1. Chest Tubes Modified by Darlene “Cookie” Wilson, RN, MSN
by Charlotte Cooper RN, MSN, CNS
modified by Kelle Howard RN, MSN
Modified by Darlene “Cookie” Wilson, RN, MSN

2. Thoracic Cavity Lungs Mediastinum Heart Aorta and great vessels
Esophagus
Trachea

3. Breathing: Inspiration
Diaphragm contracts
Moves down
Increasing the volume of the thoracic cavity
When the volume increases, the pressure inside ________.
aka?
Pressure within the lungs is called intrapulmonary pressure
Pressure DECREASES
Aka -- intra thoracic pressure

4. Breathing: Exhalation
Phrenic nerve stimulus stops
Diaphragm relaxes
This ______ the volume of the thoracic cavity
Lung volume decreases, intrapulmonary pressure _____
Lung volume ---- decreases
Pressure – INCREASES
Lungs are naturally elastic – once stretched – they RECOIL
Pressure inside is greater than pressure outside --- cheeks will puff out

5. Physics of Gases
If two areas of different pressure communicate, gas will move from the area of higher pressure to the area of lower pressure

6. Pleural Anatomy Parietal pleura lines the chest wall
Visceral pleura (pulmonary)
covers the lung
The negative pressure (or vacuum) between the 2 membranes is what helps hold the pulmonary pleura in close contact with the parietal pleura.

7. Normal Pleural Fluid Quantity: Approx. 10-20 mL per lung
Pleural Anatomy
Visceral pleura
Parietal pleura
Lung
Intercostal muscles
Ribs
Constantly produced and resorbed
mL produced daily
Normal present at any one time mL
Normal Pleural Fluid Quantity: Approx mL per lung

8. Pleural Physiology
The area between the pleura is called the pleural space (sometimes referred to as “potential space”)
Normally, vacuum (negative pressure) in the pleural space keeps the two pleura together and allows the lung to expand and contract
It is also what holds the 2 pleura’s together.
Negative pressure --- below atmospheric pressure
*****************************************
During inspiration, there is always negative pressure in the intrapulmonary cavity.
When air, fluid or blood enters between this two spaces it is called a pleural space – Not normal and results in labored breathing.
The in rush of air causes the vacuum to escape – causing the lungs to partially or fully collapse.
Why do they collapse? The lungs rely on the negative pressure to ensure expansion.
If pressure continues to build and can not be released, the individual will get a Tension pneumothorax –
If left untreated…there can be a medial sternal shift with serious complications. Solution? Chest Tube…. Similarly, if blood fills and it needs to be drained…Chest Tube.

9. Review Questions
A&P of chest (You tube

10. What happened? Air enters --- pressure causes lung collapse
Damage or trauma b/t the Parietal pleura and the Pulmonary pleura

11. What is this?
Pleural effusion, pneumothorax

12. What is this? archive.student.bmj.com/.../02/education/52.php
Tension pneumonia
Tension pneumothorax: a one way valve allows air into the pleural space during inspiration but not out during expiration
archive.student.bmj.com/.../02/education/52.php

13. What is this? What is this movement called?
Fig 3 Flail chest. The flail segment moves paradoxically during respiration
On inspiration the flail section sinks in with mediastinal shift to the uninjured side
On expiration, the flail section bulges outward with mediastinal shift to the INJURED side
Paradoxical movement

14. Flail Chest

15. What do you do when a Pleural Injury occurs?
Chest Tube to remove the fluids

16. Pleural Injury: Therapeutic Interventions
Diagnostic tests
Client position
Treatment depends on severity
Chest tube
Heimlich valve on chest tube
Visual assessment
Xray CT

17. Chest Tubes Different sizes From infants to adults
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
Different makers, Different materials – but they all do the same primary function…
Drain Fluid
Restore negative intrapulmonary pressure

18. Chest Tube Placement
In what setting/environment is a chest tube placed?
A. Operating Room
B. Bedside
C. Emergency Room
D. All of the above
E. None of the above
OR - usually through thorocotomy
ED - sitting position or lying down with affected side elevated
Bedside

19. Chest Tube Placement
--- IF AIR is removed anteriorly Second intercostal space
requires dissection of pectoral muscles
----IF FLUID is removed – posteriorly , 8th – 9th intercostal space
Some are using 4th-5th anterior or midaxillary line
AIR – tube is directed apically
Fluid – tube is directed inferiorly and posteriorly

20. Chest Tube Placement

21. Chest Tube Placement Procedure
Sterile technique
Small incision
Tube is sutured
Dressing applied
What type?
Can the client have 2 chest tubes?
When the tube is placed, is it clamped or unclamped?
why or why not?
Dressing type
Some use gauze –
Some use petroleum jelly
2 chest tubes
yes use y tube connector
Clamped – keep air from going in

22. Chest tube insertion Choose site Suture tube to chest
Explore with finger
Place tube with clamp
Photos courtesy trauma.org\

23. Chest tubes in place

24. Heimlich Valve
This is a one way valve that prevents fluid and air from going back into your chest.
The Heimlich Valve and Drainage bag allows the pt to walk around more freely without having to carry long tubing and a large collection system.
Some patients go home with a chest tube, Heimlich valve and drainage bag. (They stay in until excess fluid and or air in your chest is gone and your lungs stay inflated.)

