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Chest tubes

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  • 1. Go with the Flow of Chest Tube Therapy By Arlene M. Coughlin, RN, MSN, and Carolyn Parchinsky, RN, MA Nursing2006, March 2.5 ANCC/AACN contact hours Online: http://www.nursing2006.com © 2006 Lippincott Williams & Wilkins
  • 2. The pleural space
    • Lies between the parietal pleura (membrane lining the chest cavity) and the visceral pleura (surrounds the lungs)
    • Holds about 50 ml of lubricating fluid
    • Creates a negative pressure that keeps the lungs expanded
    • Excess fluid or air accumulation in the pleural space limits lung expansion and leads to respiratory distress
  • 3. Chest tube indications
    • Pneumothorax: Air in the pleural space caused by trauma, lung disease, invasive pulmonary procedure, forceful coughing, surgical complication, or may occur spontaneously
      • To drain air, the chest tube is placed in anterior chest at the second or third intercostal space
    • Hemothorax: Blood in the pleural space caused by blunt/penetrating trauma or a complication of chest surgery
      • To drain fluid, the chest tube is placed at lung base
    • Pleural effusion: Excessive fluid in the pleural space caused by pneumonia, left ventricular heart failure, pulmonary embolism, cancer, or complication of surgery
  • 4. Chest tube indications
    • Chylothorax: Accumulation of lymphatic fluid in the pleural space caused by chest trauma, tumor, surgery
    • Empyema: Pus from an infection, such as pneumonia; must always be drained no matter how small amount
    • Other considerations: Preventively after cardiac/pulmonary surgery to drain blood postoperatively and prevent cardiac tamponade; also used to instill fluids (chemotherapy, sclerosing agent)
  • 5. Types of CDUs
    • Chest drainage unit (CDU): Traditional chest drainage unit consists of a collection chamber, water seal chamber, suction control chamber; can drain large amounts of fluid or air
    • Smaller/lighter portable CDU: Mechanical one-way valve instead of water seal chamber; good for patient who needs drainage only (not suction to reexpand lung), such as noncomplicated pneumothorax
  • 6. Types of CDUs
    • Heimlich valve: Contains a one-way flutter valve; air drains out when patient exhales; keep collection device upright and vented to prevent air buildup
    • Indwelling pleural catheter: Drains chronic pleural effusions; drains fluid only; can be done at home every 1 or 2 days or when short of breath
  • 7. Chest tube insertion
    • Done in patient’s room, interventional radiology, or the operating room
    • Local anesthetic; patient may feel pressure as tube is inserted
    • Aseptic (sterile) procedure
    • Patient’s breathing will be easier once lung is re-expanded
  • 8. Chest tube insertion
    • Position patient for comfort depending on site to be inserted
    • Tube will be anchored with a suture
    • Insertion site will have an occlusive dressing applied
    • Connections securely taped
    • Chest X-ray to confirm position and lung re-expansion
  • 9. Risks and complications
    • Bleeding: Usually minor, but may require surgery if extensive
    • Infection: Likelihood increases the longer the chest tube is in place
    • Subcutaneous emphysema: Characterized by swelling in face, neck, and chest; crackles on palpation
    • Lung trauma/bronchopleural fistula: Rare, but patient will have signs and symptoms of respiratory distress, bloody chest tube drainage; tube will be left in place until healed
  • 10. Nursing considerations
    • Monitor vital signs
    • Assess breath sounds bilaterally
    • Assess the insertion site
    • Encourage the patient to cough
    • Make sure connections are taped securely
    • Keep collection apparatus below the level of the patient’s chest
    • Check water seal and suction control chambers frequently
    • Assess drainage for color
    • Measure drainage every 8 hours or more often depending on patient’s condition
    • Document assessment
    • Report immediately bright red blood or red free-flowing drainage >70ml/hour
    • Reposition patient frequently
  • 11. Care of chest tube and drainage unit
    • Tubing: Avoid loops, aggressive manipulation such as “stripping” or “milking”
    • Patency: To maintain patency, try “gentle” hand-over-hand squeezing of tubing and release
    • Clamping: Avoid except when replacing CDU, locating air leak, or assessing when tube will be removed
  • 12. Removing the chest tube
    • Can remove chest tube when:
    • -- There’s little to no drainage
    • -- Air leak is gone
    • -- Patient is breathing normally without respiratory distress
    • -- Fluctuations in water seal chamber stopped
    • -- Chest X-ray shows lung reexpansion with no
    • residual air or fluid
  • 13. Procedure for chest tube removal
    • Gather supplies and explain procedure to patient
    • The clinician will remove the dressing and sutures
    • During peak exhalation, the clinician will remove the chest tube in one quick movement
    • Immediately apply a sterile gauze dressing containing petroleum to prevent air from entering pleural space
    • Monitor patient’s respiratory status
    • Arrange for chest X-ray to confirm lung reexpansion
    • Monitor patient’s respiratory status and Sp O 2 for 1-2 hours after removal
  • 14. Selected Web sites
    • MedlinePlus Chest tube insertion
    • http://www.nlm.nih.gov/medlineplus/ency/article/002947.htm
    • http://www.nlm.nih.gov/medlineplus/ency/imagepages/9968.htm
    • Nursewise.com: Chest tubes and drainage systems
    • http://www.nursewise.com/courses/chestubes_hour.htm
    • Pneumothorax.org: Is a pneumothorax affecting you?
    • http://www.pneumothorax.org/pneumo.nsf