A chest tube is a drain placed into the pleural space to restore intrapleural pressure and reinflate the lung after it has collapsed. It also acts to prevent fluid and air from returning to the chest. Chest tube maintenance includes the actions performed by the nurse or other health care professional to keep the tube functioning properly.
Purpose
Under normal circumstances, intrapleural pressure is below atmospheric pressure. When this pressure changes because of excess air and/or fluid, the lung may collapse. If this occurs, a chest tube is inserted into the intrapleural space. This lets excess fluids drain, restores normal pressure, reinflates the lung, and allows adequate gas exchange. Persons experiencing a pleural effusion (accumulation of fluid in the spaces of the pleura), hemothorax (accumulation of blood in the pleural cavity), pneumothorax (collapsed lung), and empyema (accumulation of pus in the pleural cavity) may all require the insertion of a chest tube.
Precautions
The patient requiring a chest tube is acutely ill because any change in the intrapleural pressure compromises the patient's ability to breathe. An oxygen source, suction, and emergency equipment must be nearby when this procedure is performed.
Description
Depending on the patient's condition, the chest tube insertion may occur at the bedside, in the emergency room, or in the operating room. In any case, the insertion of a chest tube is a sterile procedure. Most hospitals have chest tube insertion trays containing all of the necessary supplies. First, the health care provider administers a local anesthetic. The patient is positioned according to the type of lung collapse being treated. After making a small incision, the physician inserts the chest tube. To avoid accidental puncture of the lung or pleura, the patient should be reminded not to cough or move during the procedure. Once the chest tube is in and sutured in place, the tube will be attached to a drainage system. Vaseline gauze may be placed at the chest tube insertion site to make certain an adequate seal has been achieved. Sterile 4 4 gauze pads will be placed over the Vaseline gauze, then securely taped. It is wise to tape the far end of the chest tube to the patient's chest to prevent dislodgement.
Preparation
The patient may be anxious about the procedure. Providing privacy and emotional support, along with explaining the procedure may help calm the patient. The nurse should perform a baseline assessment and take vital signs. An informed consent should be signed if the patient is able to do so. The physician may order premedications, which should be administered by the nurse as prescribed.
Aftercare
After the chest tube has been inserted, it is the nurse's responsibility to maintain a patent (clear) and intact pleural drainage system. The chest tube will be connected to about 6 ft (1.8 m) of rubbery tubing that leads to a collection device several feet below the chest. The patient should be Instructed to avoid lying on the tubing, and the nurse must make certain no kinks occur. All tubing connections should be taped to prevent air leaks.
The chest drainage system has a separate water seal that acts as a one-way valve. The nurse adds a specified amount of sterile saline to this water seal chamber and makes sure the end of the tubing stays in the fluid. When air is pushed out of the pleural space and through the tubing, it bubbles into the saline and cannot return to the chest. If necessary, suction may be added to the drainage system. The depth of the saline determines the maximal allowable suctioning for the system.
The nurse should note and document the amount and color of the chest tube drainage, and the level of drainage should be marked at the end of each shift. The patient's respiratory status should be assessed frequently. It is normal to note decreased breath sounds on the side of the chest tube. The patient should be encouraged to perform coughing and deep-breathing exercises.
Complications
Several complications can occur when managing a patient with a chest tube. If the tube accidentally becomes dislodged, the open insertion site should be quickly covered with Vaseline gauze and the physician notified. If the tubing becomes disconnected from the drainage system, the chest tube should be clamped. (Padded clamps should be kept at the bedside at all times.) Both of these situations, if untreated, could allow air to enter the lung. Sometimes clots can form within the tube and prevent free drainage. If this happens, the tube should be milked gently, squeezing it to move the clot, but not handling it so firmly that the tubing becomes occluded.
If the drainage system unit is damaged or cracked, allowing atmospheric pressure into the system, the uncontaminated end of the connective tubing should be placed into sterile saline or water to a depth of 0.79 in (2 cm) until a new system can be obtained. Finally, a patient with a chest tube is at increased risk for infection. This risk can be reduced by cleaning the chest tube site and changing the dressing regularly.
Results
The chest tube can be removed when one of the following has happened:
The lung has fully expanded.
No air leak has developed during a 24–48 hour period.
Less than 5.07 oz (150 ml) of fluid has drained in a 24- hour period.
Normally, the physician removes the chest tube while the patient performs a Valsalva maneuver. Vaseline gauze is immediately applied over the insertion point. This prevents any air from entering the pleural space.
Health care team roles
The physician is responsible for inserting the chest tube and is usually responsible for its removal. (Some nurse practiced acts allow nurses to remove chest tubes.) The nurse assists with the insertion procedure, assesses the patient's respiratory status afterwards, and maintains a patent chest tube.
KEY TERMS
Atmospheric pressure—The force exerted by air at any point on the earth's surface. Mean atmospheric pressure at sea level is approximately 1,000 millibars (100 kilopascals), give or take 5%.
Empyema—A collection of pus in the pleural space.
Hemothorax—Blood in the pleural cavity, usually caused by a chest injury.
Intrapleural—Situated within the pleura or pleural cavity
Pleura—Thin membrane that covers each half of the thorax, surrounding and protecting the lung on that side.
Pleural cavity—The space within each pleura, which contains the lungs.
Pneumothorax—Air in the pleural cavity, which causes the lung to collapse. Causes include lung disease, penetrating trauma, and certain medical procedures, including ventilation and cardiopulmonary resuscitation.
Valsalva maneuver—Holding the breath while bearing down. This maneuver may be used to interrupt a mild heart arrhythmia or to prevent air from entering the pleural cavity when a chest tube is removed.
BOOKS
Ignatavicius, Donna D., et al. Medical-Surgical Nursing Across the Health Care Continuum. Philadelphia: W.B. Saunders Company, 1999.
PERIODICALS
Blank-Reid, Cynthia A., and Paul C. Reid. "Taking the Tension Out of Traumatic Pneumothoraxes." Nursing 29 (April 1999): 41.
