Chest tube

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Chest tube

Intervention

The free end of the Chest Drainage Device is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest.

ICD-9-CM

34.04

MeSH

D013907

Size of Chest Tube: Adult or Teen Male = 2832 Fr Pp Adult or Teen Female = 28 Fr Child = 18 Fr Newborn = 1214 Fr
[1]

A chest tube (chest drain or tube thoracostomy in British medicine or intercostal drain) is a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air (pneumothorax) or fluid (pleural effusion, blood, chyle), or pus (empyema) from the intrathoracic space. It is also known as a Blau drain or an intercostal catheter.
Contents
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1 Indications 2 Contraindications 3 Technique 4 Chest Drainage Canister 5 Complications 6 References 7 External links

[edit]Indications

Pneumothorax: accumulation of air in the pleural space Pleural effusion: accumulation of fluid in the pleural space

Chylothorax: a collection of lymphatic fluid in the pleural space Empyema: a pyogenic infection of the pleural space Hemothorax: accumulation of blood in the pleural space Hydrothorax: accumulation of serous fluid in the pleural space

[edit]Contraindications
Contraindications to chest tube placement include refractory coagulopathy, lack of cooperation by the patient, and diaphragmatic hernia. Additional contraindications include scarring in the pleural space (adhesions)

[edit]Technique
The insertion technique is described in detail in an article of the NEJM.[2] The free end of the tube is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest. Alternatively, the tube can be attached to a flutter valve. This allows patients with pneumothorax to remain more mobile. British Thoracic Society recommends the tube is inserted in an area described as the "safe zone", a region bordered by: the lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi and a horizontal line superior to the nipple[citation needed]. More specifically, the tube is inserted into the 5th intercostal space slightly anterior to the mid axillary line.[3] Chest tubes are usually inserted under local anesthesia. The skin over the area of insertion is first cleansed with antiseptic solution, such as iodine, beforesterile drapes are placed around the area. The local anesthetic is injected into the skin and down to the muscle, and after the area is numb a small incision is made in the skin and a passage made through the skin and muscle into the chest. The tube is placed through this passage. If necessary, patients may be given additional analgesics for the procedure. Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied to the area. Once the drain is in place, a chest radiograph will be taken to check the location of the drain. The tube stays in for as long as there is air or fluid to be removed, or risk of air gathering. Chest tubes can also be placed using a trocar, which is a pointed metallic bar used to guide the tube through the chest wall. This method is less popular due to an increased risk of iatrogenic lung injury. Placement using the Seldinger technique, in which a blunt guidewire is passed through a needle (over which the chest tube is then inserted) has been described.

[edit]Chest

Drainage Canister

A chest drainage canister device is typically used to drain chest tube contents (air, blood, effusions). There are generally three chambers. The first chamber is a collecting chamber. The second is the "water seal" chamber which acts as a one way valve. Air bubbling through the water seal chamber is usual when the patient coughs or exhales but may indicate, if continual, a pleural or system leak that should be evaluated critically. It can also indicate a leak of air from the lung. The third chamber is the suction control chamber. The height of the water in this chamber determines the negative pressure of the system. Bubbling should be kept a gentle bubble to limit evaporating the fluid. Increased wall suction does not increase the negative pressure of the system. Newer systems are designed not to need the water seal chamber, so there is not a column of water that can spill and mix with blood, mandating the replacement of the canister. Even newer systems are smaller and more ambulatory so the patient can be sent home for drainage if indicated.

[edit]Complications
Major complications are hemorrhage, infection, and reexpansion pulmonary edema. Chest tube clogging can also be a major complication if it occurs in the setting of bleeding or the production of significant air or

