CHEST TUBE CARE &
MANAGEMENT
Practicum Lab 3 - NRSG 10070
AGENDA
• Identify the indications for chest tube placement
• Discuss chest tube assessment and care
• Review types of chest drainage systems
• Explain the importance of monitoring patients with a chest tube
• Summarize the management of a chest tube
WHAT ARE CHEST TUBES?
• Chest tubes are inserted to remove air and fluids from the pleural space, prevent air or fluid from re-entering
the pleural space, and re-establish normal intrapleural and intrapulmonic pressures.
• A chest tube is a catheter inserted through the thorax to remove fluid or air.
• Maybe inserted at bedside, emergency department & in operating room.
• Commonly used after chest surgery, chest trauma & for pneumothorax or hemothorax to promote lung
re-expansion.
• There are a variety of chest drainage systems on the market.
• In addition to the usual disposable waterless system, the mobile chest drain may be used.
• Mobile systems rely on gravity, not suction, for drainage.
• Mobile chest drains are lighter and smaller, thus the patient is able to move more easily, reducing the risk for
deep vein thrombosis and pulmonary embolism.
PNEUMOTHORAX/HEMOTHORAX
• Pneumothorax – collection of air in pleural space. Loss of negative
intrapleural pressure causes lung to collapse.
• may occur spontaneously or as a result of a chest trauma.
• Hemothorax – accumulation of blood & fluid in pleural cavity between the
parietal & visceral pleurae, usually d/t trauma.
• Produces a counterpressure & prevents the lung fr full expansion.
• Can be caused by rupture of small blood vessels fr inflammatory processes,
such as pneumonia or TB.
• In addition to dyspnea, s&s of shock can develop if blood loss is severe
FUNCTION OF A PLEURAL DRAINAGE
SYSTEM
Inspiration
Intrapleural
Pressure
Lungs re-expand
Air and fluid move
into the bottle
Pleural space becomes negative
TYPES OF DRAINAGE SYSTEMS
• Two types of commercial drainage devices: water-seal and waterless systems. Although the
principles of the waterless system are similar to those of the water-seal system, there are
structural differences.
• Waterless system
§ does not require fluid for setup, and the water seal is replaced by a one-way valve
§ The suction chamber, which does not depend on water, contains a float ball that is set by a
control dial after the suction source is initiated
§ Dry suction chest drainage systems provide higher suction pressure levels.
§ A dial is set to the prescribed suction control setting.Pressure is set between −10 cm H2O and
−40 cm H2O.
Dry Suction Drainage System
DRAINAGE SYSTEMS
• A single-chamber system allows air from a pneumothorax to bubble out of the water seal and escape
through the air outlet, preventing air from re-entering the intrapleural space.
• A two- or three-chamber system drains both a hemothorax and a pneumothorax. The two-chamber
system allows fluid to flow into a collection chamber and air to flow into the water seal chamber.
• A three-chamber system permits the drainage of fluid and air through controlled suction. The two- and
three-chamber systems have two compartments—one for fluid or blood and a second for a water seal or a
one-way valve
• The three-chamber system has a third compartment for suction control, which may or may not be used
3 CHAMBER SYSTEM
1) Collection Chamber
• Collects drainage
• Assess as per orders- may be Q4 hours, Q shift, or if newly inserted more
frequent
2) Water seal chamber
• has about 2 cm of water in it; a one way valve that allows air to transport out
from the patient- nothing goes into the thoracic cavity
3) Suction control chamber
• this tells you how much suction is applied to the patient- as per orders
DRAINAGE SYSTEMS
• EXPRESS (DRY)
OASIS (DRY)
• Collection chamber
• Collection chamber
• Remove amp of sterile water (supplied with the • No need to fill suction chamber
Express) and add to the air leak monitor • Fill water seal chamber to 2cm fill line with sterile
• Observe air leak monitor for bubbling. Bubbling right water (amp supplied with OASIS)
to left indicates an air leak • Observe water seal chamber for bubbling or
tidaling
• Adjust suction regulator to desired level by turning • Turn suction source to -80mmHg or higher.
the dial. No need to fill suction chamber • Assess bellows indicator.
• Turn suction source to -80mmHg or higher. Assess • When decreasing suction one must depress the
bellows indicator. manual high negativity vent
• When decreasing suction one must depress the
manual high negativity vent
HEIMLICH CHEST DRAIN VALVE
• Specifically designed flutter valve that is
used in place of a chest drainage unit for
small, uncomplicated pneumothorax with
little or no drainage & no need for
suction.
• The valve allows for escape of air, but
prevents the re-entry of air into the
pleural space.
• Valve is placed between the chest tube &
the drainage bag.
