Chest Tubes

The Mechanics of The Mechanics of BreathingBreathing

In normal situations, the pressure In normal situations, the pressure between the pleura of the lungs is between the pleura of the lungs is below atmospheric pressure.below atmospheric pressure.

When air or fluid enters the intrapleural When air or fluid enters the intrapleural space, the pressure is altered, and this space, the pressure is altered, and this can cause collapse of a portion of the can cause collapse of a portion of the lung.lung.

Even with adequate oxygenation Even with adequate oxygenation and an open airway, a patient with and an open airway, a patient with a collapsed portion of the lung will a collapsed portion of the lung will not have adequate oxygen - not have adequate oxygen - carbon dioxide exchange.carbon dioxide exchange.

The only treatment for this altered The only treatment for this altered condition is to restore the negative condition is to restore the negative pressure to the intrapleural space. pressure to the intrapleural space. This is accomplished through the This is accomplished through the use of a chest tube.use of a chest tube.

Pneumothorax 

Indication of Chest IntubationIndication of Chest Intubation

Drain pleural fluid or air promote lung Drain pleural fluid or air promote lung expansionexpansion

1. Pneumothorax1. Pneumothorax2. Hydrothorax2. Hydrothorax3. Hemothorax3. Hemothorax4. Chylothorax4. Chylothorax5. Pyothorax5. Pyothorax6. Post-thoracotomy etc.6. Post-thoracotomy etc.

Size of Chest Tube  

 Adult or Teen Male 

              28-32 Fr 

 Adult or Teen Female 

              28 Fr 

 Child  

              18 Fr 

Newborn              12-14 Fr

Pleural aspiration/drainage:Pleural aspiration/drainage:

Complications:Complications: Pneumothrax, apprehension, Pneumothrax, apprehension, increase restlessness, tension pneumothorax, increase restlessness, tension pneumothorax, dysponea, chest pain, tachycardia, etc. dysponea, chest pain, tachycardia, etc.

PositionPosition : : Pneumothrax = 2nd ICS Pneumothrax = 2nd ICS

:: Haemo/pyo thorax = 4-6th ICS. Haemo/pyo thorax = 4-6th ICS. 2009 Trauma Guidelines: 52009 Trauma Guidelines: 5thth Intercostal Intercostal

Space, Space, outer side of mid axillaries line. outer side of mid axillaries line.

Nursing Assessment Nursing Assessment FindingsFindings

Diminished or Diminished or absentabsent breath sounds on breath sounds on affected side.affected side.

Decreased chest wall Decreased chest wall movement on affected movement on affected side.side.

Difficulty breathing.Difficulty breathing. TachycardiaTachycardia AnxietyAnxiety RestlessnessRestlessness

Decreased oxygen Decreased oxygen saturationsaturation

Increased Peak Airway Increased Peak Airway PressuresPressures

CyanosisCyanosis Complaints of pleuritic-Complaints of pleuritic-

type chest paintype chest pain Increased respiratory Increased respiratory

raterate Pain may worsen when Pain may worsen when

attempting to breathe attempting to breathe deeplydeeply

Equipment needed for Chest Equipment needed for Chest Tube SetupTube Setup

Chest tube insertion Chest tube insertion traytray

Tube (appropriate Tube (appropriate size)size)

Local Anesthetic Local Anesthetic (Xylocaine)(Xylocaine)

Betadine (or other Betadine (or other antiseptic)antiseptic)

Suturing suppliesSuturing supplies Sterile glovesSterile gloves

2- 1000cc bottles 2- 1000cc bottles of sterile water or of sterile water or Plastic bagPlastic bag

4 x 4’s gauze pad4 x 4’s gauze pad Suction setupSuction setup Suction tubingSuction tubing Chest tube Chest tube

collection systemcollection system Vaseline GauzeVaseline Gauze TapeTape

Surgical Procedure Surgical Procedure StepsSteps

Apparatus of Chest Tube Drainage: (old method)Apparatus of Chest Tube Drainage: (old method)

1. Underwater sealed bottle: 1. Underwater sealed bottle: Separate from Separate from atmosphereatmosphere

2. Collecting bottle: 2. Collecting bottle: Decrease resistance of Decrease resistance of drainagedrainage

3. Negative pressure suction: 3. Negative pressure suction: Promote lung Promote lung expansionexpansion

Recently we use chest tube with plastic bagRecently we use chest tube with plastic bag

InsertionInsertion

The patient will need to be positioned The patient will need to be positioned according to where the chest tube will be according to where the chest tube will be placed. placed.

