ATI Closed-Chest Drainage

A nurse is caring for a patient who has a chest tube in place attached to water-seal drainage. What are some normal/expected observations about the drainage if found 5 hr after insertion?

(1) A total of 400 mL since insertion -The nurse should expect 100 to 300 mL of fluid during the first 3 hr after pleural insertion of a chest tube. Since this is 2 hr after that, this amount of drainage is within the expected reference range. (2) A gush of fluid when repositioning the patient -A sudden gush of drainage with a position change is often retained blood and not active bleeding. Unless the total amount exceeds the expected range for this patient at this time, there is no need to report this. (3) A significant decrease in drainage over the past 3 hr -The nurse should expect 100 to 300 mL of fluid during the first 3 hr after pleural chest-tube insertion. It declines after about 2 hr, so this is an expected finding.

What are some expected findings with chest tubes?

(1) Constant bubbling in the suction-control chamber -The nurse should expect constant, gentle bubbling in the suction control chamber. Vigorous bubbling in this chamber can disturb the patient, and it also increases the rate of water evaporation while decreasing the amount of suction. (2) Fluctuations in the fluid level in the water-seal chamber -The nurse should expect to see fluctuation with inspiration and exhalation, as it reflects the expected pressure changes in the pleural space during respiration. Fluctuation stops when the lung has re-expanded, but it can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the suction source is not functioning. (3) Occasional bubbling in the water-seal chamber -The nurse should expect continuous bubbling in the water-seal chamber initially and occasional bubbling after that. The bubbles indicate the removal of air from the pleural space, which is the expected result.

How does a water-seal system work?

-A traditional closed-chest water-deal drainage system regulates the amount of suction by the height of the water in the suction-control chamber, typically applying a suction pressure of -20 cm of water to the pleural cavity -This type of system might not deliver the higher suction pressures this patient requires

What is a Heimlich valve?

-A type of mobile chest drain with a one-way flutter valve that allows air to escape but keeps it from re-entering the chest cavity. -This device is appropriate for a small or partial pneumothorax and does not collect fluid. -It cannot accommodate this patient's need for high suction pressures

What is a pneumostat?

-A type of mobile chest drain with a one-way valve that attaches directly to the chest tube to collect fluid. -This device is appropriate for a small or partial pneumothorax. It cannot accommodate this patient's need for high suction pressures.

How should a nurse evaluate lung re-expansion?

-By auscultating the patient's breath sounds and also by checking various parameters of the system, such as fluctuation in the water-seal chamber.

What should you not do with a drainage system?

Coil the system's tubing, or lay it horizontally across the chair or bed before it drops vertically into the collection chamber and secure it to avoid dislodgement. Be sure the tubing remains below the level of the insertion site. Avoid creating dependent loops, kinks, or pressure on the tubing. Avoid lifting the drainage system above the patient's chest because fluid could flow back into the pleural space. If you see clots in the chest tube, check with the physician about milking the tube. Some facilities discourage this practice, however. Milking the tube involves intermittently compressing it in the area of the clot for 1 to 2 seconds. Do not strip the tubing, as this increases negative pressure within the system to a level that can damage the pleural tissue. Some sources caution that milking can also have this effect.

What should you encourage with a drainage system?

Encourage the patient to cough frequently and breathe deeply to help drain the pleural space and expand the lungs. Sitting upright promotes optimal lung expansion and splinting the insertion site while coughing can help minimize pain. Patients who undergo thoracotomy often splint the arm of the affected side to decrease discomfort. Assess pain frequently and administer analgesia to help the patient tolerate deep breathing, coughing, and range-of-motion exercises. Encourage active or provide passive range-of-motion exercises for the patient's arm on the affected side.

A nurse is planning education for a patient who has a chest tube in place attached to a closed-chest drainage system following surgery for lung cancer. Which of the following should the nurse emphasize to the patient when he is ready to ambulate freely?