• Can be worn under clothes
(Potter & Perry, 2024)
OCEAN (WET)
• Collection chamber
• Requires sterile water be
instilled into water seal and
suction chambers
• If suction applied, turn on
suction unit until slow but steady
bubbling appears in suction
control chamber
FACTORS THAT AFFECT DRAINAGE
1. Proper placement of chest catheter
2. Proper placement of chest drainage apparatus
3. Length of drainage tubing
4. Patency of chest tubing
5. Maintenance of air tight drainage system
6. Position of the patient
7. Application of mechanical suction
8. Activity of the patient
CARE OF A CLIENT WITH A CHEST TUBE
Governing Principles:
• Entry of air through the chest wall creates a pressure change, which causes collapse of the lung.
• The intrapleural negative pressure decreases or is lost.
• Trauma, disease, or surgery can result in air, blood, or fluid leaking into the intrapleural space, creating a positive
pressure that collapses the lung.
• Small leaks can be reabsorbed and may not require a chest tube. Larger leaks require a chest tube to remove the
air and fluid from the pleural space, prevent air or fluid from reentering the pleural space, and to reestablish
normal intrapleural and intrapulmonary pressures.
• The chest drainage unit is a sterile closed system and should never be opened to the environment.
• The chest drainage unit must be kept upright and below the level of the tube insertion site at all times.
CONSIDERATIONS
• Proper positioning of the patient with chest tubes to facilitate chest tube drainage
and optimal function of the system
• How to ambulate and transfer a patient with chest drainage
• To report to the nurse any changes in vital signs, including oxygen saturation, chest
pain, sudden shortness of breath, or excessive bubbling in the water-seal chamber
• To immediately report to the nurse a disconnection of the system, any change in
type and amount of drainage, sudden bleeding, or sudden cessation of bubbling
PROCEDURE
• Perform hand hygiene and assess patient
• Pulmonary status:
• Assess for respiratory distress, chest pain, breath sounds over affected lung area,
and stable vital signs
• Signs and symptoms of increased respiratory distress or chest pain include
decreased breath sounds over the affected and non-affected lungs, marked
cyanosis, asymmetrical chest movements, presence of subcutaneous
emphysema, around tube insertion site or neck, hypotension, and tachycardia.
ASSESSMENT
• Assess vital signs, SpO2, and level of orientation.
• Review patient's current hemoglobin and hematocrit levels.
• Pain assessment
• Observe:
• Chest tube dressing and site surrounding tube insertion
• Tubing for kinks, dependent loops, or clots
• Provide two shodded hemostats or approved clamps for each chest tube,
attached to the top of patient's bed with adhesive tape.
Chest tubes are clamped only under specific circumstances per prescriber's order or nursing
policy and procedure:
• Assess air leak
• To quickly empty or change disposable systems
• To assess if patient is ready to have tube removed
• Position patient:
• Semi-Fowler's to high-Fowler's position to evacuate air (pneumothorax).
• High-Fowler's position to drain fluid (hemothorax, effusion).
• Maintain tube connection between chest and drainage tubes; ensure that it is intact and secured.
• Check patency of air vents in system:
• A) Water-sealed vent must be without occlusion.
• B) Suction-control chamber vent must be without occlusion when suction is used.
• C) Confirm that valves are unobstructed. Waterless systems have relief valves without caps. For dry
suction systems, the positive pressure relief valve must remain unobstructed.
• Coil excess drainage tubing on mattress or chair.
• Secure with rubber band, safety pin, or plastic clamp.
• Allow enough space for patient to reposition.
• Adjust tubing to hang in a straight line from top of mattress to drainage chamber.
• If chest tube is draining fluid, indicate time (e.g., 0900) on drainage system with adhesive tape or
write-on surface of disposable commercial system.
oximetry as ordered or if patient's condition changes. • Provides ongoing data about the patient's level of oxygenation.
• Appearance of drainage may be due to tube occlusion, causing drainage to exit around tube.
Point: Check the dressing carefully because it must remain occlusive. It can come loose from the skin, although this may not be readily apparent. Follow hospital policy as needed to
maintain seal.
ree of kinks and dependent loops. • Straight and coiled drainage tube positions are optimal for pleural drainage. However, when a dependent
loop is unavoidable, periodic lifting and drainage of the tube will promote pleural drainage.
em: It should be upright and below level of tube insertion. • The system must be in the upright position to function and facilitate proper drainage.
or debris in tubing.
ations with patient's inspiration and expiration.
• In a nonmechanically ventilated patient, fluid should rise in the water seal or diagnostic indicator with
m: Diagnostic indicator for fluctuations for patient's inspiration and fall with expiration. The opposite occurs in a patient who is mechanically ventilated. This
tions. indicates the system is properly functioning.
