NURSING
MANAGMENT OF
CHEST TUBES
By Alice Leung RN, BSN, PCCN
02/2016
TOPICS
• Chest & Lung Anatomy
• Indications for Chest Tube Placement
• Concept of Chest Tube – 3 Bottle System
• Parts of the Chest Tube Unit
• How to set up the system
• Nursing Assessments/ Interventions!!!
LUNG ANATOMY
Parietal Pleura
Pulmonary Pleura
• Parietal pleura: Inside membrane of the rib cage
• Pulmonary or visceral pleura: Outside membrane of the lungs
• The two membranes are separated by a lubricating fluid (pleural fluid)
which enables them to slide against each other. Lung can expand and
contract
• Vacuum or “negative pressure” in the pleural space keeps the two
pleurae together. If fluid or air enters the pleural space, lungs cannot fully
expand during each respiratory cycle
LUNG ANATOMY
CHEST TUBE PLACEMENT
Normal Breathing Mechanics
INHALATION EXHALATION
Diaphragm Diaphragm relaxes,
contracts down & rises, and pushes air
draws air into & CO2 back out the
the trachea, same route.
bronchi, Negative pressure
bronchioles, and between the
alveoli. Negative pleurae is
pressure approximately
between the
pleurae is
-4cmH2O
approximately
-8cmH2O
INDICATIONS FOR CHEST TUBE
• PNEUMOTHORAX: AIR IN THE PLEURAL SPACE (TRAUMA, LUNG DISEASE,
PROCEDURE COMPLICATIONS)
• HEMOTHORAX: BLOOD IN THE PLEURAL SPACE (BLUNT OR PENETRATING
TRAUMA)
• HEMOPNEUMOTHORAX: AIR & BLOOD IN THE PLEURAL SPACE
• TENSION PNEUMOTHORAX: OCCURS WHEN INJURED TISSUE FORMS A ONE
WAY VALVE OR FLAP ALLOWING AIR TO ENTER BUT PREVENTING IT FROM
ESCAPING NATURALLY, (EMERGENT SITUATION)
• PLEURAL EFFUSION: EXCESSIVE FLUID IN PLEURAL SPACE
• EMPYEMA: COLLECTION OF PUS D/T INFECTION
• CHYLOTHORAX: LYMPHATIC FLUID ACCUMULATION IN THE PLEURAL
INDICATIONS FOR CHEST TUBE
• AUTOTRANSFUSION: USED DURING SURGERY, BLOOD
COLLECTED IN CHEST TUBE WITH AN AUTOTRANSFUSION
SYSTEM (ATS) BAG AND RETURNED TO PATIENT USING
MICROEMBOLI BLOOD FILTER AND IV BLOOD SET, MUST BE
REINFUSED WITHIN 6 HRS OF COLLECTION, PREFERABLY
IMMEDIATELY
• PREVENT POST OP COMPLICATIONS: IE POST CARDIAC SURGERY
OR CHEST TRAUMA, CT MAY BE INSERTED TO MEDIASTINUM TO
DRAIN BLOOD AND PREVENT CARDIAC TAMPONADE
• INSTILLING FLUIDS IN THE PLEURAL SPACE: IE CHEMO DRUGS
INSERTION SITE
Superior Tube Placement:
Removal of Air (ie.
Pneumothorax)
Inferior Tube Placement:
Removal of Fluids (ie.
Hemothorax, Empyema)
Posterior Tube Placement:
Loculated (confined pocket)
fluid or air
INSERTION SITE
“Safe Triangle” Recommended by The British
Thoracic Society guidelines
-Minimizes risk of injury to the
internal mammary artery, muscle
or breast tissue.
