Lecture 04 Management of the Adult Requiring Chest Tube Drainage and Therapy

Question 1

Where does the pleural space lie?

Answer 1

Between parietal and visceral pleura of the chest wall and lungs

Question 2

What does the parietal pleura line and what does the visceral pleura line?

Answer 2

Parietal pleura lines the chest walls The visceral pleura surrounds the lungs

Question 3

The pleural space contains pleural fluid, which functions as what? (2)

Answer 3

1. Pleural fluid prevents friction between the visceral and parietal pleura during inspiration and expiration in the respiratory cycle. 2. Pleural fluid helps maintain integrity of the 2 spaces and maintains negative intrapleural pressure to keep the lungs expanded.

Question 4

What may it mean if you hear pleural friction rub?

Answer 4

R/t pleural spaces being inflame, or loss of lubrication. This typically occurs in pt with PNA, PE, Pleurisy

Question 5

Some physiology of respiration?

Answer 5

•Passive, involuntary activity

• Air moves in and out due to pressure changes in the lungs
• When diaphragm is stimulated, it contracts and moves downwards
• External intercostals move the ribcage up and out
• Chest wall and parietal pleura move out, pulling the visceral pleura and lung with it
• As the volume in the thoracic cavity increases, the pressure within the lung decreases

•Intrapulmonary pressure is now lower than atmospheric pressure; thus air flows into the lung (inhalation)

Question 6

Physiology of Respiration Expiration?

Answer 6

• When the diaphragm returns to its normal, relaxed state
• The intercostal muscles also relax and the chest wall moves in
• The lungs, with natural elastic recoil, also pull inward and air flows out of the lungs

•Intrapulmonic pressure is now greater than atmospheric pressure which is what causes the air to flow from the lungs and out to the atmosphere (exhalation)

Question 7

What are functions of surfactant? (3)

Answer 7

• Increase compliance (lung expansion)
• Prevent atalectasis (collapse at the end of expiration
• Reduces fluid accumulation thereby keeping the surfaces dry

Question 8

What causes pneumo? how do you maintain it?

Answer 8

• If air or fluid enters the pleural space, it separates the visceral from the parietal pleura, disrupting the negative pressure (prevents the lungs from collapsing at the end of exhalation), and compresses the lung
• If only a small amount of air or fluid is present, it may be reabsorbed without intervention.
• If large enough, the air/fluid compromises normal breathing and must be evacuated from the pleural space.

Essentially looks to maintain negative presssure within the pleural space

Question 9

What exactly is Pneumothorax and the 3 types?

Answer 9

Pneumothroax= air in pleural space

1. Spontaneous
2. Closed
3. Open

Question 10

Pneumothorax Signs?

Symptoms?

Answer 10

Signs: Tachypnea, tachycardia, decreased or absent breath sounds over the affected area

Symptoms: Pain which worsens with inspiration, dyspnea, cough, sudden stabbing pain on the side of the pneumothorax

Question 11

Spontaneous Pneumothorax

Common causes?

Answer 11

Pt may describe hearing or feeling a “pop”

Common causes:

Excessive coughing

Smoking

Tall thin men

People with COPD and Cystic Fibrosis

Ruptured pulmonary blebs (small subpleural thin walled air containing spaces that if ruptured, allow air to escape into pleural spaces resulting in a spontaneous pneumothorax)

High impact stress from sports activities such as basketball and football

Question 12

Spontaneous Pneumothorax:

Treatments:

Answer 12

Treatments include : high flow O2., chest tube, and consider position in bed…likely more comfortable in high fowlers

Question 13

What occurs during a closed pneumothorax?

Answer 13

• Involves penetration of the pleural space but the chest wall remains intact
• Air enters the pleural space from within the lung

Question 14

Closed pneumothorax could be caused by?

Answer 14

Often caused by a rib fracture that punctures the lung or as a result of medical procedures such as insertion of a central line or cardiac pacemaker wires via the subclavian vein

Penetration is often described as blunt trauma

This is why we always get a chest xray after Central line placement and pacing wires removed

Question 15

How does an Open Pneumothorax occur?