Typically having the patient’s arms over Typically having the patient’s arms over their head.their head.

Pre-medicate the patient with sedation & Pre-medicate the patient with sedation & pain medicine as per order. pain medicine as per order.

Procedure of Chest IntubationProcedure of Chest Intubation

1. Local anesthesia, confirm location1. Local anesthesia, confirm location2. Skin incision at selected area with 11 no blade2. Skin incision at selected area with 11 no blade3. Dissect into pleural cavity thru a subcutaneous 3. Dissect into pleural cavity thru a subcutaneous

tunneltunnel4. Locate pleural cavity4. Locate pleural cavity5. Insert tube posteriorly and laterally5. Insert tube posteriorly and laterally6. Close incision wound, fixed the tube6. Close incision wound, fixed the tube7. Connect tube to underwater sealed bottle (or with 7. Connect tube to underwater sealed bottle (or with

negative pressure suction)negative pressure suction)

Attention in Massive Subcutaneous Attention in Massive Subcutaneous (Mediastinal) Emphysema:(Mediastinal) Emphysema:

1. Keep airway patent (even endotracheal tube)1. Keep airway patent (even endotracheal tube)2. CXR2. CXR3. Insert chest tube in pneumothorax or suspicious side3. Insert chest tube in pneumothorax or suspicious side4. Connect tube to negative pressure suction 4. Connect tube to negative pressure suction

immediatelyimmediately5. Close thoracostomy edge slightly loose5. Close thoracostomy edge slightly loose6. Insert another tube if no improvement6. Insert another tube if no improvement7. Low O2 nasal cannula7. Low O2 nasal cannula8. Determine the cause & treat underlying disease8. Determine the cause & treat underlying disease9. Remove tube after complete subsidence9. Remove tube after complete subsidence

Post-Insertion Post-Insertion DocumentationDocumentation

Reason for chest tube Reason for chest tube placement.placement.

Patient vital signs.Patient vital signs. Any medications given.Any medications given. Location & size of chest tube.Location & size of chest tube. Patient’s tolerance of Patient’s tolerance of

procedure.procedure. Drainage received (if any): Drainage received (if any):

color, characteristics, color, characteristics, volume, etc.volume, etc.

Dressing type applied. Dressing type applied. Connections securely Connections securely

taped.taped. Vital signs during/post Vital signs during/post

procedure.procedure. Water level ordered & set Water level ordered & set

for suction control for suction control chamber. chamber.

Post-insertion chest x-ray Post-insertion chest x-ray taken.taken.

Maintenance of Chest TubesMaintenance of Chest Tubes

Cardiovascular assessments must be performed Cardiovascular assessments must be performed every 4 hours at least for all patients with chest every 4 hours at least for all patients with chest tubes.tubes.

Encourage patient to cough & deep breathe.Encourage patient to cough & deep breathe. Check insertion site every morning at 0800 and Check insertion site every morning at 0800 and

replace dressing at that time.replace dressing at that time. Assess water levels in drainage unit each shift and Assess water levels in drainage unit each shift and

correct fluid levels if not as ordered.correct fluid levels if not as ordered. Report to Physician immediately any change or Report to Physician immediately any change or

complication with the chest tube.complication with the chest tube.

Dressing ChangeDressing Change

Maintenance of Chest TubesMaintenance of Chest Tubes

Check all tubing connections and re-tape as Check all tubing connections and re-tape as neededneeded

I & O to be completed (and marked on I & O to be completed (and marked on collection chamber). collection chamber).

Monitor for air leaks, chest x-ray results, Monitor for air leaks, chest x-ray results, oxygen saturations, and peak airway oxygen saturations, and peak airway pressures. pressures.

Report any alterations immediately.Report any alterations immediately.

Maintenance of Chest TubesMaintenance of Chest Tubes

Keep tubing coiled on bed, NEVER allow Keep tubing coiled on bed, NEVER allow tubing to dangle.tubing to dangle.

Ensure that bedside collection unit Ensure that bedside collection unit NEVER goes above chest level.NEVER goes above chest level.

