Chest Tube Procedures and Functions

Chest Tubes

• Chest tubes are catheters inserted through the thorax to remove air and/or fluid from the pleural space.
• Purpose of chest tubes/closed chest drainage: Treat conditions that disrupt the pleural space, drain pleural cavity (air, blood, pus, lymph fluid), prevent/diminish postoperative complications (cardiac surgery), and instill fluids (chemotherapy or sclerosing agents) into the pleural space.

Indications for a Chest Tube

• The potential space around the lungs is called the pleural cavity.
• Under normal conditions, the pleural cavity is maintained by negative pressure, crucial for lung expansion during breathing.
• When air, blood, pus, or lymph collects in the pleural cavity, negative pressure is lost, hindering lung expansion.

Overall Goal of Chest Tube Therapy

• Promote lung re-expansion
• Re-establish normal negative pleural space pressure
• Restore adequate oxygenation and ventilation
• Prevent complications

Conditions That Disrupt the Pleural Space

• Pneumothorax: A collection of air in the pleural space. Loss of negative intrapleural pressure causes lung collapse.
  • Primary: Occurs in the absence of lung disease or injury. Spontaneous pneumothorax is a genetic condition with unexpected occurrences in healthy individuals who develop blebs on the visceral pleura. Tall, young men are at increased risk.
  • Secondary: Develops due to chest trauma (stabbing, gunshot wound, rib fractures), rupture of an emphysematous bleb, or tearing of the pleura from an invasive procedure (surgery, insertion of a subclavian line, mechanical ventilation).
• Chylothorax: Lymphatic fluid accumulation in the pleural space, often from chest trauma, tumors, or surgery within the mediastinum. Milky-white pleural fluid.
• Hemothorax: Blood in the pleural space, due to blunt or penetrating trauma or chest surgery. A massive hemothorax is when blood rapidly accumulates in the chest cavity, resulting from penetrating or blunt trauma that disrupts systemic vessels.
• Pleural Effusion: Excessive fluid in the pleural space, caused by left ventricular failure, pulmonary embolism, pneumonia, cancer, or conditions that impede pleural fluid drainage (such as a tumor blocking the lymphatic system) or complications from surgery or fluid shifts(e.g., liver or renal failure).
• Empyema: Purulent pleural fluid, potentially from a lung abscess or pneumonia.

Risks and Complications of Chest Tube Placement

• Malposition: The chest tube is not in the proper space. This is the most common complication leading to persistent air or fluid in the pleural space
• Bleeding: Often minor and resolves on its own. Bleeding into the lung may require surgical intervention, common during insertion.
• Infection: Increases with the duration of tube placement. Sterile technique is crucial. Watch for oozing, drainage, or erythema at the insertion site. High risk category includes immunocompromised patients.
• Lung Trauma and Diaphragm Perforation: During insertion, lung trauma and diaphragm perforation can occur if the chest tube is inserted too low.
• Subcutaneous Emphysema: Air leaks from the pleural space into the subcutaneous tissue after chest tube placement. Tissues of the neck, face, axilla, and chest swell, and there may be crepitus on palpation.

Preparing the Patient for Chest Tube Placement

• Monitor vital signs, electronic monitoring equipment
• Administer analgesics or sedatives as needed
• Patient positioning (sitting or lying, affected side elevated)
• Arm positioning (brought over head and secured)
• Area cleansing with an antiseptic solution.
• Explain procedure to patient, obtain informed consent (if possible)
• Provide supplemental oxygen
• Local anesthetic is given to the area
• A small incision is made
• The chest tube is inserted and sutured to the chest wall.
• Chest tube is connected to the drainage system.

Preparing a Patient for Chest Tube Placement cont.

• Steps are illustrated by pictures that show incision at midaxillary line, between 4th and 5th ribs, lateral to nipple.
• Clamping of a rib over vessels needs to be avoided.
• Insertion site to be explored by a finger.
• Using clamps, chest tube will be guided into the place.

