1. Samantha Soto BSN, RN-BC University of Central Florida MSN Candidate
Chest Tubes
Samantha Soto BSN, RN-BC
University of Central Florida
MSN Candidate

2. Objectives
After participating in this class the learner will be able to…
Describe the anatomy and physiology of the lung
Identify potential conditions requiring need for a chest tube
List equipment and supplies used to place, maintain, and remove chest tubes
Outline the process of insertion, maintenance, and removal of chest tubes

3. Anatomy & Physiology Thoracic Cavity R Lung: 3 lobes L Lung: 2 lobes
Mediastinum: heart, aorta, esophagus, & trachea
Diaphram: separates thoracic cavity from abdomen
Visceral Pleura: covers the lungs
Parietal Pleura: lines the chest wall
Right Lung
Left Lung
Mediastinum
Parietal Pleura
Visceral Pleura
Diaphragm

4. Pleura Anatomy area between the pleura is called the pleural space
the pressure between the pleural space is always negative
negative pressure is suction
Normal pleural fluid quantity is small. There is no set number or calculation, and it is based on size.

5. Breathing Inhalation Exhalation Up Down (Carroll, 2010)
The brain stimulates the phrenic nerve when its time to breath. The phrenic nerve then stimulates the diaphragm to contract, to move DOWN. This allows for a volume increase in the thoracic cavity.
Air moves from an area of higher pressure to an area of lower pressure. Occurs when the phrenic nerve stimulus stops, the diaphragm moves up the chest, reducing the volume of the thoracic cavity and air flows out of the lungs to the area of lower atmospheric pressure, UP.
(Carroll, 2010) Up
Down

6. Conditions that require Chest Tubes
Pneumothorax
A collapsed lung is the collection of air in the space around the lungs. This buildup of air puts pressure on the lung so it cannot expand.

7. Conditions that require Chest Tubes
Open Pneumothorax
stab wound, gun shot wound, surgery where air would leak in to the thoracic cavity from the outside; also known as a “sucking chest wound”

8. Conditions that require Chest Tubes
Closed Pneumothorax
disruption of lung and visceral pleura
results when air leaks from a ruptured bronchus or a perforated esophagus and eventually ruptures into the pleural space.
Can progress to a tension pneumothorax

9. Conditions that require Chest Tubes
Hemothorax
Large Plueral Effusions
Transudate is a clear fluid that collects in the pleural space when there are fluid shifts in the body from conditions such as CHF, malnutrition, renal and liver failure(Carroll, 2010) Exudate is a cloudy fluid with cells and proteins that collects when the pleurae are affected by malignancy or diseases such as tuberculosis and pneumonia(Carroll, 2010)
transudate or exudate in the pleural space usually from CHF and Cancer
blood in the pleural space

10. Conditions that require Chest Tubes
Tension Pneumothorax
air can get in, but not OUT
there is an obstruction and an accumulation of air under pressure in the pleural space. This condition develops when injured tissue forms a 1-way valve, allowing air to enter the pleural space and preventing the air from escaping naturally

11. Conditions that require Chest Tubes
Mediastinal Shift
a shifting or moving of the tissues and organs that comprise the mediastinum (heart, great vessels, trachea and esophagus) to one side of the chest cavity. The condition occurs when a severe injury to the chest causes the entrapment of air in the pleural space
Very serious condition and requires attention immediately; can lead to cardiac arrest
Worsening closed/tension pneumothorax

12. Conditions that require Chest Tubes
Thoracic surgery
Coronary Artery Bypass Graft (CABG) and Valve replacements
Chest tubes are used to drain the chest cavity of fluid and blood (which is temporary and normal) after surgery.
Occasional placement of tubes in the left or right pleurae are used for collapsed lung during and post procedure

13. Signs & Symptoms Dyspnea Tachypnea Tachycardia Chest pain Crepitus
Decreased breath sounds on the side where the pneumothorax is
Cough
Fatigue
Cyanosis

14. Diagnostic Tools
Pulse oximetry
Ausculatation
Chest x-ray
CT scan

15. Equipment for Chest Tube placement
Chest tube cart
Clamps
Pleur Evac
Vaseline guaze
Trocar
Chloraprep
Chest tube
Suction set up
Suture with needles
Dry sterile 4x4s
Some medications will be pulled from pyxis
Where do you get your equipment and what are your duties?
Not all chest tubes are placed at the bedside

