CHEST TUBES AND CHEST DRAINAGE SYSTEMS Central Nursing Orientation April 2008 Revised September 2011
OBJECTIVES Describe common tubes and indications for use at LHSC Review indications and contraindications, where necessary Nursing responsibilities associated with each tube. Provide hands on opportunity for each tube presented. Location of online LHSC resources (SONC) 2
Purpose Evacuate air and/or fluid from the chest cavity Evacuate fluid from around the heart (mediastinal) after cardiac surgery to prevent cardiac tamponade Restore normal intrathoracic pressure (negative pressure) 3
Indications for CT Insertion Air accumulation in pleural space Fluid accumulations in the pleural space Fluid accumulations in the mediastinal space 4
Location of Chest Tube Location depends on what is being drained. Free air in the pleural space rises tube is placed above the 2 nd intercostal space. Fluids gravitate to the most dependent point tubes places at the 4 th to 5 th intercostal space. Mediastinal tubes are put in place after cardiac surgery to drain fluid from around heart. 5
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7 Chest tube placement: superior tube evacuates air, inferior tube drains fluid
What happens when air enters pleural space 1. Air separates visceral pleura from parietal pleura interrupting the (ve) pressure that prevents lungs from collapsing 2. Compresses the lung. 1. If only a small amount of air (or fluid) is present, it may be reabsorbed without intervention. 2. If the amount of air (or fluid) is large, normal respirations are compromised & must be evacuated from pleural space. 8
Pneumothorax Definition: Air in the pleural space Types: Spontaneous Traumatic Iatrogenic Tension 9
10 Pneumothorax
Spontaneous Pneumothorax Usually caused by rupture of a small bleb (enlarged air sac) on lung s surface. May also result as a complication of pre-existing lung disease that weakens lung (COPD, pulmonary disease, CF, necrotizing pneumonia). 11
Traumatic pneumothorax Closed pneumothorax: Internal trauma ie.) rib fractures where rib punctures lung. No opening outside of the chest wall. Open pneumothorax: External trauma such as stab wound or bullet wound that penetrates chest wall may puncture lung. Also called a sucking chest wound. 12
Iatrogenic Pneumothorax Iatrogenic pneumothorax: Invasive procedures such as needle aspiration, subclavian line insertion or thoracentesis may inadvertently puncture lung. Mechanical ventilation with high positive-end expiratory pressure (PEEP can also result in a pneumothorax.) 13
Tension Pneumothorax Occurs when air accumulates in pleural space more rapidly than it can be evacuated. Pressure builds up which not only causes lung to collapse but can also shift mediastinum severely impede venous return & cardiac output. In other words, it squishes the heart. Life threatening must be dealt with STAT. 14
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Fluid Accumulation in Pleural Space Pleural Effusion: Fluid in the pleural space Fluids that collect here are: lymph (chylothorax) pus (empyema) blood (hemothorax). Fluid that collects in pleural space directly compresses lung tissue & takes up space that the lung would usually fill. 16
Pleural Effusion 17
18 Hemothorax
Chest Tubes Chest tubes may also be called thoracic catheters Various Chest tubes are used at LHSC Different sizes From infants to adults Small for air, larger for fluid Different configurations Curved or straight Types of plastic PVC Silicone 19
Chest Tube insertion set up CT insertions are a medical activity Equipment: Atrium Oasis-Ensure underwater seal 2 Kelly clamps Sterile distilled water Cable ties/water-proof tape Wall suction set up Chest tube insertion tray Local Anesthetic Ensure you wear proper PPE 20
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22 Chest Tube Insertion
Making the Connection Once the patient is connected to the drainage system and the suction then: cable tie the connections or use waterproof tape Kelly clamps Establish the suction Placement of the Atrium 23
Chest Tube Dressing Equipment: Dressing tray Jelonet Two 4x4 guaze, two split drain gauze No sting Barrier Spray 3 Mefix tape (aka Hypofix) Chlorhexidine 2%/70% alcohol solution non sterile gloves 24
Chest Tube Dressing Initial dressing remains intact for the first 48 hours unless soiled, then changed daily and prn Cleanse site with chlorhexidine in a circular fashion away from insertion site Spray area where tape will be with Barrier Spray Place jelonet around tube against the skin to provide occlusive barrier Place 2 4X4 dressings under chest tube to protect skin and absorb drainage Place 2 4X4 dressings over chest tube Cover with mefix 25
