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Chest Tube Insertion Procedure Types Indications

Chest Tube Insertion Procedure Types Indications: Chest drainage is the insertion of a tube into the pleural space to evacuate air or fluid, and/or help regain negative pressure. Whenever the chest is opened, there is loss of negative pressure in the pleural space, which can result in collapse of the lung. The collection of air, fluid, or other substances in the thoracic cavity can compromise cardiopulmonary function and cause collapse of the lung.

It is necessary to keep the pleural space evacuated postoperatively and to maintain negative pressure within this potential space. Therefore, during or immediately after thoracic surgery, chest tubes/catheters are positioned strategically in the pleural space, sutured to the skin, and connected to a drainage apparatus to remove the residual air and fluid from the pleural or mediastinal space. This assists in the reexpansion of remaining lung tissue.

Chest drainage can also be used to treat spontaneous pneumothorax or hemothorax/pneumothorax caused by trauma Sites for chest tube placement are:

  • For pneumothorax (air)—second or third interspace along midclavicular or anterior axillary line.
  • For hemothorax (fluid)—sixth or seventh lateral interspace in the midaxillary line.

Indications for Chest Tube Insertion

INDICATIONACCUMULATING SUBSTANCE
PneumothoraxAir
HemothoraxBlood
Pleural effusionFluid
ChylothoraxLymphatic fluid
EmpyemaPus

Principles of Chest Drainage

Many types of commercial chest drainage systems are in use, most of which use the water-seal principle. The chest tube/catheter and collecting tubing is attached to a chest drainage system using a one-way valve principle. Water acts as a seal and permits air and fluid to drain from the chest. However, air cannot reenter the chest cavity.

Types of Chest Drainage System

One-Bottle Water-Seal System

  • The end of the collecting tube is covered by a layer of water, which permits drainage of air and fluid from the pleural space, but does not allow air to move back into the chest. Functionally, drainage depends on gravity, on the mechanics of respiration and, if desired, on suction by the addition of controlled vacuum.
  • The tube from the patient extends approximately 1 inch (2.5 cm) below the level of the water in the container. There is a vent for the escape of any air that may be leaking from the lung. The water level fluctuates as the patient breathes; it goes up when the patient inhales and down when the patient exhales.
  • At the end of the drainage tube, bubbling may or may not be visible. Bubbling can mean either persistent leakage of air from the lung or other tissues or a leak in the system.

Two-Bottle Water-Seal System

  • The two-bottle system consists of the same water-seal chamber, plus a fluid-collection bottle.
  • Drainage is similar to that of a single unit, except that when pleural fluid drains, the underwater-seal system is not affected by the volume of the drainage.
  • Effective drainage depends on gravity or on the amount of suction added to the system. When vacuum (suction) is added to the system from a vacuum source, such as wall suction, the connection is made at the vent stem of the underwater-seal bottle.
  • The amount of suction applied to the system is regulated by the wall gauge.

Three-Bottle Water-Seal System

  • The three-bottle system is similar in all respects to the two-bottle system, except for the addition of a third bottle to control the amount of suction applied. Recent research has shown that suction may actually prolong an air leak by pulling air through the opening that would otherwise heal on its own.
  • The amount of suction is determined by the depth to which the tip of the venting glass tube is submerged in the water and level of water in the suction chamber or setting of a dial—depending on the system in use.
  • In the three-bottle system (as in the other two systems), drainage depends on gravity or the amount of suction applied. The mechanical suction motor or wall suction creates and maintains a negative pressure throughout the entire closed drainage system.
  • The manometer bottle regulates the amount of negative pressure transmitted back to the patient from the suction/ vacuum device. This is accomplished through the use of water or dry system that downregulates the suction/ vacuum applied.
  • In the commercially available systems, the three bottles are contained in one unit and identified as “chambers” The principles remain the same for the commercially available products as they do for the glass bottle system.
  • First chamber acts as the collection chamber and receives fluid and air from the chest cavity through the collecting tube attached to the chest tube.
  • Second chamber acts as the water-seal chamber with 2 cm of water acting as a one-way valve, allowing drainage out but preventing backflow of air or fluid into the patient.
  • Third chamber applies controlled suction. The amount of suction is regulated by the volume of water (usually 20 cm) in the chamber not the amount of suction or bubbling with a water system. In a dry suction control system no water is used, no bubbling occurs, and a restrictive device or regulator is used to dial the desired negative pressure (up to 40 cm suction).