Keep the collection device upright at all times -The closed chest drainage system must be upright at all times to ensure that the tubing drains optimally and the system functions correctly

For closed-chest drainage systems with a wet-suction control chamber, what should you do?

aim for gentle bubbling in the suction-control chamber, and be sure to keep the fluid in that chamber at the prescribed level (usually 20 cm). Vigorous bubbling in this chamber can disturb the patient, and it also increases the rate of water evaporation. Periodically check that the air vent in the system is working properly and is not wet or blocked. Occlusion of the air vent prevents drainage and results in a buildup of pressure in the system that could cause a tension pneumothorax.

Subcutaneous emphysema

air in the tissues under the skin that produces a crackling sensation on palpation

Pneumothorax

an accumulation of air or gas in the pleural space

Spontaneous pneumothorax

an accumulation of air or gas in the pleural space that results from a breach in the visceral or parietal pleura with no apparent external trauma

Tension pneumothorax

an accumulation of air or gas in the pleural space that results from a lacerated lung or an opening in the chest wall, often a complication of other types of pneumothorax

Hemothorax

an accumulation of blood in the pleural cavity

Malignant pleural effusion

an accumulation of fluid in the pleural cavity as a result of cancer

Tube occlusion

blockage in a tube

If the system includes a water-seal chamber, what should you do?

check the fluid level regularly because water can evaporate. If necessary, add sterile fluid until the level reaches the 2-cm mark or the level the water-seal chamber gradations indicate. Check for tidaling in the water-seal chamber as the patient breathes. Expect to see 5 to 10 cm (2 to 4 inches) of fluctuation, reflecting pressure changes in the pleural space during respiration. Fluctuation stops when the lung has re-expanded, but it can also stop when the tubing is obstructed or a dependent loop hangs below the rest of the tubing. It can also stop when the suction source is not functioning. Expect continuous bubbling in the water-seal chamber initially and occasional bubbling after that. If you again see constant bubbling, there is probably an air leak.

For systems with dry-suction control, what should you do?

check to verify the correct placement of the dial and the presence of the float ball at the appropriate level in the suction control indicator window. If necessary, adjust the suction source so that the float ball is at the correct level.

Stripping

compressing a chest tube along the length of the tube to help propel clots and debris toward the collection chamber of the drainage system

A nurse is caring for a patient who is 6 hr postoperative and has a chest tube in place attached to a closed-chest water seal drainage system. The nurse should observe for which of the following indications of a problem in the drainage system?

continuous bubbling in the water-seal chamber -Excessive and continuous bubbling in the water seal chamber indicates an air leak in the drainage system. The nurse should use rubber-tipped clamps to try to locate the leak by clamping the tube momentarily at various points along its length.

What should you do if a chest tube is completely dislodged?

cover the site immediately with a sterile gauze dressing. If you can hear air leaking out of the site, make sure the dressing is not occlusive. If it is, it can cause a tension pneumothorax. Stay with the patient and monitor his vital signs while another staff member notifies the physician. Observe for signs of a tension pneumothorax, hypotension, distended jugular veins, absent or decreased breath sounds, tracheal shift, hypoxemia, weak and rapid pulse, dyspnea, tachypnea, diaphoresis, and chest pain. Make sure the equipment for chest-tube insertion and emergency equipment are nearby.

Thoracostomy

creation of an opening in the chest wall to allow drainage through a tube

Tidaling

the rise and fall of fluid within a closed-chest drainage system with inhalation and exhalation

A patient injured in a motor-vehicle crash is transported to an ED. The provider determines the need for immediate thoracotomy and chest-tube insertion and anticipates the need for maximal suction pressure. The appropriate type of closed-chest drainage system for this patient is a:

dry suction-control system -Systems that use dry suction control allow for higher suction pressures by adjusting a dial on the front surface of the system to deliver suction pressure up to -40 cm of water. Some patients need high suction pressures due to a massive air leak from the lung surface, emphysema or viscous pleural effusion, or a reduction in pulmonary compliance

Transudate

fluid that passes through a membrane

A nurse is caring for a patient who has a chest tube in place attached to a closed-chest water-seal drainage system following thoracic surgery. Which of the following strategies should the nurse use to help promote comfort for this patient?

have the patient splint the affected side during coughing -It is essential for a patient with a chest tube to cough, not only to prevent postoperative complications, but also to help drain the pleural space and expand the lungs. Splinting the affected side, such as with a pillow, can help minimize the pain of coughing. The nurse should also administer analgesia to help reduce the pain of coughing and other activities.

