Chest Tubes Flashcards
What is Boyle’s law?
- When the volume of a container increases, the pressure decreases
- When the volume of a container decreases, the pressure increases
- If you’re trying to squeeze as many people in a car as possible, they will be under much higher pressure in a VW Beetle than the same number of people would be in a minivan
How much fluid is in the pleural space in the lungs of a healthy person? What about the pressure?
50 cc, creating a negative pressure (-8cm water inspiration, -4cm expiration)
What are the indications for a chest tube placement?
- Pneumothorax (depending on size)
- Hemothorax
- Pleural effusion
- Empyema (bacterial infection, pus) (hard to drain)
- Chylothorax (lymph buildup)
- Pleurodesis of recurrent malignant effusions (removal of pleural space to prevent development of pleural effusions when frequent)
- After cardiac surgery (3-4 tubes to prevent cardiac tamponade)
- Generally when ~1500 mL’s of fluid and/or starting to impair resp system
How do we treat pleural conditions?
1) Remove fluid and air asap
2) Prevent drained air and fluid from returning to pleural space
3) Restore negative pressure in pleural space to re-expand lung
What are chest tubes attached to?
- A drainage device
- Disposable, needle-less system
- Allows air and fluid to leave the chest
- Contains a one-way valve to prevent air and fluid return to chest
- Designed so device is below level of chest tube for gravity drainage (e.g. on floor)
How does a chest drainage system work?
- Expiratory positive pressure from the patient helps push air and fluid out of the chest (cough, Valsalva)
- Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest
- Suction can improve the speed at which air and fluid are pulled from the chest
What does the pleure-evac system consist of?
- Collection chamber
- Water seal chamber
- Suction control chamber
Where is the suction control on the pleur-evac?
- Upper left side of unit
- Turn dial to desired suction level line (-10, -15, -20 (most common), -30, -40 cm of H20)
- When connected to suction, increase amount of wall suction until orange float appears in window (usually 80-100 cm H20 of wall suction)
What is the water seal chamber?
- Comes empty, with 2 cm sterile water to fill chamber
- Allows air to exit from pleural space on exhalation and prevent air from entering the pleural cavity or mediastinum on inhalation (think of it like a straw; if you suck back, it will suck back water instead of air and it is less detrimental)
- If above, needs to come out with a needle (at yellow port); if below, need to add sterile water
- ALWAYS needs to be at 2 cm
What is the patient air leak meter?
- Indicates the approx. degree of air leak from chest cavity (attached to chamber with water)
- Observe bubbling in the columns of the patient air leak meter
- Meter is labeled from LOW (1) to HIGH (7)
- Expected with pneumothorax; should decrease with treatment
- Higher the numbered column which bubbling appears, the greater the degree of air leaks
What is the positive pressure relief valve?
- Opens with increases in positive pressure to prevent accumulation (e.g. pt coughing)
- DO NOT OBSTRUCT positive pressure relief valve! That extra pressure cannot stay!
What is the high negativity float valve?
- Preserves the water seal in the presence of high negativity; used to reduce negativity (valve will release some of that pressure)
- Water floats the valve up into the closed position when excessive negativity occurs (system more negative than we want to maintain)
- Valve opens upon decrease in negativity
- Usually only for suction; if not operative while depressing this valve, negative pressure may be reduced to zero (atmosphere) and may result in a pneumothorax
Describe the action of the collection chamber:
- Calibrated up to 2500 cc
- Fluids overflow from one section to the next
- Total capacity of chamber is 2500 cc; when close, set up a new pleur-evac (i.e. one time use)
When would a chest tube be clamped?
- Trying to find the source of an airleak
- 24 hrs before chest tube removal (<50-100 mL/24 hours), will have tube clamped and will assess for compromise of resp system. If not, will be taken for diagnostics to confirm.
- Changing a pleur-evac
- After pleurodesis for malignant effusions/sclerosis
- NEVER clamp without an order!! If air escapes can cause a tension pneumo, which can be dangerous.
When would Heimlich valves be used?
