Care of the Client with

Chest Tubes
Matthew D. Byrne, RN, MS, CPAN

2/13/2018
Outline
 Basics
 Indications
 Insertion
 Function

2/13/2018
The Pleural Space
 Space between
ribs and lungs
 Filled with small
amount of fluid
 Air or fluid in
pleural space
inhibits expansion
and breathing

2/13/2018
The Pleural Space
 Physiologically, intrapleural pressure is 4-5
cm H2O below atmospheric pressure during
expiration
 Intrapleural pressure is 8-10 cm H2O below
atmospheric pressure during inspiration
 If the intrapleural pressure equals the
atmospheric pressure, the lung will collapse,
causing a pneumothorax

2/13/2018
 Chest Tubes: Basics
 Used when integrity of the pleural space
is lost
 Loss of normal intrapleural pressures
 Air or fluid may enter with loss of integrity

2/13/2018

Image from Trauma.org

Chest Tubes: Indications

 Surgery
 Traumatic chest injuries
 Pneumothorax
 Hemothorax
 Pleural effusion (build up
of fluid between the
pleura)
 Infection (empyema)

2/13/2018
Chest Tubes: Insertion
 Placed in the OR/ER/PACU or bedside
 Metal trocar used as guide
 Generally done with some sedation
 Ideally restores negative pressure and allows air
to escape/fluid to drain
 Sutured to chest wall
 Occlusive dressing applied
 Serial chest X-Rays for progress/placement
 Free end attached to drainage system
 Connections are secured (taped/banded)

2/13/2018 Pre and post vital signs and pain assessment
Chest Tubes: Location
 To drain air: Anterior (and laterally) through
2nd intercostal space

 To drain fluid/blood: Posterior through 8 or 9th

intercostal space in midaxillary line
2/13/2018
Chest Tubes: How they function

 Drainage systems:
 One chamber
 Two chamber
 Three chamber

 Two types of suction control chambers:

 1) dry (valve/regulator)
 2) wet (water chamber) control

2/13/2018
When you breathe…
 When you inhale, negative pressure is
created in your chest that pulls air in through
your mouth/nose
 What would happen if there was a hole in
your chest?
 A chest tube system can act as a one-way
valve that can remove air/fluid
 Can also be set up to create “pull” in the form
of negative pressure
2/13/2018
Chest tube systems
 What do we need to connect to this tube in
the patient’s chest?

 How can what we connect collect drainage,

allow air to escape and create a slight pull?

 We need a three part system to do this…

2/13/2018
One Bottle=One way valve

 Allows air out but not in

 Rise and fall of fluid
with breathing (WHY?
HOW?)- Tidaling
 Creates no “pull”
 Not intended for
collection
 The valve is the water
 What would happen if
we pulled the tube out
2/13/2018 of the water?
Two Bottles=Valve + Drainage

 Allows air out but

not in
 Rise and fall of fluid
with breathing
 Creates no “pull”
 Allows for collection

Water Seal Drainage

2/13/2018
(Valve)
 3 Bottles=Valve + Drainage + Pull
 Allows air out but
not in
 Rise and fall of fluid
with breathing
 Allows for collection
 Creates a “pull” in
the form of negative
pressure

Suction
(Dry or Wet)

2/13/2018
Water Seal Drainage
(Valve)
Commercial chest tubes

Dry Suction = pressure

Wet Suction = actual
and vacuum internally
column of water used
2/13/2018 regulated
(usually 20cm)
 In Clinical…
 The units are connected to wall suction unless
the order is for water seal only
 Wall suction creates a vacuum, while the
column of water creates the actual “pull”
 Turning up the wall suction, WILL NOT increase
the pull
 A column of water creates pressure, much like
when you are diving underwater
 Therefore, increasing the column of water WILL
increase the pull
2/13/2018
Nursing Responsibilities
 Standard 1 Assessment
 Patency/functioning of system (kinks, clamps,
atrium, suction, etc)
 Dressings
 Quantity and quality of drainage
 Dependency of collection system
 Coiled tubing, not hanging tubing
 Pain control
 Respiratory status and Vital signs (CDB/IS, lung
sounds, respiratory quality/number)
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Nursing Responsibilities
 Standard 5 Implementation
 Note specific orders regarding:
 Suction versus water seal
 Amount of acceptable drainage
 I&O
 X-rays
 Administer pain medications regularly
 Patient should change positions frequently
(promotes drainage, prevents complications)

2/13/2018
BSN Essentials
 Critical thinking and technical skills =
 Having the knowledge and skill to handle
problems!
 Always have at the ready:
 Extra atrium/set-up
 Oxygen
 Suction
 Occlusive dressings
 Chest tube clamps
 Bottle of sterile normal saline
2/13/2018
Patient Ed: Standard 5B
Reducing anxiety…
 Teach basics of drainage system, frequent checks,
ask for analgesics PRN
 Assure that CT is sutured in place
 Remind not to kink/compress tubing
 Drainage system to be kept below level of chest
 Fluctuations in water seal are normal
 Prepare for expected amount & type of drainage
 May hear bubbling if it is a “wet” suction system
 Discuss ambulating and repositioning
 Plan of care
2/13/2018
Chest Tubes: Removal
 When “tidaling” ceases and chest X-
ray/assessments confirm re-expansion of
lung
 Pre-medicate for pain
 Breath in & hum out (have pt practice)
 CT is quickly removed
 Occlusive dressing applied over insertion site
 Pleura seals itself off
 Chest wound heals within a week
2/13/2018