Chest Tubes Flashcards
What is the normal amount of fluid in the pleural space?
50 ml
What is the purpose for the fluid in the pleural space in a healthy patient?
Allows visceral and parietal pleura to glide over each other without friction while enabling the pleural surfaces to adhere to each other
What is the pressure in the pleural space after expiration?
-4 to -5 mmHg
What is necessary for the a breach in the chest wall to develop into a pneumothorax?
A breach develops into a pneumothorax when the injured tissue creates a one way flap/valve resulting in air entering the pleural space but not being able to exit resulting in pressure being placed on the heart
Where are pneumothoraces primarily seen?
Cases with thoracic trauma
Central line placement
Lung tissue biopsy
What does the xray of a pneumothorax look like?
Empty lung fields, no vasculature
What are the goals of chest tubes
Remove air and fluid ASAP
Prevent drained air/fluid from returning to pleural space
Restoring negative pressure within the pleural space to re-expand the lung
Where can a chest tube insertion be performed?
Situationally dependent
Beside
OR
Interventional radiology suite
What is another name for chest tube?
Thoracic catheter
What are the specific indications for chest tubes?
Pneumothorax
Hemothorax
Pleural effusions
Emyema
What equipment is needed to place a chest tube?
Thoracotomy tray
One or more chest tubes (choose range of potentially appropriate sizes)
Chest drainage unit (CDU)
Describe how chest tubes are sized
Infant pediatric adult
Use french sizing system
Describe the french sizing system
The larger the size, the larger the tube
What chest tube size do adults commonly use?
24-40 french
What are larger chest tubes used for? Smaller chest tubes?
Larger tubes are used to drain blood/transudate
Smaller tubes are used for air removal
What different configurations do chest tubes come in?
Curved or straight
PVC or silicone
Why are chest tubes coated with heparin?
They are coated with heparin to reduce friction on insertion
How should a patient be positioned when inserting a chest tube?
Flat,
With small wedge placed under shoulder blades to elevate the body
Arm on procedural side placed over patients head in order to keep it out of the way
Breasts or adipose tissue may need to be moved out of the way as well
Where are chest tubes most commonly inserted?
Midaxillary line between the 4th and 5th ribs on a lateral line to the nipple
Why might patients become hypotensive after receiving a chest tube?
Fluid loss
How should tubes be placed if the goal is to remove air from the pleural space?
Apically
How should tubes be placed if the goal is to remove fluid from the pleural space?
Posteriorly
What should be done if the fluid is loculated?
Imaging may be used as an adjunct to help plan the chest tube position and ensure the tube is directed to a precise location
What is the most common complication regarding chest tube insertion?
Bleeding
Usually revolves on its own, but may require surgical intervention
What should you instruct a patient with a chest tube not to do?
Rest their body on the tube
What basic things should you check for when caring for a patient with a chest tube?
Check for twists and kinks in tubing line
Tape tubing connections to prevent air from leaking out of the tube
What does it mean if the chest drain is on wall suction?
A chest drain on wall suction means the patients drain is attached to a vacuum regulator
What does it mean if the chest drain is on a water seal?
A chest drain on a water seal means the chest drain is not attached to the vacuum regulator
What can be suctioned via a chest tube?
Air
Blood
Chyle
Pus
Transudate
How often should drainage amounts and characteristics be documented?
At least every 8 hours
What can suction be set at for a chest drainage system?
-10, -15, -20, -30, -40 cm of H2O
What is the chest drainage unit suction usually set to when opened?
-20 cm of water
What should be charted regarding drainage from a chest tube?
Amount
Color
What helps promote fluid drainage from a chest tube?
Frequent position changes
Coughing
Deep breathing
Where should the CDU be placed in order to promote drainage?
Below the level of the patients chest
What should be done periodically to maintain the water seal and suction levels in a chest tube?
Add water
When you have a patient on a chest tube, what assessments should you be performing every 2 hours?
Respiratory rate
Work of breathing
Breath sounds
SpO2
What should be noted when inspecting the dressing of a chest tube?
Note any drainage
Assess insertion site for subcutaneous emphysema and tube migration
What things should you be checking and correcting when taking care of a patient with a chest tube?
Keep tubing free of kinks and occlusions
Prevent fluid filled dependent loops
If the CDU unit fills up replace it
How does the water level in a CDU change with spontaneously breathing patients?
Water level increases during spontaneous inspiration and decrease with expiration
Where should pleural drainage systems be placed in relation to the patient?
100 cm below the level of the patients chest
How does the water level in a CDU change with a patient who is being mechanically ventilated?
Water level decreases during inspiration and increases during expiration
Opposite of spontaneously breathing patient
What does it mean if tidaling is not occurring for a patient with a chest tube?
