Chest Tube Management

1. Chest Tube Management

2. Definition Of Chest Tube
• is A sterile, a flexible, nonthrombogenic
plastic catheter( silicone tube) that is
inserted through the side of the chest into
the pleural space. , has several eyelets--
small holes--to drain air or fluid and to
prevent catheter occlusion. The distal end
connects to the CDU.

3. The diameter selected depends
on the patient's condition
1.Size #12 to #26 French is adequate for a
pneumothorax
2. Size #28 to #40 French, is needed to drain
accumulated fluid, such as from a pleural effusion
purpose:
• To Help Regain Negative Pressure Whenever The
Chest Is Opened
• Promoting Lung Re Expansion
• To remove blood, air, fluid, and pus from inside
chest because of an injury or illness this may cause
lung collapse

4. Indication of Chest Tube:
1. Resolve pneumothorax (accumulation of air in the
pleural space )
2.Hemothorax (accumulation of blood in the pleural
space )
3. Pleural effusion (accumulation of fluid in the pleural
space )
4. To drain blood from the mediastinum after open-
heart surgery.
5.Prevention of cardiac tamponade after open-heart
surgery
6.Empysema(collection of free air or gas in the tissue
under skin)
7. Empyema (lung abscess or pus in the chest)

5. site of insertion& Positioning the
Patient for Chest Tube
Placement
TUBE PLACE FOR EACH INDICATION
• A pneumothorax
Tube place: , into the second or third
intercostals space in the anterior
chest at the midclavicular line
,because air rises to the top of the
intra pleural space
Patient position: will be placed in the
supine, high-Fowler's or semi-
Fowler's position,

6. 2.Hemothorax
Tube place: , The chest tube is
inserted between the fourth
to sixth intercostal space at
the midaxillary line
Patient position: the patient will
be sat up and leaned over a
bedside table.
The patient may also straddle
a chair, with the arms
dangling over the back.

7. Pleural effusion/ Empyema
Tube place: , Posteriorly into the fifth or sixth
ICS
• Contraindications
coagulation disorder that can not be
corrected are absolute contraindications.

8. Complications
• Major complications
1- .Tension pneumothorax, a life-
threatening emergency, occurs when the
air accumulating in the pleural space
increases pressure to a dangerous level,
causing a mediastinal shift that pushes the
heart, great vessels, trachea, and lungs
toward the unaffected side.

9. Sign of tension pneumothorax
• Decreases lung expansion, venous return,
and cardiac output.
• Severe respiratory distress, tracheal
deviation to the unaffected side, cyanosis,
muffled heart sounds, and
possibly cardiac arrest

10. 2- Hemorrhage.
3- Hypotension (vasovagal response) .
Minor complications
1. Subcutaneous hematoma
2. Anxiety
3. Dyspnea an cough (after removing large
volume of fluid).
4. Bleeding from an injured intercostals artery
(running from the aorta)
5. A local or generalized infection from the
procedure

11. Chest Tube Description System:
Chest drainage unit. All CDUs
divided to three basic
components: a collection
chamber, a water-seal chamber,
and a suction-control chamber or
regulator.

13. Water-seal chamber:
This acts as a one-way valve so air can
drain from the chest cavity but can't
return to the patien.
You can use the water-seal chamber to
monitor your patient's intrapleural
pressure. The water level fluctuates as
the pressure changes.

14. 2. Suction-control regulator.
• Water-filled or dry suction removes chest
drainage and maintains the flow .To regulate
suction, connect the CDU's vacuum line
tubing to wall set the CDU suction to the
ordered level, usually -20 cm H2O
• Gentle ,moderate bubbling indicates that the
external source is adjusted correctly.
• Rapid loud bubbling indicates that the out
side suction source is set too high,
• absent or minimal bubbling that its set too low

15. 3.collection chamber
• Grade labeling on the chamber allow
quantification of the amount of fluid
drainage

16. pre insertion patient assessment
&nursing intervention
1.Closely monitor his vital signs
(BP_HR_RR_SO2.)&breath sounds
2. Make sure he has intravenous access
3.Administer 2 to 4 liters/minute of oxygen via
nasal cannula
4.Monitor his pulse oximetry. Adjust the FIo2 to
a target Spo2 of 94%;

17. 5. Keep the head of bed position at 30 degrees
or higher to Promote chest expansion .
6.Watch for changes in his level of
consciousness, orientation, and
responsiveness.
7. Be alert to anxiety, restlessness, and central
cyanosis, which can be early signs of
hypoxemia.
8. Probably order a chest X-ray as diagnostic
tool, showing black areas where the lung is
collapsed

18. 9. Arterial blood gases (ABGs) the ABGs will reveal
respiratory alkalosis caused by tachypnea,
10.Assess coagulation profile& patient allergies.
11.Make sure a signed consent form for the procedure
is in his chart
12.. He'll probably be anxious and in pain, so
administer pain medication
13 Assure O2 and suction are available at bedside.