Answer 15

• The chest wall and pleural space are penetrated
• Air enters the pleural space

Question 16

Causes of Open Pneumothorax?

Answer 16

Caused by penetrating trauma: knife, gun shot, projectile or as a result of surgical procedure (thoracotomy) which involves a surgical incision to the thoracic cavity or may be a complication of a surgical procedure

Surgical procedure is known as a thoracotomy (need access to heart, lungs, espohagus)

Question 17

What is a Hemothorax?

Answer 17

Blood in the pleural space

Question 18

Hemothorax causes?

Answer 18

Causes: thoracic or heart surgery

blood clotting disorder

pulmonary infarction (death of lung tissue)

lung cancer

tear of a blood vessel when placing a central venous catheter or when associated with severe hypertension

TB

Question 19

What is Hemopneumothorax?

Answer 19

•Collection of blood and air in the pleural space

Question 20

What would treatment of hemopneumothorax invovle?

Answer 20

Requires two tubes to be inserted.

For a hemopneumothorax, two chest tubes inserted; one at the apex (2nd intercostal space) to drain air, the other at the base of the lung to drain fluid

Question 21

Def Tension Pneumothorax?

Answer 21

• Air leaks into the pleural space through a tear in the lung and has no way to escape
• With each breath, air accumulates in the pleural space increasing positive pressure which compresses the lung & shifts the mediastinum to the unaffected side of the chest
• Venous return and cardiac output are decreased

Question 22

Treatment of Tension Pneumothorax?

Answer 22

Having a chest tube will not prevent someone from obtaining a tension pneumo

Treatment…thorocostomy (needle or otherwise). Generally a small area will just be a needle. If fluid has leaked will see a chest tube placed

Serious issue!!

Question 23

What are CXRAY findings of Tension Pneumothorax?

Answer 23

What you might see on a chest xray that would indicate the presence of a tension pneumo… deviation of the trachea away from the side of the pneumo or a mediastinal shift

Question 24

Tension Pneumothorax Symptoms?

Answer 24

S & S include:

Rapid, labored respirations

Tachycardia

Cyanosis

Hypoxemia

Sudden chest pain that extends to the shoulders

Question 25

Def Pleural Effusion

Answer 25

Excess Fluidin the pleural space

Question 26

Causes of pleural effusion?

Answer 26

may be caused by left ventricular failure, pulmonary embolism, pneumonia, cancer, tumors, complications of surgery, or when a previously placed CT is removed prematurely

Question 27

Def Chylothorax?

Answer 27

•Accumulation of lymphatic fluid in the pleural space

Question 28

Chylothorax causes

Answer 28

Leakage of lymph from the thoracic duct which ends up accumulating the pleural space.

Caused by chest trauma, an expanding tumor, or surgery on mediastinal structures such as cardiac surgery

Looks milky white

Very rare

Generally dx via CT scan

Question 29

Empyema def

Answer 29

• Purulent drainage or pus from an infection such as pneumonia or lung abscess
• May enter and cause damage to the pleural space and membranes

Question 30

S/S and Treatments of Empyema?

Answer 30

Patients may present with: cough, chest pain, SOB, fever

Treatment includes thorocentesis “tap the lung”

Question 31

When does the clinical need for chest drainage occur?

Answer 31

The clinical need for chest drainage occurs: any time the negative pressure in the pleural cavity is disrupted by the presence of air and/or fluid resulting in pulmonary compromise.

Question 32

What is the purpsoe of a chest drainage unit?

Answer 32

The purpose of a chest drainage unit is: to evacuate the air and/or fluid from the chest cavity to help re-establish normal (negative) intrathoracic pressure.

Question 33

What does chest tube placement facilitate?

Answer 33

This facilitates: the re-expansion of the lung to restore normal breathing dynamics.

Question 34

Why are chest tubes inserted following heart surgery?

Answer 34

•Chest tubes are inserted following heart surgery to prevent the accumulation of fluid around the heart and prevent cardiac tamponade. Usually inserted as mediastinal tubes and are referred to as “MT” tubes.

Question 35

What is Pleurodesis?

