Chest Tubes and Pleural Drainage

Question 1

chest tubes are inserted to

Answer 1

drain the pleural space, reestablish negative pressure, and allow for proper lung expansion.
Tubes may also be inserted in the mediastinal space to drain air and fluid postoperatively.

Question 2

Chest tubes are approximately

Answer 2

20 inches (51 cm) long and vary in size from 12F to 40F. The size inserted is determined by the patient’s condition. Large (36F to 40F) tubes are used to drain blood, medium (24F to 36F) tubes are used to drain fluid, and small (12F to 24F) tubes are used to drain air. Pigtail tubes are very small (10F to 14F) tubes with a curly end designed to keep them in place. They are a safe and effective alternative to larger-bore chest tubes for treatment of pneumothorax.

Question 3

Insertion of a chest tube can take place in

Answer 3

the emergency department, the operating room, or at the patient’s bedside

Question 4

The patient is positioned

Answer 4

with the arm raised above the head on the affected side to expose the midaxillary area, the standard site for insertion. Elevate the patient’s head 30 to 60 degrees, when possible, to lower the diaphragm and reduce the risk of injury.

Question 5

Proper tube placement is confirmed by

Answer 5

chest x-ray.

Question 6

The chest tube placement is advanced

Answer 6

up and over the top of the rib to avoid the intercostal nerves and blood vessels that are behind the rib inferiorly. Once inserted, the tube is secured (sutured) in place, the incision is closed with sutures, and the tube is connected to a pleural drainage system. The wound is covered with an occlusive dressing.

Question 7

A flutter valve (also called the Heimlich valve after its inventor) is used to

Answer 7

evacuate air from the pleural space. This device consists of a one-way rubber valve within a rigid plastic tube. It is attached to the external end of the chest tube.

Question 8

flutter valve MOA

Answer 8

During inspiration, when pressure in the chest is greater than atmospheric pressure, the valve opens. During expiration, when intrathoracic pressure is less than atmospheric pressure, the valve closes.

Question 9

The flutter valve can be used for

Answer 9

small to moderate-sized pneumothorax. It also allows for patient mobility, since the smaller drainage bag can be hidden under the clothes while the patient ambulates.

Question 10

flutter valve drainage bag precaution

Answer 10

Drainage bags attached to the flutter valve must have a vent to the atmosphere to prevent a potential tension pneumothorax. This can be accomplished by simply cutting a small slit in the top of any drainage bag that does not have a built-in vent. Patients may go home with a flutter valve in place.

Question 11

Pleural Drainage

Answer 11

Insertion of a chest tube often requires attachment to a drainage device or chamber to collect fluid, air, and/or blood from the thoracic cavity.

Question 12

Pleural Drainage first compartment, or collection chamber

Answer 12

receives fluid and air from the pleural or mediastinal space. The drained fluid stays in this chamber while expelled air vents to the second compartment.

Question 13

Pleural Drainage second compartment,

Answer 13

the water-seal chamber, contains 2 cm of water, which acts as a one-way valve. Incoming air enters from the collection chamber and bubbles up through the water. The water prevents backflow of air into the patient. Brisk bubbling of air often occurs in this chamber when a pneumothorax is initially evacuated. Intermittent bubbling during exhalation, coughing, or sneezing (when the patient’s intrathoracic pressure is increased) may be observed as long as there is air in the pleural space. Eventually, as the air leak resolves and the lung becomes more fully expanded, bubbling ceases.

Question 14

tidaling

Answer 14

Normal fluctuation of the water within the water-seal chamber. This up and down movement of water in concert with respiration reflects intrapleural pressure changes during inspiration and expiration. Investigate any sudden cessation of tidaling, since this may signify an occluded chest tube. Gradual reduction and eventual cessation of tidaling are expected as the lung reexpands.

Question 15

Pleural Drainage third compartment

Answer 15

the suction control chamber, applies suction to the chest drainage system.

Question 16

There are two main types of suction control:

Answer 16

water and dry.

Question 17

The water suction control chamber uses

Answer 17

a column of water to control the amount of suction from the wall regulator. The chamber is typically filled with 20 cm of water. When the negative pressure generated by the suction source exceeds the set 20 cm, air from the atmosphere enters the chamber through a vent on top of the chest drainage unit and the air bubbles up through the water, causing a suction-breaker effect. As a result, excess pressure is relieved.

Question 18

The amount of suction applied is regulated by

Answer 18

the amount of water in this chamber and not by the amount of suction applied to the system. An increase in suction does not result in an increase in negative pressure to the system because any excess suction merely draws in air through the vent on top of the third chamber.

Question 19

The suction pressure is usually ordered to be

Answer 19

−20 cm H2O, although higher pressures (−40 cm H2O) are sometimes necessary to evacuate the pleural space; lower pressure (−10 cm H2O) may be used for frail and older patients at risk for tissue damage with higher pressures.

Question 20

To initiate suction

Answer 20

adjust (increase) the vacuum source until gentle bubbling is present in the third chamber. Excessive bubbling does not increase the amount of suction but does increase the rate of evaporation of the water and the amount of noise made by the device.

Question 21

The dry suction chest drainage system

Answer 21

contains no water. It has a visual alert that indicates if the suction is working. It uses either a restrictive device or a regulator to dial the desired negative pressure; this is internal in the chest drainage system. To increase the suction pressures, turn the dial on the drainage system. Increasing the vacuum source does not increase the pressure. When decreasing suction, depress the manual vent to reduce excess vacuum to the lower prescribed level.

Question 22

Clamping of chest tubes

Answer 22

during transport or when the tube is accidentally disconnected is no longer advocated. The danger of rapid accumulation of air in the pleural space, causing tension pneumothorax, is far greater than that of a small amount of atmospheric air that enters the pleural space.

Question 23

Chest tubes may be momentarily clamped to

Answer 23

change the drainage apparatus or to check for air leaks.

Question 24

Closely monitor the patient for complications associated with chest tube placement and drainage.

Answer 24

If volumes from 1 to 1.5 L of fluid and/or blood are removed rapidly, reexpansion pulmonary edema or severe, symptomatic hypotension can occur. Subcutaneous emphysema can occur from air leaking into the tissue surrounding the chest tube insertion site. A “crackling” sensation will be felt when palpating the skin. A small amount of subcutaneous air is harmless and will be reabsorbed. However, severe subcutaneous emphysema can cause drastic swelling of the head and neck with potential airway compromise.

Question 25

Nursing care and patient teaching

Answer 25

sterile technique during dressing changes can reduce the incidence of infected sites. minimize the risk of atelectasis and shoulder stiffness. Encourage coughing, deep breathing, incentive spirometer use, and range-of-motion exercises. Monitor integrity of the chest tube system. Monitor the color and amount of drainage hourly in the first few hours post-chest tube insertion. Drainage greater than 200 mL in the first hour, development of subcutaneous emphysema, or any signs and symptoms of respiratory distress should be reported to the appropriate HCP at once.

Question 26

The chest tubes are removed when

Answer 26

the lungs are reexpanded and fluid drainage has ceased or is minimal.