Nursing and Patient Care Considerations

  • Assist with chest tube insertion.
  • Assess patient’s pain at insertion site and give medication appropriately. If patient is in pain, chest excursion and lung inflation will be hampered.
  • Maintain chest tubes to provide drainage and enhance lung reinflation.
  • Maintain integrity of insertion site, observing for drainage, redness, impaired healing, and subcutaneous emphysema.

NURSING ALERT Milking and stripping of chest tubes to maintain patency is no longer recommended. This practice has been found to cause significant increases in intrapleural pressures and damage to the pleural tissue. New chest tubes contain a non-thrombogenic coating, thus decreasing the potential for clotting. If it is necessary to help the drainage move through the tubing, apply a gentle squeeze and- release motion to small segments of the chest tube between your fingers.

NURSING ALERT Clamping of chest tubes is no longer recommended due to the increased danger of tension pneumothorax from rapid accumulation of air in the pleural space. Clamp only momentarily to change the drainage system. Check for leaks to assess the patient’s tolerance for removal of the chest tube (perhaps up to 24 hours).

Assisting with Chest Tube Insertion Nurses Responsibility

EQUIPMENTS

  • Tube thoracostomy tray.
  • Syringes.
  • Needles/trocar..
  • Basins/skin germicide.
  • Sponges.
  • Scalpel, sterile drape, and gloves.
  • Two large clamps.
  •  Suture material.
  • Local anaesthetic.
  • Chest tube (appropriate size).
  • Connector.
  •  Cap, mask, gloves, gown, drapes.
  • Chest drainage system–connecting.
  • Tubes and tubing, collection bottles or commercial system, vacuum pump (if required).
  • Sterile water.

Procedure of Chest Tube Insertion

Assess patient for pneumothorax, hemothorax, presence of respiratory distressAssessment
Obtain a chest X-ray. Other means of localization of pleural fluid include ultrasound or fluoroscopic localization To evaluate extent of lung collapse or amount of bleeding in pleural space
Obtain informed consent
Verify right patient and right location/procedure
Premedicate if indicated
Assemble drainage system
Reassure the patient and explain the steps of the procedure. Tell the patient to expect a needle prick and a sensation of slight pressure during infiltration anaesthesia The patient can cope by remaining immobile and doing relaxed breathing during tube insertion
Position the patient as for an intercostal nerve block or according to physician preference  
The tube insertion site depends on the substance to be drained, the patient’s mobility, and the presence of coexisting conditions
Using universal precautions, the skin is prepared, anaesthetized, and draped, using local anaesthetic with a short 25G needle and using aseptic technique. A larger needle is used to infiltrate the subcutaneous tissue, intercostal muscles, and parietal pleura. 
The area is anaesthetized to make tube insertion and manipulation relatively painless. Use of universal precautions and aseptic technique prevent contamination of chest tube. Patient may feel pressure while tube is inserted.
An exploratory needle is inserted
  
