

The pleural space

• Lies between the parietal pleura (membrane liningthe chest cavity) and the visceral pleura (surroundsthe lungs)

• Holds about 50 ml of lubricating fluid

• Creates a negative pressure that keeps the lungsexpanded

• Excess fluid or air accumulation in the pleuralspace limits lung expansion and leads torespiratory distress



Chest tube indications

• Pneumothorax: Air in the pleural space caused by trauma, lungdisease, invasive pulmonary procedure, forceful coughing, surgicalcomplication, or may occur spontaneously

•To drain air, the chest tube is placed in anterior chest at the second or thirdintercostal space

• Hemothorax: Blood in the pleural space caused byblunt/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 bypneumonia, 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 collectiondevice upright and vented to prevent air buildup

• Indwelling pleural catheter: Drains chronic pleuraleffusions; drains fluid only; can be done at homeevery 1 or 2 days or when short of breath



Chest tube insertion

• Done in patient’s room, interventional radiology, or the operating room

• Local anesthetic; patient may feel pressure as tube isinserted

• Aseptic (sterile) procedure

• Patient’s breathing will be easier once lung is re-expanded



Chest tube insertion

• Position patient for comfort depending on site to beinserted

• 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 soundsbilaterally

• Assess the insertion site

• Encourage the patient tocough

• Make sure connections aretaped securely

• Keep collection apparatusbelow the level of the patient’schest

• Check water seal and suctioncontrol chambers frequently

• Assess drainage for color

• Measure drainage every 8hours or more often depending

on patient’s condition

• Document assessment

• Report immediately bright redblood or red free-flowingdrainage >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” hand-over-hand squeezing of tubing and release

• Clamping: Avoid except when replacing CDU,

locating air leak, or assessing when tube will beremoved



Removing the chest tube

Can remove chest tube when:

-- There’s little to no drainage

-- Air leak is gone

-- Patient is breathing normally without respiratorydistress

-- 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 petroleumto prevent air from entering pleural space

• Monitor patient’s respiratory status

• Arrange for chest X-ray to confirm lung reexpansion

• Monitor patient’s respiratory status and SpO2for 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

Chest Tubes

Documents

Transcript of Chest Tubes