Chest Tubes

Nursing cares, assessment, and

interventions

By: Morgan
Kraut, Bonnie
Glover and
Allison
Hildebrand
Purpose of Chest Tubes

 The purpose of
chest tube
therapy is to
remove air or
fluid from the
pleural space
and to restore
normal intra-
pleural pressure
helping to
promote lung re-
expansion
Anatomy and Physiology of
thoracic cavity

 The chest is composed

of ribs, sternum,
vertebrae and inter-costal
muscles.
 The lower border of the
thoracic cavity is known
as the diaphragm. This
muscle contracts with
inspiration and
expiration.
 The parietal pleura is a
membrane lining the
inside of the rib cage.
 The membrane covering
the lungs is called the
visceral pleura.
 The cavity between these
two membranes is called
the pleural space. This
space creates a negative
pressure that keeps the
lungs expanded.
 When air or fluid is
present in the pleural
space, this limits lung
expansion and causes
the lung to collapse
partially or completely
Indications for Chest
Tubes

 Pneumothorax – air in pleural

space
 Pleural Effusion – fluid in pleural
space
 Hemothorax – blood in pleural
space
 Empyema – collection of pus or
infection in pleural space
 Chylothorax – lymphatic fluid in
pleural space
Equipment

 Pleuravac collection system –

this is a sterile system and
includes a funnel and sterile NS
 Tubing connecting chest tube to
pleuravac
 Tubing connecting pleuravac to
wall suction
 Hemostats – for clamping
flexible tubing before
disconnecting patient from
pleuravac
 Vaseline impregnated gauze – to
create seal over insertion site
Pleuravac collection
chambers

 Purpose of this system is to evacuate

air or fluid from pleural space to
promote adequate re-expansion
 Collection chamber – for air, blood or
other foreign drainage from pleural
space
 Suction control chamber – promotes
faster draining than gravity
 Water seal chamber – Allows air to
pass from the collection chamber to
water seal chamber where it will leave
pleuravac
Active Orders in
Healthlink

 Suction amount – continuous,

intermittent, or dependent (water seal)
draining
 Dressing changes – during chest tube
therapy and after chest tube is
removed
 I&O
 Activity allowance – can RN
disconnect pt from suction for walking
 Post-placement chest x-ray
HEALTH LINK
Documentation
How to set up a Pleuravac

 Fill water seal chamber to 2 cm

 Fill suction control chamber to
ordered level
 Attach tube to suction source
 Tape all the connections
 Provide sterile tube for
connection to patient
Nursing Assessment and
Documentation

 Assess the pt first - color, respiratory rate/rhythm,

lung sounds bilaterally, presence of crepitus
 Monitor Vital signs
 Encourage coughing and deep breathing
 Assess for an air leak – have pt bear down by
sealing lips over thumb and blowing, or have patient
cough.
 Chest tube dressing and insertion site –
color/presence of drainage, skin color
 Tubing – free of kinks, tubing is lower than pt, tubing
is not clamped, tubing should also be coiled flat on
the bed and fall in a straight line to the drainage
system.
 Reposition frequently: drainage is promoted when
the pt is sitting in a semi-sitting position, and also by
turning the pt to the side of the chest tube and
exhaling or coughing.
If this, then what

 What if chest tube accidentally

disconnects
from tubing?
– Quickly clamp with hemostat or by kinking and
find bottle of sterile NS to put end of tube into.
Then reconnect to new tubing/pleuravac system.

 What if pleuravac is knocked over?

– Not an emergency, simply tip back up.
Reassess for correct fluid levels of each
chamber. If mixing of chambers has occurred,
change pleuravac system.
 If this, then what (cont.)

