Site:
Check for:
Clean and dry dressing: change every 72 hrs ,use a prim pore dressing and clean with sterile technique.
Subcutaneous emphysema
1. palpate contious monitoring
2.notify doctor

16. Tubing: Connections are secured No dependent loops
Straighten periodically
Keep bottle below patient’s level
Tape the connections if 2 suction tubes are used

17. Output: Amount, type and color Mark regularly Document
Use the white on column
on the drainage chamber to
mark drainage level

18. Patency: A-water seal chamber
Assess the Water seal with the suction off
If water seal level is too high, it will be more difficult for air leave the chest
If the water is too low ,it leaves the water seal chamber at risk for exposure to air can cause a pneumothorax

19. Patency: B-Bubbling:
Bubbling means there is a leak in the system unless the patient has a pneumothorax.

20. How to Check for an Air Leak?
Clamp the tube below the dressing Bubbling continues?
No Leak is between patient and dressing
Yes
Continue clamping

21. Patency: C-fluctuation
When inspiration the water seal level will reach -10cm of negative pressure normally
When expiration the water seal level will reach -4cm of negative pressure normally
When fluctuation stopped so the tubing may be obstructed
If more than 2cm the drainage will decreased
If less than 2cm there risk of pneumothorax

22. Patency :D-suction drainage units
Assess the suction control water level when the suction is off
Excessive bubbling in the suction control chamber result in evaporation of the water which will decreased in applied suction and does not increase the pressure on the pleural or mediastinal cavity
Normally 80 mmhg of wall suction is required to ensure consistent delivery of suction

23. Patient Activity A semi-fowler position is required
Position and turn the patient every 2 hrs3
Patent can be out of bed if there is no contraindication
Do (ROM) exercises to the affected arm and shoulder site
Encourage coughing and deep breathing

24. Clamping: Clamp only when: Don’t clamp when: Changing the bottle
Checking for an air leak
Tubing is disconnected and sterile water is out of reach
If changing the position and when elevating the tube system above the patient level is required
Don’t clamp when: :
Ambulating a patient

25. Milking: Milking the tube is not recommended.
It creates a pressure of –(400) to – (100) cm of water that can cause a tension pneumothorax

26. Problem solving...