Responsibilities Post Insertion CXR within 1 hour with Physician order Assess: * Respiratory status Q15min x1hr- PRN i.e. vital signs, oxygen saturation, respiratory patterns, chest sounds, patient level of apprehension * Water seal level for fluctuation Documentation Monitor: Vital signs Tube location Drainage Subcutaneous emphysema Air leaks Change Atrium contained q7d or prn Do not strip/milk chest tube 26
Water Seal Chamber One way valve so air can drain out of chest cavity but not back in Monitor fluctuations and volume at least q shift Fluctuates with breathing - tidaling water level should be at 2 cm mark 27
Monitoring air leak Water seal is a window into the pleural space If air is leaving the chest, bubbling will be seen here Bubbling in water seal chamber may be present with pneumothorax If worsens or occurs in absence of pneumo may indicate air leak 28
Question During your assessment, you note new bubbling in the water seal chamber. Describe what you would do to determine where this air leak is from. 29
Answer Clamp the chest tube momentarily, beginning at the patient. Look at the chamber to see whether the bubbling has stopped. If you clamp and the bubbling goes away, the leak is coming from the chest. Action: reinforce dressing with Jelonet, inform physician If you clamp at the chest and the bubbling persists, the leak is between the clamp and the water seal chamber. Action: change tubing 30
Drainage Record on I & O sheet, minimum q shift. Mark level on Atrium collection devise, with date and time (if this is your unit protocol) Assess Amount of drainage Rate of accumulation Characteristics of drainage Little drainage with pneumothorax 31
Clamping Chest Tubes You will only clamp for the following reasons: Prior to removing chest tube to determine if patient can do without chest tube(s) Assessing for air leak (clamp only briefly) Changing the chest drainage unit (clamp only briefly) Performing physician-ordered procedure. Some instances when sudden large volumes of fluid are evacuated 32
Specimen Collection At time of chest tube insertion, collect drainage in sterile container If specimen required later: -cleanse with alcohol/chlorhexidine swab, let dry -crimp tubing below the port -use 20 gauge needle, withdraw drainage from port and transfer to sterile container -or kink tubing, cleanse, aspirate fluid with 20 gauge needle, the silicone tubing will reseal itself Gloves should be worn when collecting specimen 33
Activity/Transport Patient should be able to move comfortably in their room. If air leak detected & depending on the size of air leak, your patient may be required to be connected to suction at all times. (obtain a portable suction) If no air leak, patients are able to leave their rooms and ambulate, without suction, provided a doctors order is received You will require a support for the chest drainage unit. DO NOT CLAMP the chest drainage system, as air needs to escape. Ensure Atrium is below level of chest If unsure of suction requirements with mobility, contact Physician 34
What to do if the Chest Tube Mistakenly Falls out??? Cover site with dry sterile dressing Call physician If there is air leaking from site or the patient becomes distressed, leave one side of dressing open to allow air to escape and prevent tension pneumothorax PPE 35
What to do if the chest tube becomes disconnected? Clamp tube Using PPE (gloves) Cleanse connector with Chlorhexidine 2%/70% Alcohol solution Reattach tube to system Unclamp tube Notify MD 36
Discontinuing Process Less than a total of 10ml/tube/hour for 6 hours (<10cc x 6h for paediatrics) Chest Xray shows re-expansion of lungs No air leak present Normal INR Order may indicate to remove suction or clamp the chest tube X 24 hrs, prior to removing chest tube. There must be an order to D/C a chest tube. (and if pt has more than one, it needs to be clearly indicated which one) Chest tube removal is an added nursing skill 37
Additional References Please refer to the LHSC intranet and visit the Nursing Practice Manual. You will find loads of information under the following title: CHEST TUBE: INITIATION, CARE AND REMOVAL OF PLEURAL/MEDIASTINAL London Health Science Centre intranet, Nursing Practice Manual, Chest tube: Initiation, Care and Removal of pleural/mediastinal. Atrium Chest tube teaching powerpoint. 38