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

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

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

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)

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

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

Chest tube insertion

Done in patients room, interventional radiology, or the operating room Local anesthetic; patient may feel pressure as tube is inserted Aseptic (sterile) procedure Patients breathing will be easier once lung is reexpanded

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

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

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 patients chest Check water seal and suction control chambers frequently Assess drainage for color Measure drainage every 8 hours or more often depending on patients condition Document assessment Report immediately bright red blood or red free-flowing drainage >70ml/hour Reposition patient frequently

Care of chest tube and drainage unit

Tubing: Avoid loops, aggressive manipulation such as stripping or milking Patency: To maintain patency, try gentle handover-hand squeezing of tubing and release Clamping: Avoid except when replacing CDU, locating air leak, or assessing when tube will be removed

Removing the chest tube

Can remove chest tube when:
-- Theres 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

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 patients respiratory status Arrange for chest X-ray to confirm lung reexpansion Monitor patients respiratory status and SpO2 for 1-2 hours after removal

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