To puncture the pleura and determine the presence of air or blood in the pleural cavity.
The IntraCath catheter is inserted through the needle into the pleural space. The needle is removed, and the catheter is pushed several centimetres into the pleural space.
The catheter is taped to the skin; may be sutured to the chest wall and covered with a dressing 
To prevent it from being dislodged out of the chest during patient movement or lung expansion. The chest tube clamp is removed once the chest tube is attached to the system
 The catheter is attached to a connector/tubing and attached to a drainage system (underwater-seal or commercial system) and all connections taped  
All connections are taped to prevent disconnection
Trocar technique for chest tube insertion: Using universal precautions and aseptic technique, a trocar catheter is used for the insertion of a large-bore tube for removal of a moderate to large amount of air leak or for the evacuation of serous effusion
A small incision is made over the prepared, anaesthetized site. Blunt dissection (with a hemostat) through the muscle planes in the interspace to the parietal pleura is performed.   
To admit the diameter of the chest tube
The trocar is directed into the pleural space, the cannula is removed, and a chest tube is inserted into the pleural space and connected to a drainage system 
There is a trocar catheter available equipped with an indwelling pointed rod for ease of insertion
Hemostat technique using a large-bore chest tube: Hemostat technique using a large-bore chest tube: Using universal precautions and aseptic technique, a large-bore chest tube is used to drain blood or thick effusions from the pleural space.
Using universal precautions, aseptic technique, and after skin preparation and anaesthetic infiltration, an incision is made through the skin and subcutaneous tissue. 
The skin incision is usually made one interspace below proposed site of penetration of the intercostal muscles and pleura.
A curved hemostat is inserted into the pleural cavity and the tissue is spread with the clamp.  
To make a tissue tract for the chest tube
The tract is explored with an examining finger.Digital examination helps confirm the presence of the tract and penetration of the pleural cavity.
The tube is held by the hemostat and directed through the opening up over the ribs and into the pleural cavity
The clamp is withdrawn and the chest tube is connected to a chest drainage system.The chest tube has multiple openings at the proximal end for drainage of air or blood.
The tube is sutured in place and covered with a sterile dressing.  
Prevents dislodgment
Catheter is attached to a connector/tube and to the system. All connections are tapedClamps are removed from the chest tube once connected to the drainage system. Chest tubes open to air at the time of insertion will result in a pneumothorax
Observe the drainage system for blood and air. Observe for fluctuation in the tube on respiration 
If a hemothorax is draining through a thoracostomy tube into a bottle containing sterile normal saline, the blood is available for autotransfusion
Secure a follow-up chest X-ray 
To confirm correct chest tube placement and reexpansion of the lung
Assess for bleeding, infection, leakage of air and fluid around the tube.With too rapid removal of fluid, a vasovagal response may occur with resulting hypotension. Continued use of petroleum gauzes or ointment can irritate the skin
Maintain integrity of the chest drainage system. 
Chest tube malposition is the most common complication

