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Learning Scope #350
1 contact hour
Expires Jan. 17, 2013
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The goal of this CE offering is to review the latest techniques for troubleshooting chest tubes. After reading this article, you will be able to:
1. Discuss the purpose of the water seal in chest drainage systems.
2. Assess patients with chest tubes for complications and provide appropriate interventions.
3. Document essential information related to the patient with a chest tube or chest drainage device.
Chest tubes are used to restore negative pressure in the pleural space after trauma/pneumothorax or chest surgery. Chest tubes also can be used to remove collections of fluid (effusions) such as blood, pus, chyle or serous fluid and/or air from the pleural space. Mediastinal chest tubes are used after cardiac surgery to prevent compression of the heart by accumulated fluid and blood.
The pressure in the chest cavity is normally lower than the atmospheric pressure; whenever the chest is opened, there is air at atmospheric pressure (positive pressure) that enters the pleural space causing collapse of the lung, much like air entering an inflated balloon. Air or fluid in the pleural space restricts lung expansion and may reduce gas exchange.1
ed during surgeries where general anesthesia is used, a local anesthetic is administered. When air is the expect product to be drained the chest tube is placed more anteriorly around the second or third intercostal space (ICS) in the anterior axillary or midclavicular line. When blood, pus or effusions are to be drained, the tube is inserted around the fifth or seventh ICS.2
Small-bore tubes, such as 7-12 French, can be used with one-way valve systems, usually for removal of air (to be discussed later). Larger bore tubes (up to 40 French) usually are connected to a chest drainage system to collect pleural fluid, monitor for air leaks and often are used if sanguinous drainage is anticipated.1
Assisting With Insertion
Chest tubes may be place in the operating room, at the bedside or under ultrasound guidance. When assisting with insertion, gather the chest tube insertion tray, the chest tube (size to be determined by the physician) and the disposable chest drainage system along with a bottle of sterile water and wide adhesive tape.
A local anesthetic is applied and the physician uses a scalpel to dissect down to the pleural space. The chest tube is inserted and immediately attached to the prepared drainage system. Expect to call for a stat chest X-ray to confirm the position of the chest tube. Palpate around the insertion site for subcutaneous emphysema, which reflects air leaking from the lung into surrounding tissues. When palpated, the tissue has a crackling sensation. While not typically dangerous, subcutaneous air may progress into the face, neck, body and scrotum. Document the extent of the subcutaneous air. If the neck is involved, collaborate with the physician to determine if a surgical airway is needed.1
Then apply an occlusive dressing using wide adhesive tape. Petrolatum gauze may be placed around the insertion site to prevent air from entering the chest cavity. Securely tape all connections of the chest tube. The dressing is changed when soiled or every 2-3 days unless otherwise ordered.3 Document the size and placement of the tube, whether suction is applied and the materials used for the dressing (below) and that it is occlusive.
Disposable Drainage Systems
Chest drainage systems are typically disposable units, with three chambers, based on the old 3 bottle systems. The water seal creates a barrier between the atomospheric pressure and the lung. In other words, the water permits air and fluid to exit the pleural space, but prevents air from entering. Fill the water seal with sterile water to the 2 cm level. Then, attach the chest tube to the chest drainage unit's long tubing.
Currently, disposable chest drainage units may have wet or dry suction regulation. When using a traditional water seal with wet suction, fill the suction control chamber with the volume of water to the line indicated on the device, usually -20 cm. Then connect the short tubing from the drainage unit to the tubing from the suction source. The wall suction should be regulated to produce gentle bubbling in the suction control chamber. More vigorous bubbling will not increase suction to the chest cavity because the water level regulates the amount of suction applied. However, more vigorous bubbling promotes evaporation and lessens the amount of suction.
Water seal units with dry suction have a regulator to dial in the suction to the ordered amount, between -20 cm and -40 cm. For dry suction, set the wall suction unit to -80 cm and increase slowly, using the lowest amount that causes the bellows or float regulator to reach the delta mark or suction indicator.1 Both systems may be used with suction, but may also operate by gravity drainage. Suction promotes drainage of fluid and removal of air.
Tape the chest drainage unit to the floor or hang from the bed, below the level of the patient's chest. The tubing should rest on the bed then fall in a straight line to the drainage unit; there should be no dependent loops in the tubing
Assessment & Documentation
During each assessment, ensure there is 2 cm of water in the water seal, since too little can permit air to enter the pleural space, further collapsing the lung. If more water is needed, fill the water seal by lifting the damper and gently pouring water in to the fill line. If accidentally overfilled, most units have a re-sealable rubber stopper where a syringe with an 18 gauge needle can be inserted to withdraw the excess fluid.
Assess for fluctuation or tidaling, where fluid level in the water seal on rises on inspiration and falls on expiration. Keep in mind if the patient is receiving positive pressure ventilation, tidaling will occur in the opposite manner; downward on inspiration and upward on expiration. Tidaling will stop when the lung is re-expanded as the eyelets of the chest tube become occluded by the expanded lung. If tidaling is absent, encourage coughing and deep breathing or check for obstruction. Tidaling may be minimal or absent in systems using suction.
Observe the water seal for an air leak. Intermittent bubbling in the water seal indicates air is exiting the pleural space, consistent with resolving pneuomothorax. Rapid, vigorous bubbling in the water seal indicates a large air leak consistent with a tear in the pleura, bronchopleural fistula, or a crack or leak in the drainage system.
To determine the source of the air leak, briefly clamp the chest tube close to the patient; if the bubbling stops, the air is from the patient's chest. If it continues, briefly clamp at intervals along the length of the tubing. When the bubbling stops, the air leak is between the clamp and the patient. Change the chest drainage unit is indicated if there is a suspected crack or leak in the system. Accidental dislodgement of the chest tube or protrusion of the eyelets of the chest tube from the patient's chest will cause an air leak. Note: The tube may be concealed under the dressing, so the dressing may need be removed for this observation. Contact the surgeon if this occurs; the tube may need re-insertion.
Monitor vital signs, breath sounds, oxygen saturation, skin color and capillary refill. Palpate around the insertion site for subcutaneous emphysema.
Monitor the amount and characteristic of the drainage, noting any sudden changes in output. After chest surgery, the nurse monitors the drainage every hour for the first several hours according to hospital policy, then every shift. Sanguinous drainage is expected, but should gradually decrease over 24 hours. Mark the drainage hourly after surgery or each shift as specified by hospital policy and record as output.
Unless otherwise instructed by the surgeon, the drainage for the first 2 hours after surgery should not exceed 150 mL/hour; if so, notify the surgeon as this may indicate hemorrhage, especially when associated with tachycardia and hypotension. The first 24 hours post operatively drainage may be as much as 500-1000 ml. If there is no drainage immediately post operatively, suspect occlusion.
Drainage for pleural effusions should be clear. Bloody effusions may indicate cancer. White drainage may indicate lymph or chyle. Purulent drainage indicates infection or empeyema. A simple pneumothorax will have scant to no drainage, but air will bubble through the water seal as it escapes the pleural cavity.