fluid. When chest tube clogging occurs in this setting, a patient can suffer from pericardial tamponade, tension pneumothorax, or in the setting of infection, an empyema. All of these can lead to prolonged hospitilization and even death. To minimize potential for clogging, surgeons often employ larger diameter tubes. These large diameter tubes however, contribute significantly to chest tube related pain. Even larger diameter chest tubes can clog.[4] In most cases, the chest tube related pain goes away after the chest tube is removed, however, chronic pain related to chest tube induced scarring of the intercostal space is not uncommon. In recent years surgeons have advocated using softer, silicone Blake drains rather than more traditional PVC conventional chest tubes to address the pain issues. Clogging and chest tube occlusion issues have been a problem, including reports of life threatening unrecognized bleeding that occurs in the chest due to an occluded or clogged drain.[5] Thus when a chest tube is inserted for whatever reason, maintaining patency is critical to avoid complications. Injury to the liver, spleen or diaphragm is possible if the tube is placed inferior to the pleural cavity. Injuries to the thoracic aorta and heart have also been described. Minor complications include a subcutaneous hematoma or seroma, anxiety, shortness of breath (dyspnea), and cough (after removing large volume of fluid). Subcutaneous emphysema indicates backpressure created by a clogged drain or insufficient negative pressure.

Chest Tube Care and Monitoring

TERMINAL LEARNING OBJECTIVE Given a scenario in a holding or ward setting, involving a patient with a chest tube, identify procedures for chest tube care and monitoring IAW the Textbook of Basic Nursing, Lippincott Introduction Trauma, disease, or surgery can interrupt the closed negative-pressure system of the lungs, causing the lung to collapse. Air or fluid may leak into the pleural cavity. A chest tube is inserted and a closed chest drainage system is attached to promote drainage of air and fluid. Chest tubes are used after chest surgery and chest trauma and for pnuemothorax or hemothorax to promote lung re-expansion Terms and definitions a. b. c. Pneumothorax collection of air in the pleura space Hemothorax an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleurae, usually as the result of trauma Chest tubes a catheter inserted through the thorax to remove air and fluids from the pleural space and to reestablish normal intrapleural and intrapulmonic pressures

Chest Tube Systems a. Pleur-Evac chest drainage system (1) One-piece molded plastic unit that duplicates the three-chambered system (2) Cost effective (3) There must be bubbles flowing in the suction control portion of the unit to provide suction to the patient Pleur-Evac Set Up (1) Fill water seal chamber (2) Fill suction control chamber (3) Attach tube to suction source (4) Tape all the connections (5) Provide sterile tube for connection to patient Procedure for Proper Usage of the Heimlich Valve (1) Heimlich valve is a plastic, portable one-way valve used for chest drainage, draining into a vented bag (2) Equipment (a) Heimlich valve (b) Kelly clamps - 2 (rubber-tipped) (c) Vented drainage bag or ostomy bag (d) Ostomy tape or rubber band (e) Suction setup (if applicable) (f) Clean scissors (3) Procedure Steps (a) Gather equipment and bring to patient area (b) Wash hands (c) Don gloves. Nonsterile gloves are acceptable as long as sterile technique is maintained while the connection is being made. (4) Heimlich Valve To Chest Tube

b.

c.

(a) (b) CAUTION:

Place rubber-tipped Kelly clamps in opposite directions on the proximal end of the chest tube as near to the patient as possible Connect the chest tube to the blue end of the Heimlich valve using sterile technique

Only the blue end of the Heimlich valve can be connected to the chest tube. If the clear end is connected, the one-way valve will be in the wrong position and no drainage will take place. (c) Tape the connection site at both ends of the valve using 2 inch cloth tape.

CAUTION:

When two chest tubes are present, two Heimlich valves must be used to ensure proper functioning of chest tubes. (d) Monitor and record character of drainage and patency of valve in nursing progress notes.

CAUTION:

Measure all drainage in a calibrated cylinder for accurate readings. (e) Record drainage output on I & O graphic every 8 hours. If conditions permit.