Dependent on the Function that the Chest Tube Performs

• Air Removal: Tube insertion at the mid-clavicular, second intercostal space, near the apex of the lung
• Fluid Removal: Tube placement inferior and posterior in the pleural space, mid-axillary line, 7th or 8th intercostal space

Documentation after Initial Chest Tube Placement

• Vital signs before and after procedure
• Chest tube size and insertion site
• Physician inserting the tube
• Drainage description (type and amount)
• Drainage system type and suction pressure
• Cultures sent
• Patient response to procedure
• Medications used
• Chest x-ray results

Nursing Care After Chest Tube Placement - Ongoing Patient Assessments

• General: Vital signs, pain, respiratory rate and pattern, respiratory status, respiratory depth, ease of respiration, oxygen saturation
• Specific to Chest Tube: Assess for re-accumulation of air or fluid in the chest; decreased or absent breath sounds; signs of respiratory distress; tachypnea, dyspnea, shortness of breath, tachycardia, decreased breathing, absent breath sounds, use of accessory muscles.
• Tube Insertion Site for Drainage and Signs of Infection: Drainage, erythema, subcutaneous emphysema, signs of infection (fever, elevated WBC count).

Ongoing Patient Assessments (cont)

• Pain/discomfort (medicate as needed)
• Subcutaneous emphysema (crackling sensation under the skin)
• Skin color

Management of the Drainage System

• Ensure that the dressing is occlusive, dry, and intact, secured on all 4 sides.
• Maintain tubing and drainage system below chest level.
• Do not let patient lie on tubing, prevent kinks and occlusions
• Tightly secure all tubing connections
• Observe for tidaling (fluctuation, movement up/down in the water-seal chamber as the patient breaths)
• Observe for intermittent bubbling in the water-seal chamber

Management of Chest Drainage - (cont)

• Do not clamp, milk, or strip the tube
• Clamping to temporarily change drainage box is OK.
• Do not elevate drainage box above patient's chest level.
• Monitor and document drainage amount and color
• Document drainage values
• Assist patient with position changes, coughing, and deep breaths to facilitate fluid drainage.
• Collection box to be changed if necessary for increased quantity and drainage type.

Tube Dislodgement or Disconnection

• Keep rubber-tipped or padded hemostats, Vaseline gauze, dry sterile dressing, and tape at bedside.
• Sterile water is also crucial.
• Instructions for patient performing Valsalva Maneuver or submerge distal end of chest tube (2cm) in sterile water.
• Cover insertion site with new Vaseline gauze or sterile dressing taped on 3 sides only. Taping on 3 sides only prevents tension pneumothorax
• Patient positioning (High Fowler's).
• Ask another nurse to contact provider

Tube Disconnected (cont)

• Immediately submerge the distal end of the tube (2 cm) in sterile water for a temporary water seal.
• New drainage collection box to be brought in by another nurse.
• Tube connection to the new drainage box
• Turn on suction system
• Notify the provider

Wet and Dry Suction Systems

• Wet System: Regulates suction pressure by the water column height in the suction control chamber.
• Dry System: Mechanically regulates suction pressure. No water column; orange bellows are the visual indicator of suction operation.

Chest Tube Removal

• Indicated when lungs are fully expanded, fluid drainage has stopped, improved chest x-rays & improved respiratory status.
• Occlusive dressing (4 sides taped)
• Comprehensive Respiratory Assessments
• Patient Comfort
• Post-removal chest x-ray is typically done.

Assisting the Healthcare Provider During Chest Tube Removal

• Educate patient and provide support
• Premedicate to relieve pain and reduce anxiety
• Gather supplies (sterile gloves, suture removal kit, hemostats, occlusive dressing)
• Position patient in semi-Fowler's and pad the area
• Remove dressing and sutures
• Practitioner clamps the tube
• Patient performs Valsalva maneuver
• Tube is quickly removed
• Immediately cover wound with an occlusive dressing.

Post Chest Tube Removal Patient Care

• Cover site with Vaseline gauze and an occlusive dressing (4 sides taped)
• Follow up chest x-ray
• Monitor wound for drainage
• Comprehensive respiratory assessments