Chest Tubes and Drainage Systems

Chest Tubes

• Re-expands the affected lung by removing excess air, fluid, and blood.
• Used for patients with thoracotomy and can treat spontaneous pneumothorax and trauma leading to pneumothorax.

Types of Chest Drainage Systems

• Traditional Water Seal: Has three chambers: a collection chamber, water seal chamber (middle), and wet suction control chamber. Requires sterile fluid in water seal and suction chambers. Intermittent bubbling indicates proper function. Additional suction can be added.
• Dry Suction Water Seal: Has collection, water seal chambers, and suction regulator dial. Requires sterile fluid in the water seal chamber at 2-cm level. Suction pressure set with a dial; quieter than traditional systems.
• Dry Suction (One-Way Valve): Contains a one-way mechanical valve allowing air to leave the chest but prevents reentry. Works even if knocked over.

Air Leak Monitoring

• Excessive/Continuous bubbling in air leak monitor is bad, suggesting an air leak.
• Intermittent bubbling is normal.
• Gentle bubbling in the wet suction control chamber is normal, indicating suction is working.
• Water may evaporate, needing replenishment.
• Check for subcutaneous crepitus/emphysema: puffy, crackling sensation.

Nursing interventions for chest tubes

• Reposition patient and encourage coughing/deep breathing.

Ventilator Settings

• IMV combo: Mechanically assisted and spontaneous breaths, allowing patient to generate their own breaths.
• SIMV: Delivers tidal volume at a set rate without additional assistance, testing the patient's breathing ability ("Weaning mode").
• Patient Controls Breath Size: Patient determines the volume of each breath, although pressure support can be included. This carries a risk respiratory alkalosis or acidosis.
• A/C (Assist Control): Machine has a preset rate and tidal volume; if the patient attempts to breathe, the ventilator delivers a full breath. Can cause excessive ventilation if the patient is tachypneic.
• APRV: Time-triggered breaths delivered every set interval (e.g., 10 seconds). Reduces the need for high sedation levels and synchronizes with patient's breathing.

PEEP

• Positive End Expiratory Pressure: Positive pressure applied by the ventilator to the lung.
• Used to keep alveoli open for gas exchange.
• Normal PEEP: 5-8 cm.
• Normal PEEP for ARDS: 15-20 cm.
• The less gas exchange the patient gets, the more PEEP the patient needs

ARDS

• Definition: Acute Respiratory Distress Syndrome.
• Key sign is refractory hypoxemia (ABG's).
• Not a primary diagnosis, often caused by sepsis.
• Diagnostic findings: patchy infiltrates and respiratory alkalosis.
• Treatment: Early feeding is important, promote getting rid of inflammatory processes, and address the underlying cause.
• Interventions include intubation and mechanical ventilation with PEEP to maintain open alveoli.
• Hypovolemia must be treated.
• Prone positioning is best for oxygenation, frequent repositioning for skin integrity.
• Nutritional support with enteral feedings is preferred.

Neuromuscular Junction (NMJ) Blockers

• Nondepolarizing: Act as antagonists to acetylcholine (ACh) at the NMJ, preventing muscle cell depolarization (e.g., Atracurium, Cisatracurium).
• Indications: Adjunct to general anesthesia, facilitates intubation/endoscopy/electroconvulsive therapy.
• Caution: Use with caution when a patient has a personal or a family history of malignant hyperthermia and also with existing Pulmonary/CV dysfunction.
• Depolarizing: Ach agonist, causes muscle cell stimulation and prevents repolarization (Succinylcholine). After 10-15 seconds you will see twitching.

ABG interpretation

• Normal pH: 7.35-7.45
• Normal HCO3 (Bicarbonate): 22-26 mEq/L (reflects kidney function).
• Normal PaCO2: 35-45 mm Hg.
• Normal PaO2: 80-100 mm Hg (less than 40 is life-threatening).
• Normal Oxygen content is 20 mL of oxygen per 100 mL of blood.
• Base excess and base deficit: Normal range = 2 mEq/L

Pneumothorax

• Simple pneumothorax causes a sudden onset of chest pain due to a breach in the pleurae.
• Tension pneumothorax arises from air entering the pleural space due to a lung laceration or chest wall opening, resulting in elevated pleural cavity pressure.
• Open pneumothorax pleural cavity pressure equals atmospheric pressure.
• Closed pneumothorax- pleural cavity pressure less than atmospheric pressure, tall skinny men at risk

VAP

• A hospital-acquired pneumonia developing 48-72hrs after endotracheal intubation.
• Interventions: Perform oral care with chlorhexidine and take sputum culture in the morning
• Semirecumbent positioning (30-45 degrees) is recommended and reduces gastroesophageal reflux, aspiration, and VAP incidence.
• Treatment: Beta-lactam (ceftriaxone, cefotaxime, or ampicillin/sulbactam) AND either a macrolide or respiratory fluoroquinolone antibiotics

Airway Obstruction

• Acute upper airway obstruction can be caused by food, vomitus, blood and foreign materials that obstruct the larynx or trachea.
• Assessment: rapid observations with inspection, palpation, and auscultation.
• Action: As soon as it is identified, nurse takes emergency measures.
• If pt. is talking, they do not have an obstruction.
• S/S of choking (cyanotic, hands on throat, and cannot talk).
• Auscultation will reveal wheezing/stridor

Intubation

• Step 1 = preparation i. suction equipment ii. O2 mask with 100% O2 iii. laryngoscope handle iv. measure ET for patients
• Step 2 = preoxygenate i. with 100% O2 for 3-5 minutes
• Step 3: pretreatment i. give medications
  1. lidocaine, fentanyl, atropine
  2. low dose paralytic agent
• Step 4 = paralysis with induction i. give sedative agent ii. give more of paralytic agent (succinylcholine or rocuronium)
• Step 5 = protection and positioning i. neck flexed ii. head slightly extended iii. oral cavity and pharynx suctioned
• Step 6 = placement of ETT i. tube is inserted ii. remove laryngoscope handle iii. placement is confirmed by chest X-ray iv. assess for bilateral breath sounds + chest movements v. inflate ballon and check that it is inflated vi. hook to vent vii. place carbon dioxide detector
• Step 7 = postintubation management i. mark level of insertion (cm_ ii. secure to patients face with tape or tube holder

Pleural Effusion

• Fluid collection in the pleural space, often due to heart failure, TB, pneumonia, or pulmonary infections.
• Signs: Fever, chills, pleuritic pain, dyspnea.
• Auscultation: Decreased or absent breath sounds, decreased fremitus, and dull, flat sounds with percussion. May observe tracheal deviation away from affected side.
• Treatment involves chest x-ray, treat underlying cause

CPAP/BIPAP

• Both non-invasive
• CPAP: positive pressure gives you extra volume at end of inspiration and expiration. Forces good gas exchange and is effective for sleep apnea.
• BIPAP: Patient has complete control over inspiratory and expiratory volumes. End of inspiration- forces extra expiration pressure.

Ventilator Weaning

• Process of withdrawal of dependence upon the ventilator
• 3 stages Off vent, off ET tube or tracheostomy tube, off oxygen. СРАР and SIMV can be used for spontaneous breathing
• Ensure adequate nutrition

Overview of chest tubes, their purpose in re-expanding the lung by removing air, fluid, and blood, and their use in treating conditions like pneumothorax. Covers the three types of chest drainage systems: traditional water seal, dry suction water seal, and dry suction (one-way valve). Focuses on monitoring for air leaks, where excessive bubbling indicates a problem.