All Experts agree:
Tube placed in the midaxillary line
btw 4th and 5th Ribs should
successfully drain fluid or vent air
CHEST TUBE SYSTEM
3 BOTTLE SYSTEM
Suction Patient
Suction Water Collection
Control Seal Bottle
COLLECTION BOTTLE AND WATER SEAL
SUCTIO Patient
N
Collection Chamber: Collects drainage
Water Seal: Maintained at 2cm, One way valve;
Prevents air or fluid from returning to the chest
SUCTION CONTROL
Tube open to
Atmosphere Air
Tube To Suction
Straw under 20cmH2O
- Suction Control: The straw submerged in the suction control bottle (typically to
20cmH2O) limits the amount of negative pressure that can be applied to the pleural space
– in this case -20cmH2O
- The submerged straw is open at the top to Atmosphere Air
As the vacuum source is increased, bubbling begins in this bottle, it means atmospheric
pressure is being drawn in to limit the suction level
SUCTION CONTROL
• THE DEPTH OF THE WATER IN
THE SUCTION BOTTLE
DETERMINES THE AMOUNT OF
NEGATIVE PRESSURE THAT CAN
BE TRANSMITTED TO THE
CHEST, NOT THE READING ON
THE VACUUM REGULATOR
• HIGHER NEGATIVE PRESSURE
CAN INCREASE THE FLOW RATE
OUT OF THE CHEST, BUT IT CAN
CHEST TUBE DRAINAGE UNIT
Modern
Day
ATRIUM DRAINAGE SYSTEM
A: Collection Chamber
B: Water Seal
CB A C: Suction Control
COLLECTION CHAMBER
• Fluids drain directly from
patient into the collection
chamber via a 6’ patient
tube.
• Fluid is calibrated in mL
• Write on surface to note
level, date & time.
WATER SEAL
• Prevents air from reentering the patient
• Intrathoracic Pressure Monitoring
• Advance Float valve at the top of water seal: protects
pt from high negativativy d/t stripping or milking
Care:
• Ensure 2cmH2O present in Chamber
• Normal: “Tidaling”- Occurs with change in pressure
when pt inhales and exhales
• Abnormal: Bubbling (from R to L) – Indicates Air leak
• Check tubing connections and pt dressing site for
withdrawn catheter
• Determine source of leak by clamping pt tube
momentarily and checking to see if bubbling stops
SUCTION CONTROL
Ocean Water Dry Suction Water
Seal Chest Seal:
Drain: • Adjust Rotary Dry
• Ensure fluids is at Suction Control to
desired level (- prescribed level, turn
20cmH2O) wall suction to
• Ensure GENTLE -80mmHg
BUBBLING is • Orange Bellow will
present, adjust expand: If level ≥ 20,
with suction bellow will reach or pass
control stop cock delta symbol. Indicates
proper functioning
OTHER TYPES…
Heimlich Valve (Flutter Valve):
• One way valve, allows air to escape but keeps it from re-entering the
chest cavity
• Accommodates a small or partial pneumothorax
• Does not collect fluid
• Inner valve should move during exhalation
indicates air is flowing through the device
• Placed in stable pts, allows for more mobility
ATRIUM SAFETY FEATURES
SAFETY FEATURES
• High Negative Float Valve
• Manual High Negative
Vent
• Positive Pressure Release
Valve
• Knock Over Protection
HIGH NEGATIVE FLOAT VALVE
• Ball located at the top of the water seal
chamber
• Protects patient during deep inspiration
and gravity drainage
• Allows the patient to draw as much
intrathoracic pressure as needed during
each respiratory cycle
• During periods of prolonged negative
pressure this valve will automatically
lower high negative pressure to a safer
level
MANUAL HIGH NEGATIVE VENT
• Located on the top of the drain on the back side of the water seal chamber
• Used to lower the water level in the water seal
• In conditions of high negative intrapleural pressure (i.e. stripping the tube or
excessive coughing), the water column may rise in the water seal chamber
• Depressing the vent will release the negative pressure and lower the water
column in the water seal chamber
• Do Not Use when suction is not operating or when pt is on gravity drainage
POSITIVE PRESSURE RELEASE VALVE
• Located on top of the
suction control chamber
(Blue ball)
• Automatically opens to
release accumulated positive
pressure
• Reduces the risk of tension
pneumothorax due to
suction tubing occlusion
KNOCK OVER PROTECTION
Water seal integrity is preserved during accidental knock over
If Chest Tube collection device is knocked over:
- Set it up right immediately
- Assess the fluid level in water seal and suction chamber if available
- Adjust levels by adding (sterile water) or aspirating fluids from each
chamber to the prescribed level.