19. Caring of patient with chest tube
Aim: To Promote drainage and lung expansion.
1.check the chest tube
• insertion site, location and tube size
• drainage for amount, color and consistency
• dressing for conclusiveness and drainage from
insertion site
• chest wall at insertion site for subcutaneous
emphysema

20. 2.Assess drainage collection system for:
• A. fluctuations in the air leak indicator
• B. air bubbles in the air leak indicator
• C. suction set at ordered level.

21. 3.check the patient
• A. comfort level head up 45c
• B. vital sign stable(rr_hr_so2_bp)
• C. Assure chest x-ray is obtained after
insertion

22. 1.Encourage your patient to cough and
breathe deeply. (physiotherapy)
2.Teach him how to splint the insertion
site (chest support)
3.make sure you administer pain
medications as needed .(PRN)
4.Encourage him to change position at
least every 2 hours. He can lie on the
side with the chest tube if he can keep
the tubing free of kinks.

23. Warning :The patient's position influences
drainage, so don't be alarmed if you note a
sudden gush of output the first time he sits up. If
he has a hemothorax, pleural effusion, or
empyema and he's been supine for a while ,If
he's well enough to walk in the hall or encourage
him to ambulate as desired.
5.Monitoring drainage output. Monitor and record
the amount and characteristics of the chest tube
drainage as ordered or according to your unit's
policy, . Notify the clinician of excessive output.
Coil the tube on the bed

24. warning:
• When your patient has a pneumothorax,
expect little if any output because the tube
is draining air, not fluid.
• if he has a hemothorax, a lack of drainage
may indicate a clot obstructing the tube.

25. 6. Dressing changes. Change the dressing
on the insertion site as ordered or
according to hospital policy.
• Change dressing QD, or more frequently,
if it becomes soiled, saturated, loose, or as
otherwise instructed by prescribe
• If it's dry and you don't see evidence of
infection, you probably won't change it
until the third day after insertion.

26. 7.make sure that the tubing doesn’t loop or
interfere with the patient movement
8. Position the drainage system in upright
position, below level of the heart at all
times
9.check the chest tube connection
periodically

27. Problems solving with chest tubes
Q: What if the chest tube becomes dislodged?
A: Immediately cover the site with a dry sterile
dressing and call the clinician. If you hear air
leaking from the site, tape the dressing on only
two or three sides to allow air to escape and
prevent a tension pneumothorax. Closely
monitor the patient and prepare for insertion of
a new chest tube.

28. Q: When should I change the CDU?
A: Change it if it breaks or it's full: Prepare the
new CDU according to the manufacturer's
instructions. Remove the current CDU from
suction, clamp the chest tube with a rubber-
tipped hemostat, and disconnect the
connecting tube from the CDU. Quickly
connect the new CDU, unclamp the tube, and
secure all connections according to your
unit's policy. Resume suction and assess the
CDU chambers for normal function.

29. Q: What if the chest tube becomes
disconnected from the chest drainage
unit (CDU) or the CDU breaks?
A: Submerge the chest tube's distal end
in 1 inch (2.5 cm) of sterile 0.9% sodium
chloride solution or water in asterile
container. This will create a liquid seal
until you prepare and attach a new
CDU. Securing the tube connections
and properly positioning the CDU help
prevent disconnection or breakage.

30. Q: When should I do milking?
lack of drainage may indicate a clot obstructing
the tube
Milking - Starting at the top of the connecting
tubing, squeeze the tube with one hand, grasp
just below with other hand and squeeze this
area while releasing with the first hand.
Continue this process along the length of the
tubing
Q: When should I do clamp?
A. changing the chest tube system
B. assessing for location of air leak
C. assessing patient's tolerance of chest tube
removal
Q: What the air leak?
Continues bubbling is seen in water seal
chamber

31. Q: what you nursing intervention toward air
bubbling?
1.Assess the insertion site ,indicate the leak
between the patient and water seal
if leak hearing do dressing and call the
physician
2.if still bubbling seen, check the connection
tube if loose or broken
do tube clamp, prepare another tubes and call
the physician
3. if still bubbling seen, check the drainage
system if broken
, prepare another drainage system and call the
physician

32. Q: When should I change the CDU?
A: Change it if it breaks or it's full: Prepare the
new CDU according to the manufacturer's
instructions. Remove the current CDU from
suction, clamp the chest tube with a rubber-
tipped hemostat, and disconnect the
connecting tube from the CDU. Quickly
connect the new CDU, unclamp the tube, and
secure all connections according to your
unit's policy. Resume suction and assess the
CDU chambers for normal function.

