1. Chest tubes are used to drain fluid or air from the pleural space to allow the lung to re-expand following a pneumothorax, hemothorax, or other condition. 2. Placement involves local anesthesia and insertion of a tube between the ribs and into the pleural space, which is then connected to a drainage system. 3. Ongoing nursing care includes monitoring drainage, ensuring tube placement and connections, and assessing for complications like continued air leaks, until removal criteria are met and the lung is fully re-expanded.

1. Chest Tubes

2. The Mechanics of Breathing
In normal situations, the pressure
between the pleura of the lungs is
below atmospheric pressure.
When air or fluid enters the intrapleural
space, the pressure is altered, and this
can cause collapse of a portion of the
lung.

3. Even with adequate oxygenation and
an open airway, a patient with a
collapsed portion of the lung will not
have adequate oxygen - carbon dioxide
exchange.
The only treatment for this altered
condition is to restore the negative
pressure to the intrapleural space. This
is accomplished through the use of a
chest tube.

4. Pneumothorax

6. Indication of Chest Intubation
Drain pleural fluid or air promote lung
expansion
1. Pneumothorax
2. Hydrothorax
3. Hemothorax
4. Chylothorax
5. Pyothorax
6. Post-thoracotomy etc.

7. Size of Chest Tube
Adult or Teen Male 28-32 Fr
Adult or Teen 28 Fr
Female
Child 18 Fr
Newborn 12-14 Fr

8. Pleural aspiration/drainage:
Complications: Pneumothrax, apprehension,
increase restlessness, tension pneumothorax,
dysponea, chest pain, tachycardia, etc.
Position : Pneumothrax = 2nd ICS
: Haemo/pyo thorax = 4-6th ICS.
2009 Trauma Guidelines: 5th Intercostal
Space, outer side of mid axillaries line.

11. Nursing Assessment Findings
Diminished or absent Decreased oxygen
breath sounds on saturation
affected side. Increased Peak Airway
Decreased chest wall Pressures
movement on affected Cyanosis
side. Complaints of pleuritic-
Difficulty breathing. type chest pain
Tachycardia Increased respiratory
Anxiety rate
Restlessness Pain may worsen when
attempting to breathe
deeply

12. Equipment needed for Chest Tube
Setup
2- 1000cc bottles
Chest tube
of sterile water or
insertion tray
Plastic bag
Tube (appropriate
4 x 4’s gauze pad
size)
Suction setup
Local Anesthetic
(Xylocaine) Suction tubing
Betadine (or other Chest tube
antiseptic) collection system
Suturing supplies Vaseline Gauze
Sterile gloves Tape

13. Surgical Procedure Steps

17. Apparatus of Chest Tube Drainage: (old method)
1. Underwater sealed bottle: Separate from
atmosphere
2. Collecting bottle: Decrease resistance of
drainage
3. Negative pressure suction: Promote lung
expansion
Recently we use chest tube with plastic bag

19. Insertion
The patient will need to be positioned
according to where the chest tube will be
placed.
Typically having the patient’s arms over
their head.
Pre-medicate the patient with sedation &
pain medicine as per order.

20. Procedure of Chest Intubation
1. Local anesthesia, confirm location
2. Skin incision at selected area with 11 no blade
3. Dissect into pleural cavity thru a subcutaneous
tunnel
4. Locate pleural cavity
5. Insert tube posteriorly and laterally
6. Close incision wound, fixed the tube
7. Connect tube to underwater sealed bottle (or with
negative pressure suction)

21. Attention in Massive Subcutaneous
(Mediastinal) Emphysema:
1. Keep airway patent (even endotracheal tube)
2. CXR
3. Insert chest tube in pneumothorax or suspicious
side
4. Connect tube to negative pressure suction
immediately
5. Close thoracostomy edge slightly loose
6. Insert another tube if no improvement
7. Low O2 nasal cannula
8. Determine the cause & treat underlying disease
9. Remove tube after complete subsidence

22. Post-Insertion Documentation
Reason for chest tube Dressing type applied.
placement. Connections securely
Patient vital signs. taped.
Any medications given. Vital signs during/post
Location & size of chest tube. procedure.
Patient’s tolerance of Water level ordered & set
procedure. for suction control
chamber.
Drainage received (if any):
color, characteristics, Post-insertion chest x-ray
volume, etc. taken.

23. Maintenance of Chest Tubes
Cardiovascular assessments must be performed
every 4 hours at least for all patients with chest
tubes.
Encourage patient to cough & deep breathe.
Check insertion site every morning at 0800 and
replace dressing at that time.
Assess water levels in drainage unit each shift and
correct fluid levels if not as ordered.
Report to Physician immediately any change or
complication with the chest tube.

24. Dressing Change

25. Maintenance of Chest Tubes
Check all tubing connections and re-tape as
needed
I & O to be completed (and marked on
collection chamber).
Monitor for air leaks, chest x-ray results,
oxygen saturations, and peak airway
pressures.
Report any alterations immediately.

