Chest Tube Definition: *Use of tubes and suction to return negative pressure to the intrapleural space. *To drain air from the intrapleural space,

Chest Tube

Definition:

*Use of tubes and suction to return negative pressure to the intrapleural space.

*To drain air from the intrapleural space, the chest tube is placed in the second or third intercostals space, to drain blood or fluid, the catheter would be placed at a lower site, usually the eighth or ninth intercostals space .

*Chest tubes also can administer therapy. Chest tubes are sometimes used to instill fluids into the pleural space as well. For example, your patient may receive cancer chemotherapy through a chest tube.

Chest tube indications:

*Pneumothorax *Hemothorax

*Pleural effusion•*Chylothorax, or accumulation of

• lymphatic fluid in the pleural space. *Empyema

* A traditional chest drainage unit (CDU) consists of:

1- a collection chamber, 2- a water seal chamber, 3- and a suction control chamber. This unit can drain both fluid and air.

*Nursing Care:

-Preparing for chest tube insertion depending on circumstances, the practitioner may insert a chest tube at the bedside or send the patient to the operating room.

*Pre-insertion:

-patient consent.

-explanation of the procedure with him and his family.

-Explain that his breathing will be easier

once the tube is inserted and his lung starts to reexpand.

-Tell them he'll receive a local anesthetic to reduce discomfort .

*prepare for the procedure:*obtain tray, which typically includes:

- injectable lidocaine ,- an antiseptic ,- sterile gloves ,

- a scalpel ,- hemostats ,

- sutures ,- dressing material .

- obtain the appropriate CDU - sterile water

- and suction control chambers .

Setting up a CDU:

* Before the patient's skin is prepared for chest tube insertion ,set up the CDU according to the manufacturer's instructions .

A traditional water seal system is set up by filling the water seal chamber to the level specified by the manufacturer

(usually the 2-cm mark.)

* Fill the suction control chamber with sterile water to the -20 cm H2O level, or as prescribed.

*connect the tubing on the suction control chamber to a suction source and turn up the pressure until you see Gentle bubbling in the chamber. *Avoid higher suction, which causes more vigorous bubbling and faster evaporation.

*Monitor the CDU water levels and add sterile water as necessary. *Momentarily turn off the suction to add water because bubbling makes the water level appear artificially high.

*Inserting the chest tube:

help position the patient for the procedure. Patient positioning depends on the site of the air or fluid to be drained and the patient's clinical status.

The practitioner cleans the patient's skin with povidone-iodine or another antiseptic solution,

drapes the area,

and anesthetizes the skin.

After inserting the chest tube:-She connects its distal end to the CDU .

-She uses suture to fix the tube at the insertion site and prevent displacement.

-She applies a 4x4-inch piece of sterile gauze with a slit over the tube ,

and places an occlusive dressing over the gauze on the chest wall .

-She tapes the chest tube to the patient's chest to prevent traction on it when he moves .

-All tube connections, from the insertion site to the drainage container, must also be securely taped to prevent air leaks or

disconnections .-A chest X-ray confirms tube position and lung expansion.

Risks and complications:

Bleeding is a potential complication of chest tube insertion if a vessel is nicked accidentally during the procedure. Usually it's minor and resolves on its own ,

but bleeding into or around the lung may require surgery.

Infection, another risk, becomes more likely the longer the chest tube stays in place.

Subcutaneous emphysema can occur if air leaks from the pleural space into

subcutaneous tissues. Notify the practitioner if you notice subcutaneous emphysema ,

which is characterized by tissue swelling in the neck, face, and chest and a crackling sound when the area is palpated.

Other rare but potential complications include lung trauma and bronchopleural fistula. In both of these complications, you'll notice respiratory distress, decreased oxygen saturation, altered level of consciousness, tachypnea, and signs and symptoms of infection. A patient with lung trauma also will have bloody chest tube drainage. In both these conditions, the chest tube remains in place until the patient heals.

Problems? Check your patient first:

Now that your patient's chest tube is in place ,your goals are to restore adequate oxygenation, promote lung reexpansion ,and prevent complications .

Whether giving routine care or managing a complication, always assess the patient before the equipment.

Monitor his vital signs—especially rate, pattern ,depth, and ease of respirations—and Spo2 level every 2 hours or as necessary.

Assess his breath sounds bilaterally, especially checking for symmetry of breathe sounds.

Assess the insertion site for subcutaneous emphysema.

•Encourage the patient to cough and coach him in deep breathing to promote drainage and lung expansion. *Teach him to support a thoracic incision if indicated.

•Keep all tubing free from kinks.

• Make sure that the connections are securely taped and that the chest tube is secured to your patient's chest wall.

*Keep the collection apparatus below the patient's chest level.

*Frequently check the water seal and suction control chambers.

*Keep in mind that the water in either chamber can evaporate, so you may need to add water to maintain the manufacturer's recommended level.

*The water seal level should fluctuate with respiratory effort; this is

called tidaling. If it doesn't, the tubing may be kinked or clamped orthe patient may be lying on it .

*The lack of tidaling may be a good sign indicating that no more air is leaking into the pleural space.

*Assess the color of drainage in the drainage tubing as well as the collection chamber.

•Measure drainage every 8 hours, or more frequently depending on your patient's clinical status.

*At regular intervals, mark the date and time at the current fluid level on the drainage chamber.

*The chamber isn't replaced until almost full, unless the unit is accidentally broken.

*Document the amount of drainage and its characteristics in your patient's medical record and fluid intake/output record.

*Immediately report more than 70 ml/hour of bright red blood or red free-flowing drainage, which could indicate hemorrhage.

*Frequently reposition the patient and help him ambulate or sit in a chair as ordered.

Clamping:

* As a rule, avoid clamping your patient's chest tube .Clamping prevents the escape of air or fluid, which increases the risk of tension pneumothorax.

* You can clamp the tube momentarily to replace the CDU or to locate the source of an air leak, but never clamp it when transporting the patient or for any extended period, except as directed by the practitioner.

*For example, she may want to clamp the tube to assess the patient's ability to do without it before removing it. *While it's clamped, observe him for any signs of respiratory distress )such as chest pain and tachypnea( that could indicate the development of a tension pneumothorax. *If this happens, remove the clamp immediately to let air escape.

Removing the tube:

The practitioner will remove your patient's chest tube according to these criteria:

*The drainage has decreased to little or none. *The air leak has disappeared.

*The patient is breathing normally without respiratory distress. *Breath sounds are at baseline.

*Fluctuations in the water seal chamber have stopped.*A chest X-ray shows lung reexpansion with no residual air or

fluid in the pleural space.

*Gather the necessary equipment and supplies, including a suture removal kit, -petroleum gauze dressing, -4x4 dressings, and occlusive tape. -Explain the procedure to the patient and answer his questions. -Administer premedication as ordered to prevent pain and anxiety.

The practitioner will remove the insertion site dressing, clean the area, and remove the sutures. Then, during peak exhalation, she'll remove the tube in one quick movement. Immediately apply sterile occlusive petroleum gauze to the wound to prevent air from entering the pleural space.

Arrange for your patient to have a chest X-ray to assess for lung reexpansion. Monitor his respiratory status and Spo2 for 1 to 2 hours after removal, or longer if necessary.