Answer 35

Pleurodesis – when chest tube placed to instill fluids into the pleural space such as chemotherapy for lung cancer or a sclerosing agent to prevent recurrent pleural effusions.

Question 36

What are nursing considerations during Chest Tube insertion?

Answer 36

Other nursing considerations: patient position – depending on location of air/fluid accumulation – often patients are placed supine or in semi-fowler’s for ease of insertion; prepare the chest drainage system prior to insertion, administer pain or sedation medications as ordered, have supplies for a dressing prepared, monitor patient’s respiratory status O2 saturation.

Question 37

What does the Chest tube insertion procedure invovle? (4)

Answer 37

A. Local anesthetic injected to site

B. Incision made with scalpel

C. Pleural space separated with scissors

D. A finger (covered with a sterile glove) is inserted into the puncture site to ensure that the lung is not adhering to the chest wall before inserting the chest tube

E. Chest tube clamped and tip used to guide catheter into pleural space

F. Chest tube unclamped and attached to chest tube drainage unit to drain air and/or fluid

G. Chest tube then covered with a dry sterile dressing and cloth tape - occlusive

H. All chest tube connections from the insertion site to the drainage unit are securely taped with cloth tape to prevent air leaks or disconnections

Question 38

Chest tubes isnerted high and anteriorly, usually at the 2nd intercostal space are used for what?

Answer 38

To drain air

Question 39

Chest tubes inserted low and posterior, generally 5th and 6th intercostal are used to drain what?

Answer 39

To drain fluids

Question 40

What does Suction Control Chamber do? (3)

Answer 40

• Dry suction control
• Automatic control valve inside the regulator adjusts to the patient and suction source
• Expansion of the red bellows helps determine whether or not suction is operating

Question 41

How do you care for a suction tube?

Answer 41

To care for the suction tube:

Ensure no kinks in the tubing

It is not kinked or clamped off EVER!!

Question 42

What is the function of the collection chamber? (6)

Answer 42

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–Fluid/blood drains here - monitored/measured

–Checked every hour initially, then spaced out

–Notify the prescriber if there is > 100 ml per hour drainage (adults)

***Every assessment: note color and quantity of fluid

and check amount of drainage present (mark on collector)***

–Document type of drainage:

–

–Chest drainage tubing may be milked without an order to remove clots

–CD tubing should never be STRIPPED without an order – rarely done due to high negative pressure.

Question 43

Water Seal Chamber: What is normal intermittent bubbling considered?

Answer 43

Normal intermittent: noted if chest tube drainage unit is on suction. Caused by fluid being displaced by air in the chamber or seen when there is an air leak in the pleural space; a person is coughing or exhaling

Question 44

What does the Tidaling in Chest drainage unit chambers indicate?

Answer 44

–Fluctuations in the fluid level indicates pressure changes in the pleural space

–Water fluctuates up with inspiration and down with expiration

–Fluctuation diminishes as the lung re-expands and fills the pleural space

Question 45

Water Seal Chamber: What does large amount of bubbling indicate?

Answer 45

Large amount of bubbling: usually caused by a large patient leak or a leak in the system

Question 46

Water Seal Chamber: What may have occured in unexpected absence of bubbling?

Answer 46

Unexpected absence of bubbling: may be a blockage in the tubing

NOTE: bubbling slowly disappears as the lung re-expands, air stops leaking, or as the lung fills the pleural space

Bubbling is normal initially

Unexpected absence of bubbling – verify tubing is attached, water level is filled to prescribed level and check wall suction

Question 47

How is negative pressure reflected by the water level in the water seal tube?

Answer 47

–Reflects the vacuum level present in the intrathoracic cavity as indicated by the water level in the water seal tube

–When the water level in the tube rises and remains above the water level in the chamber itself (normally 2 cm), negative pressure is present in the patient’s pleural or mediastinal space as the patient breathes spontaneously

Question 48

What assessments do you do for a pt with chest tubes? (4)

Answer 48

Complete the following assessments:

1. Monitor vital signs: note RR, pattern, depth, ease of respirations, note SpO2 every two hours and prn
2. Assess breath sounds anteriorly, posteriorly and bilaterally especially noting symmetry of breath sounds
3. Heart sounds: present and clear not muffled and distant – if muffled/distant ® cardiac tamponade – medical emergency as this is when fluid/blood/clot accumulates in pericardium – HR may be decreased as BP increases**
4. Skin color and temperature

Question 49

What are some nursing interventsions for pt on chest tubes?