Tubing PlacementTubing Placement

Potential Sources of Air LeaksPotential Sources of Air Leaks

Poor tubing connections.Poor tubing connections. Tube dislodgement from pleural space.Tube dislodgement from pleural space. Cracked bedside collection unit.Cracked bedside collection unit. To locate air leak, clamp the tubing To locate air leak, clamp the tubing

momentarilymomentarily at various points along tubing at various points along tubing length. length.

Nursing Care: Nursing Care:

Informed consent signed. Informed consent signed. Any allergy identified. Any allergy identified. Sedative given if prescribe. Sedative given if prescribe. Inform patient about all procedures and Inform patient about all procedures and

needs for better cooperation. needs for better cooperation. Make patient comfortable with adequate Make patient comfortable with adequate

support (Bedside, cardiac table, stand support (Bedside, cardiac table, stand chair). chair).

Support and re-assure the patient during Support and re-assure the patient during procedureprocedure

Nursing Care: Nursing Care:

After needle with drawn pressure applied at After needle with drawn pressure applied at site and small dressing applied. site and small dressing applied.

Patient is kept on bed rest. Patient is kept on bed rest. Record: details of fluid and any complains. Record: details of fluid and any complains. Evaluate Patients after procedureEvaluate Patients after procedure

Chest drainage.Chest drainage.

Two chest drain may join with Two chest drain may join with YY

Junction to same drain container. But Junction to same drain container. But preferably leave separate. preferably leave separate.

Guidelines for the management Guidelines for the management of chest drainage: (Plastic bag).of chest drainage: (Plastic bag).

Drainage tube should be attached to chest Drainage tube should be attached to chest bag and submerged 2.5 cm below water bag and submerged 2.5 cm below water level. level.

Short tube left open to atmosphere. Short tube left open to atmosphere. Original fluid level should be marked and Original fluid level should be marked and

daily/hourly recorded. daily/hourly recorded. Drainage tube should be fastened to avoid Drainage tube should be fastened to avoid

kinking.kinking.

Encourage Pt. to change position frequently. Encourage Pt. to change position frequently. Give adequate analgesic and encourage Give adequate analgesic and encourage

physiotherapy. physiotherapy. Ensure fluctuation of fluid level. Ensure fluctuation of fluid level. Stop when: - Lung re-expand. Stop when: - Lung re-expand.

• Tube blocked. Tube blocked.

• Dependent loop.Dependent loop.

Watch for air leak-report immediately. Watch for air leak-report immediately. (Air bubbling in fluid column). (Air bubbling in fluid column).

Avoid clamping: may create tension pneumothorax. Avoid clamping: may create tension pneumothorax. Observe and report – Rapid shallow breathing. Observe and report – Rapid shallow breathing.

• CyanosisCyanosis

• pressure in chest. pressure in chest.

• Subcutaneous emphysema. Subcutaneous emphysema.

• Excessive hemorrhageExcessive hemorrhage

• respiratory status and vitals. respiratory status and vitals.

Encourage deep breathing and coughing at Encourage deep breathing and coughing at frequent interval. frequent interval.

Keep drainage bag below chest level. Keep drainage bag below chest level. Checking dressing. Checking dressing. Sterile gauze and a padded clamp should be Sterile gauze and a padded clamp should be

kept at the bedside for emergency use if tube kept at the bedside for emergency use if tube is accidentally dislodged or disconnected. is accidentally dislodged or disconnected.

Drainage assessment: every hr till 24 hrs, Drainage assessment: every hr till 24 hrs, then 8 hrs subsequently. then 8 hrs subsequently.

Physician should notify if drainage exceed Physician should notify if drainage exceed 100 ml/hr. 100 ml/hr.

Assist physician while inserting and Assist physician while inserting and removing tube. (e.g. ask pt. to hold breath)removing tube. (e.g. ask pt. to hold breath)

Removal of Chest TubeRemoval of Chest Tube

IndicationsIndications• No fluctuation in the fluid column of the tube No fluctuation in the fluid column of the tube

(complete lung reexpansion or tube occlusion)(complete lung reexpansion or tube occlusion)

• Daily fluid drainage <100ml in 24 hours Daily fluid drainage <100ml in 24 hours (< 50 c.c./day)(< 50 c.c./day)

• Air leakage has stoppedAir leakage has stopped

Proper timing (controversy)Proper timing (controversy)• Spontaneous pneumothorax after thoracostomySpontaneous pneumothorax after thoracostomy

– removal tube within 6 hours of reexpansion--25% collapse removal tube within 6 hours of reexpansion--25% collapse

When to Remove Chest Tube ?When to Remove Chest Tube ?

