Go with theflow of. chest tube theraf BY ARLENE M. COUGHLIN, RN, MSN, AND CAROLYNPARCHINSKY,RN, MA

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1 Go with theflow of chest tube theraf BY ARLENE M. COUGHLIN, RN, MSN, AND CAROLYNPARCHINSKY,RN, MA

2 HIPPOCRATESMAYHAVEBEEN the first physician to use a chest tube when he inserted a metal tube into a patient's pleural space to drain an empyema. Today,although typically inserted to remove air or fluid from the pleural space, chest tubes have other uses too. In this article, we'll discuss when chest tubes are indicated and how to care for a patient who has one. Lets start with a brief physiology review: Smooth moves The pleural space lies between the parietal pleura, a membrane lining the chest cavity,and the visceral pleura, which suitoundsthe lungs. Normally, this potential space holds about 50 ml of lubricating fluid that prevents friction between the pleurae as they move during inhalation and exhalation. (See Takingupspace.)The fluidalso holds the two layers together, creating negative pressure that keeps the lungs expanded. For various reasons, excess fluid or air may accumulate in the pleural space. Smallvolumes can be absorbed by the body over time, but large volumes limit lung expansion. As a result, the patient experiences shortness of breath and increased respiratory rate and effort. Inserted into the pleural space, a chest tube can drain air or excess fluid and relieve respiratory distress. Typically,a small-bore chest tube (12 to 20 French) is adequate to remove a small amount of air, but for adults, a larger-bore tube (24 to 40 French) is usually needed to remove excess fluid or blood and larger amounts of air. Chest tube indications Now lets look at some specific indications for chest tubes.. Pneumothorax,or air in the pleural space, can be caused by trauma, lung disease, invasive pulmonary procedures, or forceful coughing. It can also be a surgical complication, or it may occur spontaneously. To remove air from the pleural space, the clinician inserts a small-bore tube into the anterior chest near the apex of the lung, at the second or third intercostal space, midclavicular line.. Hemothorax, or blood in the pleural space, can be caused by blunt or penetrating trauma, or it may be a complication of chest surgery. If air also is in the pleural space (a hemopneumothorax), a chest tube will be inserted at the apex to drain air, in addition to the one inserted at the base of the lung to drain fluid.. Pleural effusion, or excessive fluid in the pleural space, can be caused by left ventricular heart failure, pulmonary embolism, pneumonia, cancer, and conditions that interfere with drainage of the pleural fluid (such as a tumor blocking the lymphatic system). It can also be a complication of surgery.the decision to insert a chest tube depends on the reason for the effusion (which should be addressed), the patient's pulmonary and overall condition, and the amount of fluid in the pleural space. Thoracentesis (using a needle to rapidly remove fluid from the pleural space) is indicated for patients who are clinically unstable, such as those with respiratory compromise, hemodynamic instability,or massive pleural effusion with a contralateral shift. Chylothorax, or accumulation of lymphatic fluid in the pleural space, can be caused by chest trauma, an expanding tumor, or surgery on mediastinal structures. Empyema, or pus from an infec- Taking up space The pleural space is a potential space between the visceral pleura, the outer lining of the lung, and the parietal pleura, the inner lining of the thoracic cavity. These two surfaces are separated and lubricated by a thin fluid that's produced by the cells of the pleura. Its purpose is to let the surfaces glide smoothly during respirations. Normally the pleural space contains about 50 ml of fluid. Hursln1l2006.March 31