- Behind each chamber is a grommet (self-sealing diaphragm)
- Swab with alcohol wipe, access with 20 gauge or smaller needle.
- If blood or body fluid has enter water seal, the system may have to be
changed.
SETTING UP THE SYSTEM
1. Fill the water seal chamber with 2cm of sterile water (included with
chest tube set up), water will turn blue
2. Connect 6' patient tube to thoracic catheter
3. Set Up Suction
- Water Suction: Fill chamber to 20cm,
connect the drain to vacuum, and slowly
increase vacuum until gentle bubbling
appears in the suction control chamber
- Dry suction: Set the dial to prescribed
pressure, connect to suction source and
turn to -80mmHg or higher if needed.
NURSING ASSESSMENTS
AND INTERVENTIONS
ASSESSMENT
USE THE ACRONYM
S = Site
T = Tubing
O = Output
P = Patency
STOP
S = Site
Check Site:
• Ensure tube is in place,
• No S&S of infection
• Dressing CDI, change q48h & PRN wet
or soiled. Sterile technique, occlusive
dressing
Subcutaneous emphysema
Subcutaneous Emphysema
(Air Underneath the Skin)
Subcutaneous emphysema
(air trapped under skin)
a. Palpate – Crepitis (Rice Krispies)
b. Notify MD
c. Continuous Monitoring
Check the Dressing & Site
T
S OP
T = Tubing
Connections are secured
No dependent loops, kinks
Straighten periodically
Keep the drainage system below
patient’s level
ST OP
O = Output
Document amount, type and color
Check the level regularly
Document in Epic – LDA
Use the white write-on column on
the drainage chamber to mark
drainage include date & time
(Check with your unit to see how
often)
STO P
P = Patency (A: water seal)
Assess the water seal with the suction off
If water seal level is too high, it will be more difficult
for air to leave the chest (aspirate water via grommet)
If the water seal level is too low, it leaves the water
seal chamber at risk for exposure to air and can cause
a pneumothorax (add sterile water via grommet)
STO P
P = Patency (B: Bubbling)
Bubbling means there is a leak in the system unless the
patient has a pneumothorax.
• Intermittent bubbling may indicate air leak from
pleural space, will resolve when lung re-expands
• Continuous bubbling suspect a leak in the system
STO P
P = Patency (C: fluctuations)
Normal:
Inspiration the water seal level will reach -10cm
Expiration the water seal level will reach -4cm of
negative pressure normally
If fluctuations stop, the tubing may be obstructed
(kinks, pt lying on tubing, stuck in railing, etc.)
If more than 2cm of water the drainage will decrease
If less than 2cm of water there is risk of pneumothorax
ASSESS PULMONARY STATUS
• Respiration Rate
• Work of Breathing
• Breath Sounds
• Continuous SpO2
Monitoring
AT THE BEDSIDE
• Always keep drain BELOW the
chest for gravity drainage
• Creates a pressure gradient with
relatively higher pressure in the
chest
• Fluid moves from an area of
higher pressure to an area of
lower pressure
AT THE BEDSIDE –
EMERGENCY ACTIONS
DISLODGED TUBE FROM PT. DISLODGED FROM COLLECTION DEVICE
• COVER OPEN INSERTION SITE WITH • PLACE THE END OF THE TUBE INTO
VASELINE GAUZE AT PEAK INSPIRATION BOTTLE OF STERILE WATER TO CREATE
A ONE WAY VALVE.