26. Maintenance of Chest Tubes
Keep tubing coiled on bed, NEVER allow
tubing to dangle.
Ensure that bedside collection unit
NEVER goes above chest level.

27. Tubing Placement

28. Potential Sources of Air Leaks
Poor tubing connections.
Tube dislodgement from pleural space.
Cracked bedside collection unit.
To locate air leak, clamp the tubing
momentarily at various points along tubing
length.

29. Nursing Care:
Informed consent signed.
Any allergy identified.
Sedative given if prescribe.
Inform patient about all procedures and
needs for better cooperation.
Make patient comfortable with adequate
support (Bedside, cardiac table, stand
chair).
Support and re-assure the patient during
procedure

30. Nursing Care:
After needle with drawn pressure applied at
site and small dressing applied.
Patient is kept on bed rest.
Record: details of fluid and any complains.
Evaluate Patients after procedure

31. Chest drainage.
Two chest drain may join with Y
Junction to same drain container. But
preferably leave separate.

32. Guidelines for the management
of chest drainage: (Plastic bag).
Drainage tube should be attached to chest
bag and submerged 2.5 cm below water
level.
Short tube left open to atmosphere.
Original fluid level should be marked and
daily/hourly recorded.
Drainage tube should be fastened to avoid
kinking.

33. Encourage Pt. to change position frequently.
Give adequate analgesic and encourage
physiotherapy.
Ensure fluctuation of fluid level.
Stop when: - Lung re-expand.
• Tube blocked.
• Dependent loop.

34. Watch for air leak-report immediately.
(Air bubbling in fluid column).
Avoid clamping: may create tension pneumothorax.
Observe and report – Rapid shallow breathing.
• Cyanosis
• pressure in chest.
• Subcutaneous emphysema.
• Excessive hemorrhage
• respiratory status and vitals.

35. Encourage deep breathing and coughing at
frequent interval.
Keep drainage bag below chest level.
Checking dressing.
Sterile gauze and a padded clamp should be
kept at the bedside for emergency use if tube
is accidentally dislodged or disconnected.

36. Drainage assessment: every hr till 24 hrs,
then 8 hrs subsequently.
Physician should notify if drainage exceed
100 ml/hr.
Assist physician while inserting and
removing tube. (e.g. ask pt. to hold breath)

37. Removal of Chest Tube
Indications
• No fluctuation in the fluid column of the tube
(complete lung reexpansion or tube occlusion)
• Daily fluid drainage <100ml in 24 hours (< 50 c.c./day)
• Air leakage has stopped
Proper timing (controversy)
• Spontaneous pneumothorax after thoracostomy
– removal tube within 6 hours of reexpansion--25% collapse

38. When to Remove Chest Tube ?
Criteria:
1. No air leakage
2. Drained fluid < 50 c.c./day
3. Clear serosanguineous color of fluid
4. Full expansion of lung in CXR
Clear sterile fluid remove directly
Turbid, infected fluid withdraw progressively

39. 9-S for successful, safe chest tube
insertion:
1. sedation: Adequate analgesia
2. Site: a safe area above the nipple, posterior
to the anterior axillary's fold should be
chosen. (5th ICS)
3. Sensitive: finger dissection will reduce
insertion complications.
4. Sterility: single dose antibiotic
:Prophylaxis
5. Suturing: to fix drain with heavy silk

40. 6. suction: applied to drain (=20 cm of water)
7. Seal carefully: on removal of tube
8. Side effects: RT poor technique
9. Sessions: CME/Procedural Exposure.

41. Thank You

42. Extra Slides

43. Components of the Chest Tube
Drainage System
Suction control
chamber
Water Seal Chamber
Collection chamber

44. Suction Control Chamber
The use of suction helps overcome
an air leak by improving the rate of air
and fluid flow out of the patient.
Lower the water content, lower the
suction. Raise the water level, raise
the amount of suction.

45. Water Seal Chamber
The water seal chamber which is
connected to the collection chamber,
allows air to pass down through a
narrow channel and bubble out through
the bottom of the water seal.
Continuous bubbling confirms a
persistent air leak.

46. Collection Chamber
Fluids drain
diirectly
from patient
into the
collection
chamber via
a 6’ patient
tube.

47. Preparing for Insertion
Gather supplies.
Prepare patient.
Open chest drainage
system.
Swing out floor stand
to stabilize the unit.
Close suction control
stopcock.

48. Components of the Chest Tube
Drainage System
Suction control
chamber
Water Seal Chamber
Collection chamber

49. Suction Control Chamber
The use of suction helps overcome
an air leak by improving the rate of air
and fluid flow out of the patient.
Lower the water content, lower the
suction. Raise the water level, raise
the amount of suction.

50. Water Seal Chamber
The water seal chamber which is
connected to the collection chamber,
allows air to pass down through a
narrow channel and bubble out through
the bottom of the water seal.
Continuous bubbling confirms a
persistent air leak.

51. Collection Chamber
Fluids drain
diirectly
from patient
into the
collection
chamber via
a 6’ patient
tube.