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05.04 Chest Tube Management

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Overview

  1. Chest tube is inserted through chest wall into pleural space, in order to:
    1. Drain fluid, blood, or air
      1. Pleural Effusion
      2. Hemothorax
      3. Pneumothorax
      4. Post-Op drainage
    2. Establish negative pressure (one-way valve)
    3. Facilitate lung expansion

Nursing Points

General

  1. Setup
    1. Chest tube – varying sizes
      1. Holes in end
      2. Secured with suture
    2. Drainage system
      1. Tubing
      2. Collection chamber (2000 mL with markings)
      3. Water seal chamber (should be at 2 cm level)
        1. Port on back to add sterile water
      4. Suction pressure dial
      5. Suction port
        1. Will need suction tubing
      6. Foot to prevent tipping
      7. Hangers to keep off floor
    3. Occlusive Dressing
    4. Must remain upright, below chest

Assessment

TWO AA’S

  1. Tidaling
    1. Movement of fluid with breaths
      1. Rise with inspiration
      2. Fall with expiration
    2. Could be normal
    3. NO tidaling = re-expansion or obstruction (assess)
  2. Water seal level
    1. Should be at 2 cm at all times
    2. Add more sterile water if needed
  3. Output
    1. Quantity
      1. Measure every 4 or 8 hours (per facility policy)
      2. Mark on chamber
      3. Report increased volume (per provider orders)
    2. Quality
      1. Color
        1. Sanguineous
        2. Serosanguinous
        3. Serous
      2. Character
        1. Purulent
        2. Clots
      3. Report unexpected finding to provider
  4. Air leak
    1. Continuous bubbling in water seal chamber
    2. May indicate:
      1. Pneumothorax
      2. Dislodgment
      3. Disconnection
      4. Equipment failure
  5. Ability to breathe
    1. Always assess the patient (not just the system).
    2. Shortness of breath? Pain?
  6. SpO2
    1. Determine oxygenation status

Therapeutic Management

  1. Complications
    1. Air Leak
      1. Indicates air getting into the system
      2. Cross-Clamp technique to find the leak
      3. May have to change whole system
      4. If chest tube or site are source — call provider
    2. Dislodged/Removed (accidentally)
      1. Apply 3-sided occlusive dressing immediately
      2. Call provider

Nursing Care

  1. Coil tubing in bed
    1. NO dependent loops
  2. Do NOT clamp except:
    1. Troubleshooting air leak
    2. Specific instructions from provider
    3. Could cause Tension Pneumo
  3. Do NOT strip (pull fingers along tube to move drainage down)
    1. Causes increased negative pressure
    2. Could cause tissue damage
    3. Squeeze gently, instead
  4. Keep system upright and below chest
  5. Keep at bedside:
    1. 2 hemostat clamps (for cross-clamping)
    2. Sterile water / syringe for water seal
    3. Occlusive dressing & tape

Patient Education

  1. Importance of not pulling on chest tube
    1. Also not to get out of bed without help
  2. Purpose for chest tube
  3. Explanation of procedures (NOT informed consent)
  4. Splinting with deep breaths or coughing.

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Video Transcript

In this lesson we’re going to review the most important things you need to know about chest tube management. These are things you will most definitely see on your NCLEX or in your nursing school curriculum.

The purpose of chest tubes are to drain fluid, blood or air from around the lung to allow for expansion of a collapsed lung. The tube inserted through the chest wall and into the pleural space. In this case it would be removing this air surrounding the lung. The other benefit is that chest tubes function as a one-way valve, so it creates negative pressure in this space. That encourages expansion of the lung, and also makes sure that any more air or fluid or blood also comes out of that space.

So let’s talk about the chest tube set up. You’ll have the tube itself which comes in varying sizes, depending on what you’re draining. It has multiple holes at the end, as you can see here, to allow for better drainage. Then you’ll have the drainage system itself. This is the Atrium chest tube system, if you go to Atrium’s website they have a ton of great resources to learn more about chest tubes. There’s also Pleur-Evac and a few others you might see, but they’re all basically the same. You’ll have the tubing that comes off to connect to the chest tube itself, and you’ll have the collection chamber. It’s important that we don’t have any dependent loops like you see here because blood can clot and block the tubing – so we will usually coil this tubing in the bed with the patient. You can see here, each system can hold up to 2000 mL of fluid – at which point you’d need to get a new system. Down here in the bottom left you’ll see blue liquid, that’s your water seal chamber – this is what helps create that one-way valve. It’s like blowing air through a straw into a glass of water. It’s easy to get the air out, but once that bubble is gone, you can’t get that same air back up through the straw. Then there’s the suction set up. You can see the suction tubing here. On most systems there’s a dial on the front or the side to choose your suction level. Most of the time it will be at 20 cmH2O. You will need to have an occlusive dressing like vaseline gauze to cover the insertion site. And this system must remain upright and below the patient’s chest. Most of them have some sort of foot that swings out to keep it from tipping over, or little handles up here that will swing out so you can hang it on the bed if you want.

