Week 10 - Chest Tubes

Pneumothorax

- Air in the pleural space - Can be classified as either spontaneous or traumatic - Most common symptoms are chest pain and dyspnea (SOB) - May hear decreased or no breath sounds - May see lack of movement on affected side - asymmetrical

Heimlich valve

- Can be used in place of a Chest Drainage Unit. - Also a one way valve: fluid and air out. - Connect drainage bag if excess fluid.

What to do if - Drainage unit needs to be changed

- Clamp the tube - Change the unit - Unclamp in no more than 30 seconds.

Clamping of Chest Tubes

- Clamping of chest tubes during transport or when the tube is accidentally disconnected is no longer advocated - There is a danger of rapid accumulation of air in the pleural space, causing tension pneumothorax.

Empyema

- Condition in which pus accumulates in the area between the lungs and the inner surface of the chest wall (pleural space). - Also called pyothorax or purulent pleuritis. - Usually develops after pneumonia.

Tensions Pneumothorax

- EMERGENCY - Occurs when air accumulates in the pleural space more quickly than it can be evacuated. - Quickly becomes life threatening and must be relieved promptly. - Pressure builds up which can: i. Collapse the lung ii. Shift the mediastinum iii. Impede venous return and cardiac output

What to do if - Tube is accidentally removed from the chest

- Emergency situation. - Place gauzes with vaselline to block the whole: occlusive dressing. - Contact HCP.

Pleural Effusion

- Fluid accumulation in the pleural space. - Fluid occupies space the lung would usually fill - Direct compression of lung tissue - Symptoms: muffled or absent breath sounds and dullness to percussion - Can be: i. Pus (empyema) d/t pneumonia ii. Lymph (chylothorax) d/t cancer iii. Blood (hemothorax) iv. Non-specific serous fluid

Chest tube insertion site for Hemothorax

- Hemothorax = Fluid sinks - 4th-5th intercostal space - Midaxillary line - Laterally near the base of the lung.

Iatrogenic Pneumothorax

- Invasive or therapeutic procedures causing a puncture in the lung. - Possible causes: i. Needle aspiration ii. Thoracentesis iii. CVAD (central vascular access device) insertion iv. Patients on positive pressure ventilation with weak lungs

Removing the chest tube - Indications

- Lungs are re-expanded - Fluid drainage has ceased

Rib fracture

- Most common type of chest injury resulting from trauma - Ribs 5 through 10 are most commonly fractured because they are least protected by chest muscles - Clinical manifestations: Pain (especially on inspiration) at the site of injury - Main goal: decrease pain to promote good chest expansion and adequate oxygenation.

Which type of dressing is applied over the chest tube insertion site?

- Occlusive (airtight) dressing: prevents air from entering the pleural space.

When assisting in the removal of the chest tube, what should the nurse instruct the patient to do?

- Perform the Valsalva maneuver: take a deep breath, exhale, and bear down. - Reduces the possibility of air entry into the pleural space.

Indications for a chest tube insertion

- Pneumothorax - Hemothorax

Chest tube insertion site for Pneumothorax

- Pneumothorax = Air rises - Second intercostal space - Midclavicular line - Apex of the lung

Post-operative Pneumothorax

- Post-operative procedures that may disturb the pleural or chest wall: i. Lobectomy or other lung surgeries ii. Lung transplant iii. Heart transplant iv. CABG (coronary artery bypass graft)

Hemothorax

- Presence of blood in the pleural space - Caused by chest trauma where blood vessels can bleed into the pleural space - Iatrogenic hemothorax can occur from complication of CVAD (central venous access device)

Purpose of chest tubes

- Remove air or fluid from the pleural space - Facilitates re-expansion of the lung to restore normal breathing dynamics - Prevent accumulation of fluid around the heart post cardiac surgery

Chest Tubes - Monitoring includes

- Respiratory status - Comfort - Drainage: volume, colour, consistency. - Dressing: clean, dry, intact, secure. - Drainage System: connections, kinks, loops, water-seal chamber for bubbling. - Collection chamber: fluctuation, bubbling. - Patient mobility

Flail chest

- Results from multiple rib fractures, causing instability of the chest wall. - Paradoxical chest movements: during inspiration, the affected portion is sucked in, and during expiration, it bulges out. - Goal of treatment: re-expand the lung and ensure adequate oxygenation. - Interventions: i. Adequate ventilation ii. Administration of humidified O2 iii. IV solutions iv. Pain control

How much drainage should the nurse expect from a chest tube?

- Up to 50 mL/hour of drainage is expected in a client pot-op. - More than 70 to 100 mL/hour = excessive and requires health care provider notification.

Spontaneous Pneumothorax

- Usually caused by rupture of a small bleb - enlarged air sac - on the lung's surface. - Typical patient is tall, thin males who smokes: decreased surface area, stress on the apex of the lung. - Can be a complication of pre-existing lung disease: COPD< emphysema, cystic fibrosis, necrotizing pneumonia.

Traumatic Pneumothorax

1. Blunt trauma - Body struck by blunt object - External injury may appear minor but can mask life-threatening internal injuries 2. Penetrating trauma - Foreign body impales or passes through the body tissues - Stab wound - Bullet wound

Chest Drainage System - 3 parts

1. Collection chamber: fluid drains into the chest tube and into the CDU's (Chest Drainage Unit) collection chamber. 2. Water-seal chamber: one way valve; air can drain from the chest cavity but can't go back into the patient. 3. Suction control regulator: attaches to wall suction.

Tensions Pneumothorax - Signs and Symptoms

1. Initial or mild: - Mild tachycardia and dyspnea 2. Late or major: - Respiratory distress, including shallow, rapid respirations - Dyspnea - Air hunger - Decreased oxygen saturation

Catheter size for chest tubes - Pneumothorax or Serous Drainage

16-24 French

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? 1. Serous 2. Bloody 3. Serosanguineous 4.Bloody, with frequent small clots

2. Bloody In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

Catheter size for chest tubes - Hemothorax or Empyema

28-36 French

Where should the drainage system be positioned?

Below the client's chest: allows gravity to drain the pleural space.

Where can a sample of the drainage be obtained from?

From a port in the unit: sterile sample.

Milking or Stripping

No longer recommended because it can cause dangerously high intrapleural pressure and damage to pleural tissue.

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take?

Place the tube in a bottle of sterile water.