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Chest-tube care: The more you know, the easier it gets part 2
Date Posted: 02/Jul/2014
 
Patient positioning
Patient positioning depends on the insertion site, whether air or fluid will be drained, and the patient’s clinical status. Generally, the patient is positioned flat, with a small wedge or bolster (several folded towels or a blanket) placed under the shoulder blades to elevate the body and give the practitioner easier access. The arm on the procedural side must be kept out of the way; usually, it’s brought over the patient’s head and secured. Pendulous breasts or excessive adipose tissue may need to be secured out of the way as well.
 
The specific insertion site may vary with the condition being treated. Commonly, a chest tube is inserted at the midaxillary line between the fourth and fifth ribs on a line lateral to the nipple. 
 
Potential complications
Chest-tube insertion may cause bleeding, especially if a vessel is accidentally cut. Usually, bleeding is minor and resolves on its own, but bleeding into or around the lung may warrant surgical intervention.
 
Infection risk increases with duration of tube placement. Regular dressing changes done according to facility policy can help identify and prevent site infections. Note changes in drainage amount and character, which may indicate increased bleeding or new-onset infection.
 
Subcutaneous emphysema may arise as pleural-space air leaks into subcutaneous tissue. When this happens, tissues of the neck, face, and chest swell and you may note crepitus on palpation. Notify the physician if you suspect subcutaneous emphysema; tube placement and suction level must be evaluated.
 
Nursing care: From patient to system
At least every 2 hours, document a comprehensive pulmonary assessment, including respiratory rate, work of breathing, breath sounds, and arterial oxyhemoglobin saturation measured by pulse oximetry (SpO2). Inspect the dressing and note any drainage. Assess the insertion site for subcutaneous emphysema and tube migration. Keep all tubing free of kinks and occlusions; for instance, check for tubing beneath the patient or pinched between bed rails. Take steps to prevent fluid-filled dependent loops, which can impede drainage.
 
To promote drainage, keep the CDU below the level of the patient’s chest. Monitor water levels in the water-seal and suction-control chambers. Water in both chambers evaporates, so be sure to add water periodically to maintain the water-seal and suction levels.
 
Be aware that tidaling—fluctuations in the water-seal chamber with respiratory effort—is normal. The water level increases during spontaneous inspiration and decreases with expiration. However, with positive-pressure mechanical ventilation, tidaling fluctuations are the opposite: the water level decreases during inspiration and increases during expiration. If tidaling doesn’t occur, suspect the tubing is kinked or clamped, or a dependent tubing section has become filled with fluid. Also, don’t expect tidaling with complete lung expansion or with mediastinal tubes, because respirations don’t affect tubes outside the pleural space.
 
Intermittent bubbling, corresponding to respirations in the water-seal chamber, indicates an air leak from the pleural space; it should resolve as the lung reexpands. If bubbling in the water-seal chamber is continuous, suspect a leak in the system. To locate the leak’s source, such as a loose connection or from around the site, assess the system from the insertion site back to the CDU. When searching for the source of an air leak, use rubber-tipped or padded clamps to momentarily clamp the tubing at various points; bubbling stops when you clamp between the air leak and water seal. If you’ve clamped along the tube’s entire length and still can’t find the source, the CDU might be faulty; replacement should be considered.
 
Assess drainage
Assess the color of drainage in the drainage tubing and collection chamber. Know that old drainage in the collection chamber may inaccurately reflect current drainage as shown in the tubing. At regular intervals (at least every 8 hours), document the amount of drainage and its characteristics on the clinical flow sheet. Report sudden fluctuations or changes in chest-tube output (especially a sudden increase from previous drainage) or changes in character (especially bright red blood or free-flowing red drainage, which could indicate hemorrhage). Frequent position changes, coughing, and deep breathing help reexpand the lung and promote fluid drainage.
 
Don’t milk, strip, or clamp the tube
Avoid aggressive chest-tube manipulation, including stripping or milking, because this can generate extreme negative pressures in the tube and does little to maintain chest-tube patency. If you see visible clots, squeeze hand-over-hand along the tubing and release the tubing between squeezes to help move the clots into the CDU.
 
As a rule, avoid clamping a chest tube. Clamping prevents the escape of air or fluid, increasing the risk of tension pneumothorax. You can clamp the tube momentarily to replace the CDU if you need to locate the source of an air leak, but never clamp it when transporting the patient or for an extended period, unless ordered by the physician (such as for a trial before chest-tube removal).
 
In the event of chest-tube disconnection with contamination, you may submerge the tube 1" to 2" (2 to 4 cm) below the surface of a 250-mL bottle of sterile water or saline solution until a new CDU is set up. This establishes a water seal, allows air to escape, and prevents air reentry.
 
Chest-tube removal
Indications for chest-tube removal include:
. improved respiratory status
. symmetrical rise and fall of the chest
. bilateral breath sounds
. decreased chest-tube drainage
. absence of bubbling in the water-seal chamber during expiration
. improved chest X-ray findings.
Before starting chest-tube removal, inform the patient that the chest tube will be removed, and briefly describe the steps involved. Make sure the patient is premedicated to relieve pain and ease anxiety. Teach the patient how to do the Valsalva maneuver, which he or she must perform before tube removal to prevent air from reentering the pleural space.
 
Gather the supplies you’ll need, including sterile gloves, goggles, gown, mask, dressing supplies, sterile suture-removal kit, rubber-tipped hemostats, and wide occlusive tape. Place the patient in the semi-Fowler’s position and put a pad underneath the chest-tube site to catch any drainage.
 
After the dressing is removed and the sutures are cut, the practitioner clamps the chest tube with hemostats. Instruct the patient to perform the Valsalva maneuver as the practitioner quickly removes the tube at maximum inspiration. Immediately after tube removal, apply an occlusive dressing to the site and secure it with tape. Another chest X-ray should be taken several hours later to ensure that the lung is still fully inflated.
 
Nursing care after chest-tube removal includes:
. ongoing respiratory assessment
. vital-sign documentation
. monitoring the site for drainage
. assessing the patient’s comfort level.
 
De-stress over chest tubes
By understanding the indications for chest tubes and providing appropriate nursing care, from chest-tube insertion to removal and beyond, you’ll find chest-tube care less stressful while helping your patient breathe easier and recuperate without complications.
 
 
Selected references
American College of Surgeons. ATLS: Advanced Trauma Life Support Program for Doctors. 8th ed. Chicago, IL: American College of Surgeons; 2008.
Coughlin AM, Parchinsky C. Go with the flow of chest tube therapy. Nursing. 2006; 36(3):36-41.
Morton PG, Fontaine D, eds. Critical Care Nursing: A Holistic Approach. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
Parrillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management in the Adult. 3rd ed. St. Louis, MO: Mosby; 2008.
Protocol for autotransfusion: information from the Atrium 2450 self-filling ATS blood bag instruction insert. R Adams Cowley Shock Trauma Center, University of Maryland Medical Center. Last revised February 2008.
West JB. Respiratory Physiology: The Essentials. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
 
Both authors work at R Adams Cowley Shock Trauma Center, University of Maryland Medical Center in Baltimore. Mark Bauman is a senior clinical nurse II. Claudia Handley is a nurse manager in Select Trauma Critical Care. The authors and planners of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.

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