So what do we need to assess for in our patients with chest tubes. We use the mnemonic TWO AA’S to remember these. First is Tidaling. Tidaling is movement of the fluid in the tubing with respirations. It will go up with inspiration and down with expiration. This is a normal and expected finding because we know the pressure within the thoracic cavity changes with respiration. If you don’t see tidaling, either your patient’s lung has completely re-expanded, or there’s some sort of occlusion in your system. That might mean a clot in the tubing – but don’t strip the tubing, just squeeze it gently between your fingers. Stripping can cause negative pressure and cause damage. Then, we check the water seal chamber to make sure it’s at the 2cm level. It must be at that level to provide a proper water seal – so there’s a port on the back that we can use to add more sterile water to this chamber if necessary. Then we’ll look at the output. We will use the markings on the chamber to count how much output we’ve had. Most facilities mark this every 4-8 hours, but if it’s a fresh chest tube, we check it hourly for the first few hours. Ask your surgeon what they want you to report to them in terms of output volume – it’s important to know what they are expecting to see. We also want to look at quality – is it clear, yellow, bloody, purulent? Again, you need to know what your patient has their chest tube for to determine what the expected drainage is. If you’re draining a hemothorax, bloody drainage would be expected – but not if it’s supposed to be a pneumothorax. Next we’ll look for an air leak – which means air is in your system somehow. If you have one, there will be continuous bubbling in the water seal chamber. We’ll address how to troubleshoot that in a second. Then, finally, we always want to make sure we assess the system AND our patient – so we assess their ability to breathe (are they short of breath? is expansion symmetrical?) and their SpO2 to make sure they’re oxygenating okay.

So there are two main complications that you might see in these patients and that you will see on a test or the NCLEX. The first is an air leak. Remember we said this is continuous bubbling in the water seal chamber and means that you have air in your system somehow. This could be a disconnection somewhere, a hole in the tubing, or it could mean your patient has a pneumothorax. So when we troubleshoot an air leak, the goal is to determine where the air leak is coming from. So if this is our patient with his chest tube, it comes out and then connects to the tubing for the system, which then goes down to the collection chamber. We’re going to get two hemostat clamps and begin systematically cross clamping to find the leak. This is the ONLY time you should EVER clamp the chest tube, unless you’re under specific instructions from the provider. So we start at the patient and clamp on the tube itself. If that stops your air leak – you know your tube or site are the issue and you need to call the provider immediately. If not and there’s still bubbling, use the second clamp just below the connection to see if the connection is the problem. If you still have an air leak, you’ll take the top clamp and move it down a few inches, and determine if the leak is in that section. You keep repeating this until you’ve found where your leak is. If the connection tubing or your system is the problem – just change the system.

The second complication is dislodgement or removal – and of course we’re talking about accidental or unintentional removal. Maybe your patient somehow reached up and grabbed it and pulled it out, or maybe something got pulled during transport. This is an emergency because it essentially creates a sucking chest wound like we talked about in the pneumothorax lesson, and could cause a tension pneumo. So we do exactly what we talked about in that lesson, we apply an occlusive dressing over the site and tape it on 3 sides. That creates a one-way valve and allows that air to escape, but not return. So to be prepared for these complications, make sure you always have 2 hemostats and an occlusive dressing at the bedside.

Okay, let’s recap quickly. Chest tubes are placed to drain air, fluid, or blood to allow for lung re-expansion. We always want to assess the system AND the patient using the mnemonic TWO AA’S. We can troubleshoot an air leak with the cross-clamp method. Just remember if the problem is the tube or site, you need to notify the provider. For accidental removal we’ll quickly apply a 3-sided dressing to create that one-way valve to prevent a tension pneumothorax. And finally, remember to be prepared by having your safety equipment at bedside and to protect your tubing by coiling it in the bed and not stripping or clamping it.

Okay guys those are the most important things you need to know about chest tubes. Let us know if you have any questions. Go out and be your best selves today. And, as always, happy nursing!

  • Question 1 of 10

A nurse is caring for a client who has a chest tube. While turning the client in bed, the tube is accidentally removed. Which of the following should be the nurse’s first response?

  • Question 2 of 10

The provider writes an order for a client to have a chest tube removed. Which of the following are appropriate reasons to discontinue a chest tube? Select all that apply.

  • Question 3 of 10

A client has a right chest tube in place after recovering from a pneumothorax. The provider is preparing to remove the chest tube. Which nursing action is most appropriate as part of chest tube removal?

  • Question 4 of 10

A ventilated client has developed a pneumothorax and requires a chest tube. The nurse knows that the chest tube will be inserted where?

  • Question 5 of 10

A 36-year-old client must have a chest tube placed after an injury from a motor vehicle accident. The nurse is preparing to assist the provider with a chest tube placement in the left lung. In which position should the nurse place the client?

  • Question 6 of 10

A nurse is caring for a client who has a chest tube after a motor vehicle accident. The provider has ordered low suction for the chest tube. Which interventions would the nurse utilize when managing suction on this chest tube? Select all that apply.

  • Question 7 of 10

The nurse is caring for a client with a chest tube. While assessing the tubing, the nurse notes a clot in the tubing. What action is appropriate in order to remove the clot from the tubing?

  • Question 8 of 10

The nurse is caring for a client with a chest tube. The nurse will refrain from clamping the chest tube because which of the following could happen?

  • Question 9 of 10

The nurse enters a client’s room to find that the client has pulled out her chest tube. Which of the following actions by the nurse is most appropriate?

  • Question 10 of 10

A nurse is caring for a client with a chest tube. He notes that the dressing around the client’s tube insertion site is wet and there is some crepitus with mild palpation. Which actions by the nurse are most appropriate in this situation? Select all that apply.

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