Chest Tubes and Drainage Systems

• Chest tubes are inserted into the pleural space to drain fluid, blood, or air.
• Chest tubes reestablish negative pressure, facilitate lung expansion, and restore intrapleural pressure.
• Chest tubes are removed when the lungs have re-expanded or there is no more fluid drainage into the pleural space.

Chest Tube Systems

• A disposable three-chamber drainage system is used most often.
• First chamber is for drainage collection.
• Second chamber is the water seal.
• Third chamber is for suction control (can be wet or dry).
• Water seals are created by adding sterile fluid to a chamber up to the 2 cm line and this is the minimum amount required for functioning, although recommended amounts can vary.
• The water seal allows air to exit from the pleural space on exhalation and stops air from entering the lungs with inhalation.
• To maintain the water seal, keep the chamber upright and below the chest tube insertion site at all times.
• Routinely monitor the water level due to the possibility of evaporation.
• Add fluid as needed to maintain the manufacturer's recommended 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 commonly prescribed.
• The level of water in the suction control chamber determines the suction pressure.
• The system is attached a suction source, and suction initiated until gentle bubbling begins in the suction chamber.
• For dry suction, the provider prescribes a level of suction for the device, typically -20 cm H₂O.
• When connected to wall suction, the regulator on the chest tube drainage system is set to the manufacturer's recommendation.
• Tidaling, which is movement of the fluid level with respiration, is expected in the water seal chamber.
• With spontaneous respirations, the fluid level will rise with inspiration and 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.
• Continuous bubbling in the water seal chamber indicates an air leak in the system.
• When the tubes are inserted to remove air from the pleural space, intermittent bubbling is expected.
• It is common to see bubbling during exhalation, sneezing, or coughing.
• In this case, when bubbling is no longer seen, it indicates that all the air has been removed.
• When tubes are in the mediastinal space, bubbling and tidaling are not expected; pulsations in the fluid level might be seen.

Chest Tube Insertion

• Potential diagnoses include pneumothorax, hemothorax, postoperative chest drainage, pleural effusion, and pulmonary empyema.

Client Presentation

• Includes dyspnea, distended neck veins, hemodynamic instability, pleuritic chest pain, cough.
• Additional symptoms are absent or reduced breath sounds on the affected side and hyperresonance on percussion of affected side (pneumothorax).
• Dullness or flatness on percussion of the affected side (hemothorax, pleural effusion) and asymmetrical chest wall motion are included as well.

Preprocedure

• Confirm the consent form is signed.
• Inform the client that breathing will improve when the chest tube is in place.
• Assess for allergies to local anesthetics.
• Assist the client into the desired position (supine or semi-Fowler's).
• Prepare the chest drainage system per the facility's protocol.
• Administer pain and sedation medications as prescribed.
• Prep the insertion site with povidone-iodine or other facility-approved agent.

Intraprocedure

• When the chest tube is inserted to drain fluid from the lung, the tip of the tube is inserted near the base of the lung.
• When the chest tube is inserted to remove air from the pleural space, the tip of the tube will be near the apex of the lung.
• Assist the provider with insertion of the chest tube, application of a dressing to the insertion site, and set-up of the drainage system.
• Place the chest tube drainage system below the client's chest level with the tubing coiled on the bed.
• Ensure that the tubing from the bed to the drainage system is straight to promote drainage via gravity.
• Continually monitor vital signs and response to the procedure.

Postprocedure

• Assess vital signs, breath sounds, SaO2, color, 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's chest level, at all times, including during ambulation.
• Monitor chest tube placement and function.
• Check the water seal level every 2 hr, and add fluid as needed.
• The fluid level should fluctuate with respiratory effort.
• Document the amount and color of drainage hourly for the first 24 hr 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 to the provider.
• Drainage often increases with position changes or coughing.
• Monitor the fluid in the suction control chamber and maintain the prescribed fluid level.
• Ensure the regulator dial on the dry suction device is at the prescribed 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, occlusions, or loose connections.
• Monitor the chest tube insertion site for redness, pain, infection, and crepitus (air leakage in subcutaneous tissue).
• Tape all connections between the chest tube and chest tube drainage system.
• Position the client in the semi- to high-Fowler's position to promote optimal lung expansion and drainage of fluid from the lungs.
• Administer pain medications as prescribed.
• Obtain a chest x-ray to verify the chest tube's placement.
• Keep two enclosed hemostats, sterile water, and an occlusive dressing located at the bedside at all times.
• Due to the risk of causing a tension pneumothorax, chest tubes are clamped only when prescribed in specific circumstances.
• Examples include in the case of an air leak, during drainage system change, accidental disconnection of tubing, or damage to the drainage system.
• Do not clamp, strip, or milk tubing; only perform this action when prescribed to avoid high negative pressure that can damage lung tissue.
• Notify the provider immediately if the client's SaO2 is less than 90%, if the eyelets of the chest tube become visible, if drainage is above the prescribed amount or stops in the first 24 hr, or complications occur.

Complications

• Air leaks can result if a connection is not taped securely.
• Monitor the water seal chamber for continuous bubbling (air leak finding).
• If observed, locate the source of the air leak, and intervene accordingly (tighten the connection, replace drainage system).
• Check all connections.
• Notify the provider if an air leak is noted.
• 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

• These complications can occur at any time and require immediate notification of the provider or rapid response team.
• If the tubing separates, instruct the client to exhale as much as possible and to cough to remove as much air as possible from the pleural space.
• If the chest tube drainage system is compromised, immerse the end of the chest tube in sterile water to provide a temporary water seal.
• If a chest tube is accidentally removed, dress the area with dry, sterile gauze.

Tension Pneumothorax

• Sucking chest wounds, prolonged clamping of the tubing, kinks or obstruction in the tubing, or mechanical ventilation with high levels of positive end expiratory pressure (PEEP) can 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.
• Notify the provider or rapid response team immediately.

Chest Tube Removal

• Provide pain medication 30 minutes before removing chest tubes.
• Assist the provider with sutures and chest tube removal.
• Instruct the client to take a deep breath, exhale, and bear down (Valsalva maneuver) or to take a deep breath and hold it during chest tube removal.
• Apply airtight sterile petroleum jelly gauze dressing.
• Secure in place with a heavyweight stretch tape.
• Obtain chest x-rays as prescribed to verify continued resolution of the pneumothorax, hemothorax, or pleural effusion.
• Monitor for excessive wound drainage, findings of infection, or recurrent pneumothorax.