33. Q: when bubbling is normal?
1.the patient is first connected to the
drainage system
2.the fluid drainage displace air into
collection chamber
3.patient has air leak in pleural space
noted when he exhales or coughs

34. Q: what is tidaling?
Fluctuation in the fluid level indicate
pressure changes in the pleural space,
which occur when your breathes
The water level fluctuates as patient
breathes,
it goes up when the patient inhale and
down when the patient exhales

35. Q: when the fluctuation stopped?
1.Lung is re expanded
2.The tube is obstructed by blood clots or
fibrin
3.Adependent loop develops
4.Wall suction is not operating properly

36. Chest Tube Removal
The following criteria must be assessed
prior to the removal of chest tubes:
Minimal drainage: (less than a total of
10ml/hour/tube for six hours prior to
removal).
Absence of air leak : by having the
patient take a deep breath and cough. If
bubbling it seen, the chest tube is not
removed and the physician is informed

37. Stable Respiratory Status: the patient's
respiratory status has improved, i.e..
non-laboured respirations, absence of
shortness of breath (dyspnea) and
respiratory rate less than 30 breaths
per minute, and breath sounds are
audible bilaterally, and type/amount of
ventilatory support has stabilized.

38. Coagulation status--if current
Coagulation are not within normal
range, this should be reported to the
physician before tubes are pulled--
removal of the tubes when the coags
are high may increase the risk of
bleeding
A written physician's order for chest tube
removal

39. Procedure
1.Assess chest drainage for air leak.
Do not remove chest tubes if drainage is
> 10ml/hour/tube or if air leak is present.
2. Explain the procedure to the patient. have
the pt practice taking a deep breath and
holding it a few times.
3. Obtain an assistant to help with the
dressing application.

40. 4. Premeditate the patient with pain
medication.
to Reduces potential discomfort and
analgesia as anxiety, facilitating patient
cooperation.
5. Discontinue suction of the chest tube

41. Technique Of Removal
1. All of the tubes can be removed as a group (eg
mediastinal and pleural)
2.If you only removing the mediastinal and leaving the
pleural tube, clamp the pleural tube while removing
the mediastinal. to prevent air entry.
3. Prepare 4 x 4 gauze prepare elastoplast tape to
cover dressing over the removal site.
4. Put on non-sterile gloves. Reduces transmission of
infectious micro-organisms.
5. Remove dressing over chest tube and clean the
drain site(s) with antiseptic solution.

42. 6.Remove sutures holding chest tubes in place.
7.Have the patient inspire maximally and hold his/her
breath. Initially retract the chest tubes 1/2-1 inch
prior to removing them smoothly and rapidly. Apply
pressure with prepared dressings over chest tube
insertion site when removing. Instruct patient to
breathe normally. Most of the discomfort of chest
tube removal relates to the initial movement of the
tube. Removing the chest drain at end-inspiration
prevents the accidental entrance of air into the
pleural space.
• Removal of chest tube must be accomplished rapidly
with the simultaneous application of an occlusive
dressing to prevent air from entering the pleural
space. .

43. 8.Secure dressing with elastoplast tape. Creates an
airtight dressing and absorbs any drainage that may
seep from the insertion site.
9.Dispose of equipment. According to hospital policy
10.Call radiology for chest x-ray. It is the responsibility
of the ICU physician to review the post chest removal
x-ray. The X-ray must be reviewed before the pt is
transferred to the ward. Assess that the lung has
remained expanded.
11.Observe the patient closely for complications, e.g..
respiratory distress, air leak, or bleeding from the
drain site. Do a STAT x-ray for SOB, chest pain or
subcutaneous emphysema. Inform the physician
immediately.

44. 12.Document according to unit
protocol.(noting the date and time, the type
of chest tube(s) removed, patient's status,
when chest x-ray was done and which
physician was notified to interpret x-ray).

45. 12.Document according to unit
protocol.(noting the date and time, the type
of chest tube(s) removed, patient's status,
when chest x-ray was done and which
physician was notified to interpret x-ray).