With uncomplicated pneumo or little to no drainage
Describe the procedure prior to insertion:
- Obtain informed consent
- Complete Baseline vital signs (HR, RR, BP, Sp02)
- Complete respiratory assessment
- Gather equipment if procedure is done at bedside
- Thoracotomy tray
- Chest tube
- Dressing material (mepore tape, drain sponge)
- Pleur-evac
Describe post insertion procedure:
- Prepare patient for chest x-ray
- Vital Signs (HR, RR, BP, Sp02) – see agency policy for frequency
- Respiratory assessment
- Palpate around site for subcutaneous air
- Note drainage amount, colour, type
- Note the presence of bubbling in the water seal chamber
- Have two padded clamps at bedside
- 250-500ml bottle of sterile water
Describe ongoing patient assessment:
- At the start of shift and every four hours (or more frequently depending on findings and agency policy)
- Respiratory assessment
- Vital signs
- Presence of chest pain
- Trachea position
- Chest tube dressing intact
- Presence of subcutaneous emphysema (feels like rice-krispies under the skin)
Describe system assessment:
- System below level of patient’s chest
- Tube free of kinks, or external obstruction and coiled on patients bed
- All connections secured
- Color and amount of drainage – should be marked at start of shift and according to policy
- Fluctuation of fluid level in water-seal chamber
- Constant bubbling in water-seal chamber (if pneumo or suction present) (disconnect from suction if you want to see if there is an air-leak)
- Float in appropriate location indicating appropriate suction
What do you do if a chest tube falls out or dislodges?
- Stay with patient and call for help
- Monitor VS and respiratory status
- If air leak unknown, place gauze and tape three sides (allow air expiration)
- If no air leak present, cover site with occlusive dressing and secure
What do you do if the tubing disconnects?
- Cleanse both ends with alcohol swab
- Notify physician
- If visibly contaminated, place chest tube in bottle of sterile water until new system can be set up
- If unit tips integrity compromised, replace unit
Describe chest tube documentation:
- Respiratory assessment
- Condition of the chest tube insertion site
- All tubings and connections tight
- Colour, consistency, and amount of any drainage
- Presence of subcutaneous emphysema
- Presence of tidalling in water seal chamber
- Presence of bubbling in water seal chamber
- Amount of suction
- Patient tolerance and education
When is it time to come out?
- No air leak evident the day before considering chest tube removal
- Drainage less than 50cc/8 hours or 100cc/day
- Patient able to tolerate chest drainage system being brought to water seal from suction
- Chest x-ray shows complete re-expansion of the lung
Describe post removal documentation:
- Tolerance of the procedure
- Respiratory Assessment
- Vital signs (HR, RR, BP, Sp02)
- Post procedure dressing
- Patient teaching
If a mediastinal tube is inserted after heart surgery, how much drainage is expected?
- Less than 100 cc/hr immediately after surgery
- No more than 500 cc in first 24 hours
How much drainage is expected from a posterior chest tube?
- 100 to 300 cc first 3 hours after insertion
- Total of 500 to 1000 cc in first 24 hours
- May be grossly bloody during first several hours after surgery and then change to serous
What might a sudden gush of drainage result from aside from active bleeding?
Coughing or changing patient’s position, releasing pooled/collected blood
What does fluctuation or stopping of movement in the water-seal chamber indicate?
Either the lung is fully expanded or the system is obstructed
Why is stripping chest tubes controversial?
Greatly increases negative pressure inside the tube, causing lung injury
Where might an air leak occur?
- At insertion site
- Connection between tube and drainage device
- Within drainage device itself
- Locate leak by clamping tube at different intervals
- Leaks corrected when constant bubbling stops
- If bubbling stops while clamped close to patient, air leak is inside patient’s thorax or at insertion site; un-clamp to prevent collapse, reinforce dressing and notify physician immediately
What are the S&S of tension pneumothorax?
- Severe resp distress
- Dyspnea
- Low O2 sat
- Chest pain (stabbing)
- Absence of breath sounds on affected side
- Tracheal shift towards unaffected side
- Hypotension and signs of shock
- Tachycardia
- Can be life threatening!
If the rate of drainage increases dramatically, there is need to rapidly alert physician. What amounts would this be?
20 cc over 4 hours (50 cc/hr)