Managing the Patient with Water-Seal Chest Drainage 

Equipment for Water-Seal Chest Drainage 

  • Closed chest drainage system
  •  Holder for drainage system (if needed) connector for emergency use
  • Vacuum motor
  •  Sterile connector for emergency use (ie, sterile water)
Attach the chest tube from the pleural space (the patient) to the collecting/drainage tubing and water-seal drainage system. Add sterile water to water-seal chambers as needed. Adjust suction until bubbling is seen or set gauge as directed. Keep drainage system below level of chest.Water-seal drainage provides for the escape of air and fluid into a drainage bottle. The water acts as a seal and keeps the air from being drawn back into the pleural space. Vigorous bubbling is not indicated.
Check the tube connections periodically. Tape if necessary.
1;The tube should be as straight as possible and coiled below level of chest without dependent loops
2;Do not let the patient lie on collecting/tubing drainage.
Tube connections are checked to ensure tight fit, patency of the tubes, and to prevent backflow of drainage or air.
Mark the original fluid level with tape on the outside of the drainage system. Mark hourly and daily increments (date and time) at the drainage level.  This marking will show the amount of fluid loss and how fast fluid is collecting in the drainage bottle. It serves as a basis for blood replacement, if the fluid is blood. Grossly bloody drainage will appear in the bottle in the immediate postoperative period and, if excessive, may necessitate reoperation. Drainage usually declines progressively after the first 24 hours.
Assess patient’s clinical status at least once per shift. Observe and report immediately signs of rapid, shallow breathing, cyanosis, pressure in the chest, subcutaneous emphysema, or symptoms of hemorrhage. 
Removal of 1,000 to 1,200 mL of pleural fluid at one time can result in hypotension and rebound pleural effusion. Report to physician immediately. More frequent monitoring is required at the initiation of therapy and when warranted by patient’s condition. Many clinical conditions may cause these signs and symptoms, including tension pneumothorax, mediastinal shift, hemorrhage, severe incisional pain, pulmonary embolus, and cardiac tamponade. Surgical intervention may be necessary.
Make sure the tubing does not loop or interfere with the movements of the patient.Fluid collecting in the dependent segment of the tubing will decrease the negative pressure applied to the catheter. Kinking, looping, or pressure on the drainage tubing can produce back pressure, thus possibly forcing drainage back into the pleural space or impeding drainage from the pleural space
Encourage the patient to assume a position of comfort. Encourage good body alignment. When the patient is in a lateral position, place a rolled towel under the tubing to protect it from the weight of the patient’s body. Encourage the patient to change position frequently.The patient’s position should be changed frequently to promote drainage and body kept in good alignment to prevent postural deformity and contractures. Proper positioning helps breathing and promotes better air exchange. Pain medication may be indicated to enhance comfort and deep breathing.
Put the arm and shoulder of the affected side through ROM exercises several times daily. Some pain medication may be necessary  
Exercise helps to avoid ankylosis of the shoulder and assists in lessening postoperative pain and discomfort
Make sure there is fluctuation (“tidaling”) of the fluid level in the drainage system.Fluctuation of the water level in the tube shows that there is effective communication between the pleural space and the drainage system; provides a valuable indication of the patency of the drainage system, and is a gauge of intrapleural pressure.
Fluctuations of fluid in the tubing will stop when:
1: the lung has reexpanded
2: the tubing is obstructed by blood clots or fibrin
3: a dependent loop develops.
Watch for leaks of air in the drainage system as indicated by constant bubbling in the water-seal bottle.
1: Report excessive bubbling in the water-seal change immediately.
 Leaking and trapping of air in the pleural space can result in tension pneumothorax
Encourage the patient to breathe deeply and cough at frequent intervals. If there are signs of incisional pain, adequate pain medication is indicated.
Deep breathing and coughing help to raise the intrapleural pressure, which allows emptying of any accumulation in the pleural space and removes secretions from the tracheobronchial tree so the lung
expands
If the patient has to be transported to another area, place the drainage system below the chest level (as
close to the floor as possible).
The drainage apparatus must be kept at a level lower than the patient’s chest to prevent backflow of fluid into the pleural space.
.If the tube becomes disconnected, cut off the contaminated tips of the chest tube and tubing, insert a sterile connector in the chest tube and tubing, and reattach to the drainage system. Otherwise, do not clamp the chest tube during transport.
When assisting with removal of the tube:
1: Administer pain medication 30 minutes before removal of chest tube.
2: Instruct the patient to perform a gentle Valsalva maneuver or to breathe quietly.
3: The chest tube is clamped and removed.
4:Simultaneously, a small bandage is applied and made airtight with petroleum gauze covered by a 4”  4” gauze and thoroughly covered and sealed with tape.

 The chest tube is removed as directed when the lung is reexpanded (usually 24 hours to several days). Signs of reinflation include little or no drainage, absence of air leak, no noted respiratory distress, no fluctuations in fluid in water-seal chamber, no residual air or fluid in chest X-ray. During the tube removal, avoid a large sudden inspiratory effort, which may produce a pneumothorax.


Monitor the patient’s pulmonary status for signs and symptoms of decompensation. Observe insertion site for signs of infection and changes in drainage.   Patient could have reformation of pneumothorax after removal as well as infection at injection site.

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