CHEST TUBE INSERTION AND MONITORING

CHEST TUBE INSERTION AND MONITORING

Overview

• Chest tubes are inserted into the pleural space to drain fluid, blood, or air; reestablish a negative pressure, facilitate lung expansion, and restore normal intrapleural pressure. 
• Chest tubes can inserted in the emergency department, at the client's bedside, or in the operating room through a thoracotomy incision. 
• Chest tubes are removed when the lungs have re-expanded or there is no more fluid drainage. 

CHEST TUBE SYSTEM 

A disposable three-chamber drainage system is most often used. 

• First chamber: drainage collection 
• Second chamber: water seal
• Third chamber: suction control 

Water seals are created by adding sterile fluid to a chamber up to the 2 cm line. The water seal allows air to exit from the pleural space on exhalation and stops air from entering with inhalation. 

• To maintain the water seal, the chamber must be kept upright and below the chest tube insertion site at all times. The nurse should routinely monitor the water level due to the possibility of evaporation. The nurse should add fluid as needed to maintain the 2 cm water seal level. 
• The height of the sterile fluid in the suction control chamber determines the amount of suction transmitted to the pleural space. A suction pressure of -20 cm H2O is common. The nurse should monitor the fluid level and add fluid as needed to maintain the prescribed level of suction. 
• Tidaling (movement of the fluid level with respiration) is expected in the water level chamber. With spontaneous respiration's, the fluid level will rise with inspiration (increasing in negative pressure in lung) and will fall with expiration. With positive pressure mechanical ventilation, the fluid level will rise with expiration and fall with inspiration. 
• Cessation of tidaling in the water seal chamber signals lung re-expansion or an obstruction within the system. 

Chest tube insertion 

Indication

Diagnosis 

• Pneumothorax
• Hemothorax 
• Post-operative chest drainage 
• Pleural effusion 
• Lung abscess 

Client presentation 

• Dyspnea 
• Distended neck vein 
• Poor circulation 
• Cough
• Absent or reduced breath sound

Preprocedure

Nursing action 

• Verify that the consent form is signed
• Reinforce client teaching. Breathing will improve when the chest tube is in place 
• Assist client into the desired position 
• Prepare the chest drainage  system prior to the chest tube insertion per the facility 
• Administer pain and sedation medication as proscribed.
• Prep the site with povidone- lodine 

Intraprocedure

Nursing action

Assist the provider with insertion of the chest tube, application of a dressing to the insertion site, and set-up of the drainage system.

• The chest tube tip is positioned up towards the shoulder (pneumothorax ) or down towards the posterior (hemothorax or pleural effusion)
• The chest tube is then sutured to the chest wall, and an airtight dressing is placed over the puncture wound
• The chest tube is then attached to drainage tubing that leads to a drainage system.
• Place the chest tube drainage system below the client chest level with the tubing coiled on the bed. Ensure that the tubing from the bed on the drainage system is straight to promote drainage via gravity 

Postprocedure

• Nursing action
• Assess the client vital signs, breath sounds, SaO2, and respiratory effort as indicated by the status of the client and at least every 4 hr.
• Encourage coughing and deep breathing every 2 hr.
• Keep the drainage system below the client chest level, including during ambulation.
• Monitor the chest tube placement and function.
• Check the water seal level every 2 hr.
• Document the amount and colour of drainage hourly for the first 24 hours and then at least every 8 hr. Mark the date, hour, and drainage level on the container at the end of each shift. Report excessive drainage (greater than 70 ml/hr) or drainage that is cloudy or red.
• Monitor the fluid in the suction control chamber, and maintain the fluid level.
• Check for expected findings of tidaling in the water seal chamber and continuous bubbling only in the suction chamber.
• Routinely monitor tubing for kinks, occlusion, or loose connection.
• Monitor the chest tube insertion site for redness, pain, infection, and crepitus (air leakage in the subcutaneous tissue)
• Position the client in the semi-Fowler's position to promote optimal lung expansion and drainage of the fluid from the lungs.
• Administer pain medications as prescribed.
• Obtain a chest x-ray to verify the chest tube placement.

COMPLICATIONS

• Air leaks
• Air leaks can result if connection is not taped securely.
• Nursing action
• Monitor the water seal chamber for continuous bubbling (air leak findings). If observed, locate the source of the air leak, and intervene accordingly (tighten the connection, replace drainage system).
• Check all of the connections.
• Notify provider if an air leak noted, and if prescribed, gently apply a padded clamp to determine the location of the air leak. Remove the clamp immediately following assessment.
• Accidental disconnection, system breakage, or removal
• This complication can occur at any time.
• Nursing action
• If the tubing separates, the client is instructed to exhale as much possible and to cough to remove as much air as possible from the pleural space. The nurse cleanses the tips and reconnects the tubing.
• If the chest tube drainage system is compromised, the nurse immerses the end of the tube in sterile water to restore the water seal.
• If a chest tube is accidentally removed, an occlusive dressing taped immediately  placed over the insertion site
• Tension pneumothorax
• Sucking chest wounds, prolonged clamping of the tubing, kinks in the tubing, or obstruction may cause a tension pneumothorax.
• Assessment findings include tracheal deviation, absent breath sounds on one side, distended neck veins, respiratory distress, asymmetry of the chest, and cyanosis.

CHEST TUBE REMOVAL

• Provide pain medication 30 min before removing chest tube.
• Assist the provider with sutures and chest tube removal.
• Instruct the client take deep breath, exhale, and bear down or to take a deep breath and hold it (increases intrathoracic pressure and reduce the risk of emboli) during chest tube removal.
• Apply airtight sterile gauze dressing. Secure in place with a heavyweight stretch tape.
• Obtain chest x-ray as prescribed. This is performed to verify continued resolution of the pneumothorax, hemothorax, or pleural effusion.