 What if there is bubbling in water seal

chamber?
– This indicates possible air leak. Attempt to
locate air leak (insertion site, tubing
connections, etc). Contact MD.
 How do I assess for crepitus?
– Crepitus will sound like rice krispies under the
skin around chest tube site. This is trapped air
that is incorrectly leaving pleural space.
 What if drainage is bright red in color and
increases output?
– If pt (with all types of disruptions to thoracic
cavity) starts having large output of blood,
especially bright red drainage >70 ml an hour,
this may indicate hemorrhage. Assess pt and
immediately contact MD.
Pleuravac assessment

 Suction control chamber – should

have steady bubbling, should be filled
to ordered suction level with water
 Water seal chamber - Check the fluid
level in the water seal and adjust to 2
cm, is the negative pressure indicator
visible, potential air leak if bubbling,
assess for rise and fall (tidaling) with
inspiration and expiration, this is
normal
 Collection chamber – is chamber full,
color/amount of drainage, should be
no bubbling present
Indications for the removal of
a chest tube

 Little to no
drainage q shift
 Patient is
breathing normal
with no
respiratory
distress
 X-ray confirms
that the lung is
re-expanded.
Removal of chest tube
and nursing assessment

 Physician will order for chest

tube removal, this is done at bedside
 Gather all supplies and explain
procedure to patient.
 During peak exhalation, physician will
remove the tube in one quick motion
 Apply sterile gauze over site to
prevent air from entering the chest
cavity.
 Monitor vital signs closely
CS Catalog

 How to order a new pleuravac system:

 In U-Connect, click on CS catalog:
 Under Search by item description type in:
– chest : this will bring up both the chest
tube sets, and drainage systems.
– Most commonly pts will have:
 DRAINAGE CHEST ADULT/PEDS PLEUR-
EVAC single A7002-08LF item #1216245
 Order item that fits your patients specific needs:
proceed to check out.
 Account # specific to orthopedics is 93430
 Finalize order.
References

 Albuquerque D, et al. The effect of experimental pleurodesis

caused by aluminum hydroxide on lung and chest wall mechanics.
Lung. 179(5):292–303, October 2001.

 Anders K. Chest drainage to go. Nursing2004. 34(5):54–55, May

2004.

 Baumann MH. What size chest tube? What drainage system is

ideal? And other chest tube management questions. Current
Opinion in Pulmonary Medicine. 9(4):276–281, July 2003.

 Brubacher S, Gobel BH. Use of the Pleurx pleural catheter for the
management of pleural effusions. Clinical Journal of Oncology
Nursing. 7(1):35–38, January/February 2003.

 Carroll P. Mobile chest drainage: Coming soon to a home near

you. Home Healthcare Nurse. 20(7):434–441, July 2002.

 Conces DJ Jr, Tarver RD, Gray WC, Pearcy EA. Treatment of

pneumothoraces utilizing small caliber chest tubes. Chest.
1988;94:55–57.[Abstract/Free Full Text]

 Coughlin, A.M., Parchinsky, C. “Go with the flow of chest tube

therapy.” Journal of Nursing 2006, 36, (37-41).
References (cont.)

 LeMone P, Burke K. Medical-Surgical Nursing. Critical

Thinking in Client Care, 3rd edition. Upper Saddle River,
N.J., Prentice Hall, 2003.

 Lewis, S. M., Heitkemper, M. M., Dirkson, S. R. Medical

and Surgical Nursing: Assessment and Management of
Clinical Problems. St. Louis: 2004.

 Morton PG, Fontaine D, eds. Critical Care Nursing. A

Holistic Approach, 8th edition. Philadelphia, Pa.,
Lippincott Williams & Wilkins, 2005.

 Niemi T, Hannukainen J, Aarnio P. Use of the Heimlich

valve for treating pneumothorax. Ann Chir Gynaecol.
1999;88:36–37.[Medline]

 Perlmutt LM, Braun SD, Newman GE, et al. Transthoracic

needle aspiration: use of a small chest tube to treat
pneumothorax. AJR Am J Roentgenol. 1987;148:849–
851.[Abstract/Free Full Text]

 Rossi A, Ganassini A, Polese G, Grassi V. Pulmonary

hyperinflation and ventilator-dependent patients. Eur
Respir J. 1997;10: 1663–1674.[Abstract]]
 CHEST
TUBES
A Reference Guide for Nurses

By: Morgan Kraut,

Allison Hildebrand
and Bonnie Glover