• When system is initially connected to patient, bubbles are expected from the chamber. These are from
m: Bubbling in the water-seal chamber. air that was present in the system and in the patient's intrapleural space. After a short time, the bubbling
stops. Fluid will continue to fluctuate in the water seal on inspiration and expiration until the lung is re-
expanded or the system becomes occluded.
• The suction-control chamber has constant gentle bubbling. Tubing remains free of obstruction and the
Bubbling in the suction-control chamber (when using suction). suction source is turned to the appropriate setting.
bbling in diagnostic indicator. • Mechanism to observe for the presence of tidalling.
• The suction float ball dictates the amount of suction in the system. The float ball allows no more suction
than allowed by its setting. If the suction source is set too low, the suction float ball cannot reach the
prescribed setting. In this case, the suction must be increased for the float ball to reach the prescribed
setting.
TYPE AND AMOUNT OF FLUID
DRAINAGE
• Note colour and amount of drainage, patient's vital signs, and skin colour.
• Assess the fluid in the collection tubing, not just the drainage in the collection
chamber.
• The normal amount of drainage:
• In the adult: <50–200 mL/hour immediately after surgery in a mediastinal chest tube;
approximately 500 mL in first 24 hours
• In the adult: Between 100 and 300 mL of fluid may drain in a pleural chest tube in an adult
during the first 3 hours after insertion. The 24-hour rate is 500–1000 mL.
• Drainage is grossly bloody during the first several hours after surgery and then changes to
serous.
• Remember that a sudden gush of drainage may be retained blood and not active
bleeding.This increase in drainage can result from patient position changes.
NURSING ASSESSMENTS
• Auscultate lungs q shift
• Inspect chest tube insertion site q4h for
§ Drainage
§ Subcutaneous emphysema
• Check drainage tubing for patency q4h
§ does fluid move in tubing with breathing?
§ is there bubbling in water seal chamber?
§ if YES, is it intermittent or continuous?
OTHER NURSING RESPONSIBILITIES
• Check for required equipment @ bedside
- two hemostats (clamps)
- vaseline gauze
• Monitor amount of drainage in collection chamber – q4h and at
end of shift
- note colour
- report large increase in amount of drainage
- NEVER EMPTY DRAINAGE (mark fluid level
with date and time on plastic container)
• Do not ROUTINELY milk chest tubes (this increases pleural
pressure)
EXAMPLES
Suction pressure Suction port on the
set at -20 cm top of the drainage
system
Suction control
window Air leak
meter
CHARTING FOR A CLIENT WITH
A CHEST TUBE
DATA
• Location and patency of chest tube
• Negative pressure setting (__ mm)
• Presence of fluctuations
• Chest tube insertion site
• Colour of drainage (possibly)
• Respiratory Assessment
ACTIONS
• Care of client
• *Document vital signs on flow sheet*
RESPONSE
• Patient’s response
• Full Signature and designation
DEFINITIONS
Visceral
Parietal Pleura pleura
Waterless
Empyema System
Hemothorax Subcutaneous
Mediastinal Emphysema
Shift
Tension
Pneumothorax Pneumothorax
Pleural Effusion
Water-seal
system
Bubbling
Water Seal
Tidaling
• Visceral pleura covers the lungs and adjoining structures, via blood vessels, bronchi and nerves.
• Pleural effusion “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the
lungs.
• Pneumothorax is a collection of air in the pleural space.
• The loss of negative intrapleural pressure causes the lung to collapse.
• There are a variety of mechanisms that are associated with a pneumothorax.
• Hemothorax is an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleurae,
usually as a result of trauma. Produces a counterpressure and prevents the lung from full expansion.
• Tension pneumothorax occurs when air accumulates between the chest wall and the lung and increases
pressure in the chest, reducing the amount of blood returned to the heart.
• Water less system does not require fluid for setup, and the water seal is replaced by a one-way valve
• Tidaling The water in the water-seal chamber should rise with inhalation and fall with exhalation (this is called
tidaling), which demonstrates that the chest tube is patent.
• Bubbling- Continuous bubbling may indicate an air leak, and newer systems have a measurement system for leaks
— the higher the number, the greater the air leak.
• Empyema a collection of pus in the space between the lung and the inner surface of the chest wall (pleural
space).
• Mediastinal shift deviation of the mediastinal structures towards one side of the chest cavity, usually seen on
chest radiograph. It indicates a severe asymmetry of intrathoracic pressures.
• Subcutaneous emphysema air trapped in the subcutaneous tissue. surgical, traumatic, infectious, or
spontaneous etiologies. Injury to the thoracic cavity, sinus cavities, facial bones, etc. Any
NEXT STEPS:
• In person lab:
§ Assessment and management of chest tubes
§ Continued practice of IV Medication Administration (Secondary)