Criteria:Criteria:

1. No air leakage1. No air leakage

2. Drained fluid < 50 c.c./day2. Drained fluid < 50 c.c./day

3. Clear serosanguineous color of fluid3. Clear serosanguineous color of fluid

4. Full expansion of lung in CXR4. Full expansion of lung in CXR Clear sterile fluid remove directlyClear sterile fluid remove directly Turbid, infected fluid withdraw progressivelyTurbid, infected fluid withdraw progressively

9-S for successful, safe chest tube 9-S for successful, safe chest tube insertion: insertion:

1.1. sedation: Adequate analgesiasedation: Adequate analgesia2.2. Site: a safe area above the nipple, posterior Site: a safe area above the nipple, posterior

to the anterior axillary's fold should be to the anterior axillary's fold should be chosen. (5chosen. (5thth ICS) ICS)

3.3. Sensitive: finger dissection will reduce Sensitive: finger dissection will reduce insertion complications.insertion complications.

4.4. Sterility: single dose Sterility: single dose antibiotic :Prophylaxisantibiotic :Prophylaxis

5.5. Suturing: to fix drain with heavy silkSuturing: to fix drain with heavy silk

6. suction: applied to drain (=20 cm of water)6. suction: applied to drain (=20 cm of water)

7. Seal carefully: on removal of tube7. Seal carefully: on removal of tube

8. Side effects: RT poor technique8. Side effects: RT poor technique

9. Sessions: CME/Procedural Exposure.9. Sessions: CME/Procedural Exposure.

Thank YouThank You

Extra SlidesExtra Slides

Components of the Chest Components of the Chest Tube Drainage SystemTube Drainage System

Suction control Suction control chamber chamber

Water Seal Water Seal ChamberChamber

Collection chamberCollection chamber

Suction Control ChamberSuction Control Chamber

The use of suction helps The use of suction helps overcome an air leak by overcome an air leak by improving the rate of air and fluid improving the rate of air and fluid flow out of the patient. flow out of the patient.

Lower the water content, lower Lower the water content, lower the suction. Raise the water the suction. Raise the water level, raise the amount of level, raise the amount of suction.suction.

Water Seal ChamberWater Seal Chamber

The The water seal chamberwater seal chamber which is which is connected to the collection chamber, connected to the collection chamber, allows air to pass down through a allows air to pass down through a narrow channel and bubble out through narrow channel and bubble out through the bottom of the water seal. the bottom of the water seal.

Continuous bubbling confirms a Continuous bubbling confirms a persistent air leak.persistent air leak.

Collection ChamberCollection Chamber

Fluids drain Fluids drain diirectly diirectly from patient from patient into the into the collection collection chamberchamber via via a 6’ patient a 6’ patient tube.tube.

Preparing for InsertionPreparing for Insertion

Gather supplies.Gather supplies. Prepare patient.Prepare patient. Open chest drainage Open chest drainage

system. system. Swing out floor stand Swing out floor stand

to stabilize the unit.to stabilize the unit. Close suction control Close suction control

stopcock.stopcock.

Components of the Chest Components of the Chest Tube Drainage SystemTube Drainage System

Suction control Suction control chamber chamber

Water Seal Water Seal ChamberChamber

Collection chamberCollection chamber

Suction Control ChamberSuction Control Chamber

The use of suction helps The use of suction helps overcome an air leak by overcome an air leak by improving the rate of air and fluid improving the rate of air and fluid flow out of the patient. flow out of the patient.

Lower the water content, lower Lower the water content, lower the suction. Raise the water the suction. Raise the water level, raise the amount of level, raise the amount of suction.suction.

Water Seal ChamberWater Seal Chamber

The The water seal chamberwater seal chamber which is which is connected to the collection chamber, connected to the collection chamber, allows air to pass down through a allows air to pass down through a narrow channel and bubble out through narrow channel and bubble out through the bottom of the water seal. the bottom of the water seal.

Continuous bubbling confirms a Continuous bubbling confirms a persistent air leak.persistent air leak.

Collection ChamberCollection Chamber

Fluids drain Fluids drain diirectly diirectly from patient from patient into the into the collection collection chamberchamber via via a 6’ patient a 6’ patient tube.tube.