3 tion such as pneumonia, must always be drained, no matter how small the volume, because purulent fluid can damage the pleural membranes. Besides treating these disorders, chest tubes may also be insened to head off problems. After cardiac surgery or chest trauma, for example, one or more chest tubes may be inserted into the patient's mediastinum to drain blood postoperatively and to prevent cardiac tamponade. 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 or a sclerosing agent to curtail recurr~nt pleural effusions. For more on this procedure, called pleurodesis, see Solving reeultcnt pleural effusions. Where does the drainage go? When a chest tube is inserted to remove air or fluid, its distal end is connected to a drainage device. (For more on these systems, see Loollingat c/testtubesand traditional water seal drainage systems.) The type depends on the nature of the problem its treating. A traditional chest drainage unit (CDU) consists of a collection chamber, a water seal chamber, and a suction control chamber. This unit can drain both fluid and air and handle large amounts of drainage. A smaller, lighter, portable CDU has a mechanical one-way valve instead of a water seal chamber. This system holds less drainage but gives the patient more freedom to move about. It's appropriate for a patient who needs a chest tube for drainage but doesn't need suction to reexpand his lung; for example, someone with a simple, noncomplicated pneumothorax. A Heimlich valve is a one-way flutter valve made of rubber tubing encased in a clear plastic chamber. When the patient exhales, air exiting the chest creates positive pres- 38 Nursing2006, Volume 36, Number 3 Solving recurrent pleural effusions Forpatients suffering recurrent pleural effusions, usuallybecause of cancer, repeated thoracentesis may not be the best clinicalapproach. An alternativeis chemical pleurodesis, which involvesinserting a chest tube and instillinga sclerosing agent such as doxycycline,minocycline,or bleomycin into the pleural space. Thisirritatingagent creates pleuritis, an inflammatoryresponse that causes the visceraland parietal pleura to adhere to each other. Byobliterating the pleural space, the procedure helps prevent recurrent pleural effusions. Although chemical pleurodesis typicallyis used for patients with recurrent pleural effusions, it also may be done to prevent recurrence of pneumothorax in patients who've had three or four episodes in a short period. The procedure can be done at the bedside under local anesthesia, in the interventional radiology department using local anesthesia or moderate sedation and analgesia, or in the ORunder general anesthesia. Once the sclerosing agent is administered, the chest tube is clamped to prevent the drug from draining out The patient is repositi9ned frequently over the next 2 hours to ensure that all the pleural surfaces are covered. After2 hours, the tube is unclamped and attached to a soction device. Suction continues until the drainage is less than 150 mli!] 24 hours. The tube can then be removed and an occlusivedressing applied to the site for 48 hours. Ifyour patient is undergoing chemical pleurodesis, reinforce explanations of the procedure to him and tell him he'll receive pain medication to keep him comfortable. Because pleurodesis creates an inflammatory response, he may develop a low-grade fever and pleural pain, so continu~ to administer analgesics as ordered. Afterthe procedure, monitor the patient's vitalsigns and assess his respiratory status every 30 minutes for the next 2 hours. Note the color and amount of the drainage from the tube. sure, opening the valve and letting air escape. The tube collapses on itself at rest, creating a one-way valve that prevents air from entering. (The valve isn't designed to collect fluid.) The collection device must be vented to prevent air buildup and must be kept upright so fluid doesn't seep through the ventilation holes, soiling the patient's clothing and bed linens and posing an infection risk..an indwelling pleural catheter is placed in the patient's chest to drain chronic pleural effusions. This catheter drains fluid, not air. A valve on the catheter's proximal end prevents air from entering and fluid from nowing out until the catheter is connected to a 500-ml vacuum drainage bottle. The patient can drain fluid at home every 1 to 2 days or whenever he gets short of breath. Preparing for chest tube insertion Depending on circumstances, the practitioner may insen a chest tube at the bedside or send the patient to the operating room or interventional radiology department for the procedure. Because chest tube insertion is an invasive procedure, make sure your patient has given informed consent. Reinforce the practitioner's 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 but that he may feel pressure while the tube is being inserted. To prepare for the procedure, obtain a thoracostomy tray, which typically includes injectable lidocaine, an antiseptic, sterile gloves, a

Looking at chest tubes and traditional water seal drainage systems let's look at the components of a typical chest tube and drainage system and what they do.