Answer 49

• Comfort level and pain control
• Tube insertion site and dressing

–note any drainage on or around the dressing

–If the dressing is completely saturated and coming off, DO NOT reinforce it - apply a new dry sterile dressing

• Coughing and deep breathing: encourage patient to cough and deep breath to promote drainage and lung expansion
• Keep all tubing free from kinks and prevent fluid filled dependent loops that can interfere with drainage
• Make sure all connections are securely taped & CT tube is secured to the patient’s chest wall
• Keep the collection unit below the patient’s chest level
• Check water seal and suction control chambers (at ordered levels)
• Measure and record drainage every 8 hours or more frequently per orders or as patient condition warrants
• Document the amount of drainage and characteristics on appropriate eRecord documentation flow sheet

Question 50

What are 4 chest tube complications?

Answer 50

• Bleeding: may occur if a blood vessel nicked during chest tube insertion. Report any bleeding to provider.
• Infection: high risk and becomes more likely the longer the chest tube remains in place
• Subcutaneous emphysema: occurs if air leaks from the pleural space into the subcutaneous tissues. It is characterized by swelling in the face, neck , and chest. Sounds like “rice krispies” when the area is palpated
• Tension pneumothorax: may be a complication any time a chest tube is inserted

Question 51

What occurs if there’s a chest tube leak?

Answer 51

1. –Clamp tubing by patient’s chest. If the chamber stops bubbling, the leak is in the patient. If the chamber does not stop bubbling, clamp intermittently along the tubing towards the end of the tube. If you reach the end of the tube and it does not stop bubbling, the leak is in the system
2. Leaks are evidenced by cont rapid bubbling in the water seal chamber

Question 52

What should you do immediate if the tube falls out?

Answer 52

–Immediately cover the site with petrolatum (Vaseline) gauze to prevent external air from entering the chest.

–If patient has known air leak prior to tube out, cover with dry sterile dressing and tape.

–NOTIFY THE PROVIDER IMMEDIATELY

Question 53

Why do you place tubing next to the pt on the bed or near their feet?

Answer 53

To prevent dependent loop formation.

DON’t hang the tubing down the side of the bed

Question 54

what should you do to the chest tube if it disconnects from the collector?

Answer 54

Immediately immerse the chest tube in a bottle of sterile water to form a new water seal

Question 55

What should you do if the system falls over?

Answer 55

•System falls over:

–If to wall suction: set up a new system, clamp the chest tube 1 ½ to 2 ½ inches from the patient; place a second clamp one inch distal to the first clamp, remove the old system and connect the new system. Tape connections and record the amount of drainage from the old system

–If to gravity drainage: set up new drainage system, disconnect the old system and connect the new one; tape the connections, record the drainage from the old system

CLAMPING: NEVER CLAMP A CHEST TUBE FOR MORE THAN ONE MINUTE AND ONLY CLAMP IT TO CHANGE DRAINAGE UNITS!!!

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Question 56

What are 4 things you keep at the bedside of a chest tube pt?

Answer 56

–Vaseline gauze

–One bottle of sterile water

–1 roll of cloth tape

–2 pairs padded Kelly clamps (hemostats)

Question 57

What are some indications for chest tube removal? (8)

Answer 57

•Indications:

–Drainage has decreased to little or none

•guidelines: less than 300 ml in 24 hours or less than 100 ml in 8 hours - (use 100 mL in 24 hours for exam purposes)

–Air leak has disappeared

–Patient is breathing normally without signs of respiratory distress

–Breath sounds are at patient’s baseline

–* Fluctuations in the water seal chamber have stopped

–* Chest x-ray shows lung re-expansion with no residual air or fluid in the pleural space

–* After the tube is removed, a sterile Vaseline gauze is placed over the site.

–* Assess patient respiratory status including quality and symmetry of breath sounds for one or two hours or longer after chest tube removal.

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