16. Drainage Systems Heimlich Valve used primarily to release air Mobile
Pleur Evac
used for both fluid and air drainage
PluerX
used for effusions that rapidly reaccumulate

17. Insertion Diagram

18. Insertion Diagram

19. Maintenance of the Chest Tube
Vital Signs
with O2 sats as per hospital policy
q 15min x4, q 30min x2, q 1hr x4, then q 4hr until removed
Site
tape securely
check for bleeding, crepitus around insertion site,
mark it with a marker, if its growing…that’s could be a problem
assess color at insertion and for swelling or bruising

20. Maintenance of the Chest Tube
Tubing
Start at the insertion site and move down towards drainage system
You should never see any holes
Remove any loops
Check for patency/clots
Check color of fluid
DO NOT CLAMP a chest tube unless you have been instructed to or you are changing the drainage box
Do not strip or milk your chest tube

21. Maintenance of the Chest Tube
Pleur Evac/Drainage System
Do not touch sterile tip, you will hand this to the physician during insertion
Fill in the H2O chamber with sterile water
If air is leaking then you will see it in this chamber as shown. It is numbered 1-5 to indicate the grade of the air leak.
you will almost always have an air leak when the tube is inserted, but is resolves
Hang drainage box at the foot of the bed

22. Maintenance of the Chest Tube
Suction
You will set the suction dial on the Pleur Evac as ordered by the physician
The wall suction is increased until the orange buoy floats
Output
What does it look like?
Check for stop cocks
How much is ok, or not enough?
Mark the Pleur Evac at the beginning of your shift
Check the amount of drainage at least every 2 hrs.

23. Maintenance of the Chest Tube
What is water seal?
Water seal acts as a one way valve
Fluid and air can go out, but not back in.
What if your water seal is low?
You can refill it with a syringe and a bottle of sterile water
How often does the dressing need to be changed?
Daily unless it is saturated and needs to be changed sooner
Is this a sterile procedure?
No, but should be as clean a technique as possible

24. Patient Education Description of procedure IS and cough/deep breath
Ambulation/sitting up in chair(pts can do these things even with a chest tube!)
Pain management
The pt can expect to have chest x-rays performed daily until the tube is removed

25. When to call for HELP! My patient’s having trouble breathing
My patient’s sats are below 90% and staying there
My patient’s chest tube is making whistling noises
My patient pulled out their chest tube

26. Chest Tube Removal
A chest x-ray has confirmed that the patient’s problem has resolved or well enough to remove their chest tube
Your patient should have breath sounds over the affected area now
Drainage has also decreased significantly.
Sometimes a physician will ask that the chest tube be clamped for a few hours prior to removal
Usually a physician will order for a chest tube to be removed from wall suction and placed to water seal for a day prior to tube removal.

27. Chest Tube Removal What will you need?
Kelly Clamps to clamp the chest tube
Chloraprep or betadine swab to clean the site before you remove the chest tube
Suture removal kit-to remove the sutures
Vaseline gauze or Adaptic-to help create a seal
Dry sterile 4x4, that will go over the Vaseline dressing
Tegaderm or Occlusive Dressing (at first you want a dressing that will help make a seal)
Red Bag for disposal of the chest tube and Pleur Evac

28. Chest Tube Removal Procedure make sure you have an order first
Explain what your going to do to the patient.
The patient must be in bed, always
Pre-medicate: some physicians will pre-medicate for large bore chest tubes 15-30min prior to pull.
Practice breathing deep. Explain to the pt that on the third breath they will hold it until you say so, at that time you will pull the chest tube quickly
Get your red bag ready and place the Pleur Evac in the bag prior to pulling the chest tube
Clamp the chest tube with the Kelly Clamps

29. Chest Tube Removal Procedure continued… Remove old dressing
Cleanse the area with chloraprep or betadine prior to pull and make sure it is dry.
Remove sutures
As you pull the chest tube you will place the Vaseline gauze and dry sterile 4x4s.
Remind your patient to breath and that IT’S OVER!
Place Tegaderm over the gauze. Time and date the dressing.
Instruct your patient on when to call for help
Dispose of your waste in the red bin