Check if tubing is kinked or clamped
Check to see if dependent section of tubing has become filled with fluid
Should you expect tidaling with complete lung expansion or with mediastinal tubes?
No, respirations dont affect tubes outside of the pleural space
What should you do when looking for a leak in a chest tube?
Use rubber tipped or padded clamps to momentarily clamp tubing at various points - BUBBLING STOPS WHEN YOU CLAMP BETWEEN AIR LEAK AND WATER SEAL
What should be done if you have checked along the entire length of the tube and have not found a leak?
The CDU may be faulty and may need to be replaced
What should be avoided when caring for a patient with a chest tube?
Milking the tube
Aggressive chest tube manipulation
What is a risk associated with clamping a chest tube for too long?
Increases the chance for a tension pneumothorax
When is it ok to clamp a chest tube and when is it not ok?
Ok to clamp tube for changing CDU or looking for a leak
Not ok for an extended period of time or for transport
When is the only time it is appropriate to clamp a chest tube for an extended period of time?
Physician order
Trial prior to chest tube removal
What should be done in the event of a chest tube disconnection
Submerge tube 1-2 inches below the surface of a 250 ml bottle of sterile water
Establishes a water seal and prevents air reentry
What can lower the risk of infection in patients with chest tubes?
Regular dressing changes
Noting changes in drainage amount and color
What qualifies as indications for chest tube removal?
Improved respiratory status
Symmetrical rise and fall of the chest
Bilateral breath sounds
Decreased chest tube drainage
Absence of bubbling in the water seal chamber during expiration
Improved chest x ray findings
What must the patient do during a chest tube removal?
Perform the valsalva maneuver
Why should a patient perform the valsalva maneuver when the chest tube is being removed?
To prevent air from reentering the pleural space
What position should a patient be placed in for the removal of a chest tube?
Semi fowler
What supplies should you have for a chest tube removal?
Sterile gloves
Goggles
Gown
Mask
Dressing supplies
Sterile suture removal kit
Rubber tipped hemostats
Wide occlusive tape
What should you instruct the patient to do just before the tube is removed?
Take the deepest breath they can and perform the valsalva maneuver
What should be done immediately after the chest tube is removed?
Apply occlusive dressing to the site and secure it with tape
What should be done after the chest tube is removed to ensure that the patient is doing well?
Get an xray to ensure that the lung is still fully inflated
How should a patient be cared for after chest tube is removed?
Ongoing respiratory assessment
Vital sign documentation
Monitor site for drainage or infection
Assess patients comfort level
What are specific indications for chest tubes?
Pneumothorax
Empyema
Pleural effusion
Hemothorax
What are potential complications associated with chest tubes?
Subcutaneous emphysema
Bleeding
Respiratory failure
T/F: After the dressing is removed and the sutures are cut, the practitioner clamps the chest tube with hemostats
true
What is the purpose of the valsalva maneuver?
used to prevent air from re-entering the pleural space
Chest tubes placed for air should be directed…
Apically
Tubes placed for fluid should be directed…
Posteriorly
To remove a chest tube from a patient, the patient should be placed in…
Semi-fowlers position
What can an untreated pneumothorax cause?
Death
Respiratory
Cardiovascular collapse
If clots are forming in the chest tube, what maneuvers should you NOT do?
Strip
Milk
Clamp (long term)
Tidaling may not occur in what situations?
In mediastinal tubes
If the tubing is kinked
If there is complete lung expansion
If the tubing section is full of fluid
If the tubing is clamped
What are indications for chest tube removal?
Improved respiratory status
Improved chest xray
Symmetrical rise and fall of chest
Decreased Chest tube drainage
Bilateral breath sounds
Absence of bubbling in the water seal chamber during expiration
When does a tension pneumothorax develop?
when injured tissue forms a one way valve or flap trapping air in between the pleura
During positive pressure ventilation tidaling fluctuations cause what?
the water level to decrease during inspiration and increases during expiration
Where is the chest tube usually inserted?
at the midaxillary line between the 4th and 5th rib
What can clamping a chest tube for too long cause?
a tension pneumothorax
What should ongoing chest tube assessment include?
Ongoing respiratory management
Monitoring the site for drainage
Vital sign documentation
Assessing the patient comfort level
What are the goals of chest tubes?
Removal of air and fluid
Preventing air and fluid from returning
Restoring negative pressure to the pleural space
What size chest tubes are usually put in adult patients?
24-40 french
What is suction usually preset to on a chest tube?
-20 cm H2O
What should be assessed every two hours on a chest tube patient?
Breath sounds
Work of breathing
SpO2
Respiratory rate
T/F: for a chest catheter placement a needle is inserted before a chest catheter?
True