25. Heimlich Valve What are some problems with this valve?
One is that the chest tube can clog. When this occurs, the pneumothorax or subcutaneous emphysema can recur. The other is that these tend to leak fluid. To address this, some have turned to small chest tube drainage alternatives, such as the Atrium Mini or the Teleflex Mini Sahara

26. 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

27. 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

28. Interventions Dressing changes No dependent loops Oxygen therapy
When?
No dependent loops
What is this?
Why?
Oxygen therapy
Record output
How often?
Analgesics
***IS and turn, cough, deep breathe
Output ---- q1h – q4-8hrs upon intsertion

29. What about dependent loops?

30. 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 respiratory symptoms
Pertinent nursing problems
Acute pain
Ineffective airway clearance
Impaired gas exchange
Home care

31. How a chest drainage system works

32. Purpose of Chamber One:
Correct any fluid coming back from the patient.
Purpose of Chamber Two:
Water seal, one-way valve allows air out of the patient but not back into the patient.
Purpose of Chamber Three
Suction control. Manual or Fluid filled (most hospital systems)

33. Prevent Air and Fluid Backflow
Tube open to atmosphere vents air
Tube from patient
Bottle # 2

34. 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

35. How a chest drainage system works
Expiratory positive pressure
Gravity
Suction

36. How a chest drainage system works
Expiratory positive pressure from the patient helps push air and fluid out of the chest (cough, Valsalva)
Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest
Suction can improve the speed at which air and fluid are pulled from the chest

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

38. From box to bedside

39. Water suction on left Dry suction on right Lewis p. 589 Fig 28-8

41. Atrium Chest Tube System
Chamber A
Suction control chamber
How do you know what level the water should be at?
Chamber B
Water seal chamber
Should the ball be fluctuating in this chamber?
What if it isn’t?
Chamber C
Air leak monitor
What does bubbling mean?
Chamber D
Collection chamber
When do you record output?
A – per md order
B – 2cm
intrathoracic pressure ---- blue water & float ball plus suction control setting
no suction – just float ball height
Yes there should be fluctuation – with breaths
If not – the lung has most likely reexpanded, has a clot, or is kinked,
C –
Be sure you under stand how to set up the system, the function of each chamber and how to troubleshoot issues with each chamber.

44. Monitoring 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?

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

46. Assessment Cardiovascular assessment Level of consciousness Pain
Chest tube
Amount of drainage
Insertion site & dressing
Insertion site & dressing

47. Interventions r/t chest tubes
System position
Tubing position
What happens when the patient lays on it?
Connections to patient and system
Assessing the system
Monitoring output
SYSTEM – floor stand,
what about bed rails
TUBING No dependant loops, strait as possible, below level of chest
CONNECTIONS – keep tight, taped
OBSERVE SYSTEM periodically & on initial assessment
OUTPUT
report greater than 100mls/hr

48. Complications What are some common complications?
Pleural effusion, pneumothorax
Air leak
Medistinal shift

49. Complications & Troubleshooting
Chest tube malposition (most common)
Subcutaneous emphysema
What is this?
What are some nursing interventions related to this complication?
High Fluid in Water Seal Chamber
Chest system may need to be vented
Air leak
How do you know?
What do you do?
Others
pleural effusion, inc. pneumo
mediastinal shift
Do chest tubes get clotted off?
What can happen when fluid is removed too fast?
MALPOSITION
monitor resp status changes, decreases in output,
SUBCUTANEOUS EMPHYSEMA
Crackles under the skin -- air under subq tissue
Mark area outlining the margins – monitor – usually resolves.
High fluid in WATER SEAL chamber
use high negativity release valve on system to release residual pressure (FILTERED MANUAL VENT)
usually caused by stripping or milking or deep inspiration after air leak resolves
SYSTEM MUST BE ON SUCTION
AIR LEAK
Bubbles from Right to left in section C ---- confirms air leak\
continuous bubbling means persistent air leak
intermittent bubbling (with float ball oscillation) means intermittent air leak
No bubbling with minimal float ball oscillation – means no air leak
What do you do?
Clamp starting at the pt --- look for cease in bubbling
when cease occurs --- leak is above the clamp
CLOTTED OFF
turn off suction --- see that float ball moves with inspiration
FLUID off to too fast
reexpansion pulmonary edema, hypotension keep at max of 1000ml at one time

50. If chest tube comes out?
Sterile – vented dressing

51. 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 has been knocked over
Note the amount, color and consistency of drainage

52. Review
mVBk (Atrium’s Set Up part 2, 2:47)
e8 (set up part 3 – to 5 mins)
Qxm34&playnext=1&list=PLFCFEACCE12F1D 1E0&index=26 (dry suction – start at 5:10)

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

54. 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

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

56. Portable chest drainage system

57. PleurX Catheter
The PleurX® pleural catheter system from CareFusion provides effective at-home palliation of symptoms of recurrent pleural effusions.
Traditionally, patients suffering from recurrent pleural effusions have faced extended hospitalization, discomfort and time away from home with unscheduled visits to a physician office or ER to relieve the pain and discomfort of fluid buildup. The PleurX® system is a clinically-proven treatment option that allows patients to manage their symptoms through intermittent drainages in the comfort of their homes.
With the PleurX® in-dwelling catheter system, you can help your patients spend more time at home and less time fitting into your procedural schedule.

58. Removing the Chest Tube
If time permits
Oasis dry suction set up
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59. The END
Thank you, Thank you, Thank you, Thank you, etc.