4 Looking at chest tubes and traditional water seal drainage systems let's look at the components of a typical chest tube and drainage system and what they do. Chest tube (not shown) A sterile nonthrombogenic catheter of vinyl or silicone, measuring about 20 inches (50 cm) long with a diameter of size 12 to 40 French. The proximal end, which rests in the pleural space or mediastinum, has several eyelets-small holes to drain air or fluid. Suction control chamber The higher the chamber's water level, the greater the suction applied to the pleural space. The practitioner orders the amount of suction; you fillthe column with sterile water to the ordered amount and maintain it at that levelby adding water as needed. Water seal chamber This consists of a tube submerged under 2 em of water that functions like a one-way valve: As the patient breathes spontaneously, the bubbles pass through the water as he exhales. When he inhales, the water barrier prevents air from going into his chest This helps reestablish normal negative intrapleural pressure. Drainage collection chamber This reservoir in which drainage can accumulate must be kept below the patient's chest level to ensure gravity flow. Markings on the chamber indicate the fluid level. scalpel, hemostats, sutures, and dressing material. For a traditional CDU setup, also obtain the appropriate CDU and sterile water for the water seal and suction control chambers. SeUing 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 H20 level, or as prescribed. To start suction, connect the tubing on the suction control chamber to a suction source and turn up the pressure until you see gentle, steady bubbling in the chamber. Avoidhigher 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 As indicated, 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. (The patient also may receive moderate sedation and analgesia.) Through a small skin incision, the practitioner penetrates the pleural space with a hemostat and creates a tract that she can use to insert the catheter. If she uses a trocar, she makes a puncture through the intercostal muscles with the trocar stylet instead of using tissue dissection with a hemostat. After inserting the chest tube, she connects its distal end to the CDU. She uses a purse-string suture to anchor the tube at the insertion site and prevent dislodgment. 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 Hursing2006.March 39

5 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. maneuvers if he needs it. Regularly assess his pain using a pain intensity rating scale. Optimal pain management can prevent hypoventilation and complications such as atelectasis and pneumonia.. Keep all tubing free from kinks and prevent fluid-filleddependent Avoidaggressivechesttubemanipulation,includingshippingor milking;studieshaveshownthat thesemaneuversincreasenegative pressurein the tubeanddo little to maintainchesttube patency. Other rare but potential complications include lung trauma and bronchopleuralfistula. In both of thes~ 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? Checkyour patient first Now that your patients 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 SP02level every 2 hours or as necessary. Assess his breath sounds bilaterally, especially checking for symmetry of breath 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 splint a thoracic incision if indicated. Provide analgesia before these 40 Hursing2006.Volume36, Number3 loops that can interfere with drainage..make sure that the connections are securely taped and that the chest tube is secured to your patients 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 manufacturers 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 or the patient may be lying on it. Other possible problems include a fluid-filled dependent loop in the tubing or blocked catheter eyelets. Or, if the lung has reexpanded, 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. The appear-. ance of mixed drainage in the collection chamber may not accurately reflect current drainage as shown in the tubing..measure drainage every 8 hours, or more frcquently depending on your patients clinical status. At regular intcrvals, 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 or cracked..document the amount of drainage and its characteristics in your patients medical record and fluid intake/output record..immediately report more than 70 ml/hour of bright red blood or red free-flowingdrainage, which could indicate hemorrhage. Also report paradoxical chest movement and tracheal deviation, which could indicate a tension pneumothorax..frequently reposition the patient and help him ambulate or sit in a chair as ordered. Tips on......tubing. Tomaintain tube patency,avoid dependent loops in the drainage tube. Avoid aggressive chest tube manipulation, including stripping or milking; studies have shown that these maneuvers increase negative pressure in the tube (as high as -400 em H20) and do little to maintain chest tube patency. If necessary, however, you may try gentle techniques, such as squeezing hand over hand along the tubing and releasing the tubing between squeezes....clamping.as a rule, avoid clamping your patients chest tube. Clamping prevents the escape of air or fluid, which increases the risk of tension pneumothorax or, in the case of a mediastinal chest tube, cardiac tamponade. Youcan 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 patients 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 II I ~

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:.

6 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..breathsounds 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. Thcn, 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. If the practitioner used a purse-string suture, she'll pull it to close the hole in the chest wall, then apply an occlusive dressing. Arrange for your patient to have a chest X-ray to assess for lung reexpansion. Monitor his respiratory status and Sp02 for 1 to 2 hours after removal, or longer if necessary. By understanding when chest tubes are used and how they're used, you can help your patient recover without complications and breathe easily again. <> SELECTED REFERENCES Albuquerque D, et a!. The effect or experimental plcurodesis ~'aused by aluminum hydroxide on lung and chest wall mechanics. lung. 179(5): , October 200l. Anders K. Chcst drainage to go. Nursing (5):54-55, May Baumann MH. What size chest tube? What drainage system is ideal? And other chest tube managememqueslions.cult..,,!opinionin Pulmonary Medicine. 9(4): , July J

Procedure: Chest Tube Placement (Tube Thoracostomy)

Procedure: Chest Tube Placement (Tube Thoracostomy) Basic Information: The insertion and placement of a chest tube into the pleural cavity for the purpose of removing air, blood, purulent drainage, or