Care of patients with chest tubes a. b. c. Assess patient for respiratory distress and chest pain, breath sounds over affected lung area, and stable vital signs Observe for increase respiratory distress Observe the following: (1) Chest tube dressing, ensure tubing is patent (2) Tubing kinks, dependent loops or clots (3) Chest drainage system, which should be upright and below level of tube insertion Provide two shodded hemostats for each chest tube, attached to top of patients bed with adhesive tape. Chest tubes are only clamped under specific circumstances: (1) To assess air leak (2) To quickly empty or change collection bottle or chamber; performed by soldier medic who has received training in procedure (3) To change disposable systems; have new system ready to be connected before clamping tube so that transfer can be rapid and drainage system reestablished (4) To change a broken water-seal bottle in the event that no sterile solution container is available (5) To assess if patient is ready to have chest tube removed (which is done by physicians order); the solider medic must monitor patient for recreation of pneumothorax Position the patient to permit optimal drainage (1) Semi-Flowers position to evacuate air (pneumothorax) (2) High Flowers position to drain fluid (hemothorax) Maintain tube connection between chest and drainage tubes intact and taped (1) Water-seal vent must be without occlusion (2) Suction-control chamber vent must be without occlusion when suction is used Coil excess tubing on mattress next to patient. Secure with rubber band and safety pin or systems clamp

d.

e.

f.

g.

h.

Adjust tubing to hang in straight line from top of mattress to drainage chamber. If chest tube is draining fluid, indicate time (e.g., 0900) that drainage was begun on drainage bottles adhesive tape or on write-on surface of disposable commercial system (1) Strip or milk chest tube only per MD/PA orders only (2) Follow local policy for this procedure

Problems solving with chest tubes a. Problem: Air leak (1) Problem: Continuous bubbling is seen in water-seal bottle/chamber, indicating that leak is between patient and water seal (a) Locate leak (b) Tighten loose connection between patient and water seal (c) Loose connections cause air to enter system. (d) Leaks are corrected when constant bubbling stops (2) Problem: Bubbling continues, indicating that air leak has not been corrected (a) Cross-clamp chest tube close to patients chest, if bubbling stops, air leak is inside the patients thorax or at chest tube insertion site (b) Unclamp tube and notify physician immediately! (c) Reinforce chest dressing Leaving chest tube clamped caused a tension pneumothorax and mediastinal shift

Warning:

b.

Problem: Bubbling continues, indicating that leak is not in the patients chest or at the insertion site (a) Gradually move clamps down drainage tubing away from patient and toward suction-control chamber, moving one clamp at a time (b) When bubbling stops, leak is in section of tubing or connection distal to the clamp (c) Replace tubing or secure connection and release clamp (4) Problem: Bubbling continues, indicating that leak is not in tubing (a) Leak is in drainage system (b) Change drainage system Problem: Tension pneumothorax is present (1) Problems: Severe respiratory distress or chest pain (a) Determine that chest tubes are not clamped, kinked, or occluded. Locate leak (b) Obstructed chest tubes trap air in intrapleural space when air leak originates within patient (2) Problem: Absence of breath sounds on affected side (a) Notify physician immediately (3) Problems: Hyperresonance on affected side, mediastinal shift to unaffected side, tracheal shift to unaffected side, hypotenstion or tachycardia (a) Immediately prepare for another chest tube insertion (b) Obtain a flutter (Heimlich) valve or large-guage needle for short-term emergency release or air in intrapleural space (c) Have emergency equipment (oxygen and code cart) near patient (4) Problem: Dependent loops of drainage tubing have trapped fluid (a) Drain tubing contents into drainage bottle (b) Coil excess tubing on mattress and secure in place (5) Problem: Water seal is disconnected (a) Connect water seal (3)

(6)

(7)

(b) Tape connection Problem: Water-seal bottle is broken (a) Insert distal end of water-seal tube into sterile solution so that tip is 2 cm below surface (b) Set up new water-seal bottle (c) If no sterile solution is available, double clamp chest tube while preparing new bottle Problem: Water-seal tube is no longer submerged in sterile fluid (a) Add sterile solution to water-seal bottle until distal tip is 2 cm under surface (b) Or set water-seal bottle upright so that tip is submerged

SUMMARY Caring for a patient with a chest tube requires problem solving and knowledge application. Remember, a chest tubes is a catheter inserted through the thorax to remove air and fluids from the pleural space and to reestablish normal intrapleural and intrapulmonic pressures. When caring for and maintaining a patient with a chest tube, it is important to note the patency of chest tubes, presence of drainage, presence of fluctuations, patient's vital signs, chest dressing status, type of suction, and level of comfort.