• COVER WITH 4X4’S GAUZE & TAPE
THREE SIDES ONLY • PREPARE NEW DRAINAGE DEVICE AND
CONNECT TO PT TUBING
• NOTIFY M.D. STAT
• CHART EVENT
ITEMS TO BE KEPT AT
BEDSIDE
• 2 CLAMPS
• VASELINE GAUZE
• 4X4 GAUZE DRESSING
• NON-POROUS TAPE
• STERILE WATER BOTTLE OR NS
CHEST TUBE MANIPULATION
• Avoid it!!
• Stripping and Milking may generate
extreme Negative pressure, does
little to maintain chest tube patency
• If clot is present, squeeze hand over
hand, releasing tubing between
squeezes to help move clots
CLAMPING
Clamp Only When
Changing the device (the drainage system)
Checking for an air leak
Tubing is disconnected and sterile water is out of reach
Checking lung re-expansion prior to chest tube removal
DO NOT Clamp
Ambulating Patient (will increase risk of tension
pneumothorax)
Transport – Disconnect suction tubing at Suction Control Stop
cock, leave open
CHEST TUBE REMOVAL
INDICATIONS:
• Improved respiratory status
• Symmetrical rise and fall of chest
• Bilateral Breath Sounds
• Decreased chest tube drainage
• Absence of bubbling in the water seal chamber
during inspiration
• Improved CXR findings
CHEST TUBE REMOVAL
Process:
• Premedicate to relieve pain
• Teach valsalva maneuver (preformed before tube removal to
prevent air from reentering pleural space)
• Supplies: sterile gloves, goggles, gown, mask, dressing supplies,
sterile suture removal kit, wide occlusive tape.
• Semi-Fowlers position
• Practitioner clamps chest tube, pt peforms Valsalva maneuver,
chest tube removed
• Occlusive dressing applied
• Post CT removal CXR – ensure lung remains fully inflated
WHAT IS THE FIRST STEP IN SETTING
UP A CHEST DRAIN SYSTEM?
a) Fill the water seal chamber to the level specified
by the manufacturer
b) Fill the water seal chamber to the 10 cm mark
c) Connect the drain to the vacuum and rapidly
increase the pressure
d) Connect the drain to the vacuum and slowly
increase the pressure
AS NEEDED, THE SUCTION
CONTROL CHAMBER SHOULD
BE REFILLED WITH:
a) Nonsterile water
b) Sterile saline solution
c) Nonsterile saline solution
d) Sterile Water
A COMMON INSERTION SITE
FOR A CHEST TUBE:
a) Midaxillary line between the 4th and 5th ribs
b) Posterior axillary line between the 4th and 5th ribs
c) Midaxillary line between the 3rd and 4th ribs
d) Posterior axillary line between the 3rd and 4th ribs
CREPITUS ON PALPATION OF
THE SKIN SURROUNDING
THE CHEST TUBE MAY
INDICATE:
a) Deep tissue emphysema
b) Excessive drainage
c) Subcutanous emphysema
d) Inadequate drainage
IF A CHEST TUBE BECOMES DISCONNECTED
AT THE CHEST DRAINAGE UNIT, THE
CORRECTION ACTION:
a) Submerge the tube 3” – 5” (8 – 12 cm) below the surface of a
250mL bottle of sterile saline solution
b) Submerge the tube 1” – 2” (2 -4 cm) below the surface of a
250mL bottle of sterile water
c) Remove the tube completely and place an occlusive dressing
over the site
d) Remove the tube completely and place a non-occlusive
dressing over the site
REFERENCES
Atrium Medical Corporation. (2012). A personal guide to managing chest
drainage.
Bauman. M., & Handley, C. (2011). Chest tube care: the more you know,
the easier it gets. American Nurse Today, 6, 27-32. Retrieved from
http://www.americannursetoday.com/chest-tube-care-the- more-you-know-
the-easier-it-gets/
Carroll, C. (2003). Chest tube insertion: part one. Clinical Update,
Retrieved from http://www.atriummed.com/en/chest_drainage/Clinical
%20Updates/ClinicalUpdateSept03.pdf
Lee-Riggins, A., & Singh, S. (2015). Managing Chest Tubes. [PowerPoint
Slides].
ANY QUESTIONS/ COMMENTS???
