Chest Tubes

Question 1

What might require a CT into pleural space?

Answer 1

Pneumothorax (spontaneous, tensioned, closed, open)
Pleural effusion
Hemothorax
Empyema (pyothorax)

Question 2

What is a spontaneous pneumo?

Who is most at risk?

Answer 2

Pneumothorax in the absence of underlying disease or trauma; this is termed spontaneous pneumothorax.

Tall, thin male smokers

Question 3

Describe an open pneumothorax

Answer 3

Traumatic Pneumothorax (open) 
Penetrating chest trauma causes hole in chest wall.  Communication between the pleural space and the environment 
 Atmospheric air is sucked into the pleural space through the chest wall wound. Lung collapses. Mediastinal movement with each respiration

Question 4

Describe iatrogenic causes of pneumothorax

Answer 4

 Thoracentesis
 Chest surgery
 Insertion of central line
 Incorrect placement NG tube

Question 5

S and S of tensioned pneumo?

What are the complications ?

Answer 5

Tachypnea
Dyspnea
Anxiety 
Tachycardia 
Pleuritic chest pain        
Cyanosis
Use of accessory muscles
Decreased or Absent breath sounds
Decreased movement of affected side
Subcutaneous Emphysema 

impaired oxygenation and/or ventilation. 
hemodynamic instability (pressure on heart prevents contraction)

Question 6

What is mediastinal shift and what can it cause?

Answer 6

shifting or moving of the tissues and organs that comprise the mediastinum (heart, great vessels, trachea, and esophagus) to one side of the chest. impairs ventilation, venous return and can compress/twist blood vessels

Question 7

Two CT placements for pleural drainage?

Answer 7

Chest tubes placed high (second-third intercostal space) are to remove air (air rises).

Chest tubes placed low (fifth- sixth intercostal space) are to remove blood and fluid.

Question 8

Describe different chambered systems?

Answer 8

one- For pneuma only (drain and water seal
Two- Drain then water seal
Three- Drain water seal, suction

Question 9

What is a waterless system?

Why use it?

Answer 9

Heimlich valve (one way)

Little to no drainage, no suction

Question 10

Who can remove sutured CT’s

Answer 10

Two RN’s in Island Health

Question 11

When can you see tidying in water seal pressure gauge.

Answer 11

Tidaling is normal and represents can in negative pressure of pleural space inspiration to expiration. More visible when suction is off.

Question 12

What 3 things should you document about fluid coming into CT drainage system?

Answer 12

Volume
Rate
Nature of drainage

Question 13

Why might tidaling stop

Answer 13

The lungs have re-expanded

The drainage tubing is kinked

There is an obstruction

Question 14

In wet suction is bubbling normal?

Answer 14

Yes… the water is used as a suction control. Dry uses the dial with billows indicator instead

Question 15

When are air leaks likely and unlikely?

How do you solve them?

Answer 15

Normal to have a small air leak first 24 hours

Air leak will often clear after a couple of coughs

Often air leaks are managed with increase in suction

Very rare to have increased air leak after 24 hours - In this case it is usually from the system so clamp briefly from patient down to locate the leak

Question 16

What is subcutaneous emphysema?

Answer 16

Subcutaneous emphysema is the collection of air in the tissues just under the skin – once you feel it you’ll never forget it (as though Rice Krispies had been spread around under the patient’s skin).

r/t to pneumo/tensioned pneumo

Question 17

When is clamping a CT appropriate

Answer 17

Never clamp chest tubes except:

1. Momentarily to locate the source of a persistent air leak
2. Momentarily to replace drainage system
3. Physician’s order to assess whether tube can be removed
4. Physician’s order following pleurodesis (chemical or surgical procedure to disrupt the parietal pleura)

Two non-toothed clamps with the patient at all times

Question 18

Why is DB and Coughing important

Answer 18

Deep breathing and coughing helps remove bacterial from the lung (reducing chances of pneumonia). It also prevents atelectasis and helps re-expand the lung.

Question 19

Steps in CT removal

Answer 19

Disconnected from wall suction
Clean around site
Cut suture
Client to take deep breath and hold OR breath out
One person removes tube
Second person applies the dressing
(and pulls the purse string suture if present)

Question 20

What equipment should be at the side of the bed of a patient with a CT?

Answer 20

o Petroleum based gauze / Occlusive dressing
o Sterile saline (for disconnected tube_
o 2 clamps (presbyterian, i.e flat/rubber)