Thoracotomy

incision into the pleural space of the chest

Milking

intermittently compressing a chest tube in the area of a clot for 1 to 2 seconds

What should you do when transporting the patient?

keep the drainage device below the patient's chest and disconnect the system from the suction source. Check your facility's policies to see if the physician must first prescribe discontinuing suction for transport. Some closed-chest drainage systems and suction devices contain a vent from the water-seal chamber. This allows the drainage unit to remain vented without suction. Be sure the exit vent is open. Other systems allow air to exit through the suction-control tubing. With these systems, keep the suction-control tubing uncapped and free from occlusion to prevent a buildup of air inside the pleural cavity. Disconnect systems without an exit vent from the suction source before turning it off to prevent a tension pneumothorax. Remind patients who are ambulatory to keep the drainage system below chest level and not to disconnect the tubing. With a suction system, they must stay within range of the length of tubing attached to a wall outlet or portable pump. Typically, the physician will allow patients to disconnect from suction briefly for ambulation; however, check your facility's policies to see if you need a prescription for this.

What should you do after your initial assessment of the patient and the closed-chest drainage system?

note the character, consistency, and amount of drainage in the collection chamber at regular intervals, generally every hour during the first few hours and then at least every 4 hours. Mark the drainage level in the collection chamber by noting the time and date at the drainage level on the outside of the chamber or on tape affixed to the outside of the chamber every 8 hours or more often if the drainage is continuous or copious.

Empyema

pus in the pleural (or other body) cavity

What should you do when a chest tube disconnects from a closed-chest drainage system?

quickly clamp the tube as long as there is no bubbling in the water-seal/air-leak meter. Use a disinfectant to clean the end of the chest tube and the reattachment site and re-establish the connection. If there is bubbling in the water-seal/air-leak meter and your assessment has determined that there is an air leak from the chest, do not clamp the chest tube as this will cause air to accumulate in the pleural cavity with no means of escape. This can rapidly lead to a collapsed lung and tension pneumothorax, a potentially life-threatening event. Instead of clamping the tube, submerge the distal end of the tube in 1 inch of sterile water to create a temporary water seal while you prepare the system for reattachment or replacement.

Thoracic

referring to the chest

Parietal pleura

serous membrane lining the inner surface of the chest wall, the top of the diaphragm, and the mediastinum

Pericardial fluid

serous, lubricating liquid within the pericardial cavity, the space between the layers of the membranes of the pericardium (the fibrous covering that surrounds the heart)

Tracheal deviation

shifting of the trachea (windpipe) to one side

A nurse is assessing a patient who has a chest tube in place attached to a closed-chest water-seal drainage system. When the nurse palpates the area around the chest-tube insertion site, she is checking for

subcutaneous emphysema -Palpating the area surrounding the insertion site helps identify crepitus, a dry, crackling, or grating sound. This is the classic manifestation of subcutaneous emphysema, which indicates that air is leaking into the subcutaneous tissue surrounding the chest-tube insertion site.

Pulsus paradoxus

systolic blood pressure that is more than 10 mm Hg higher during exhalation than during inhalation, a finding with pericardial effusion and cardiac tamponade

Alveolar ventilation

the exchange of gases via the alveoli, often quantified as the volume of air breathed in per minute that reaches the alveoli and takes part in gas exchange

Intrapleural pressure

the pressure (force) within the pleural cavity (the space formed when the pleural layers spread apart) that is normally negative in relation to intra-alveolar pressure

What does milking a chest tube involve?

-Milking the tube involves intermittently compressing it in the area of the clot for 1 to 2 seconds. -This action could increase negative pressure within the system to a level that can damage the pleural tissue.

What are some indications of an obstruction in the chest tube or the drainage system's tubing?

-Visible clots in the tubing and an absence of drainage

Kelly clamp

a medical instrument that resembles scissors but has blunted grips instead of blades and a locking mechanism for use as a hemostat or clamp; also called Kelly forceps

Chyle

a milky, fatty fluid found in lymph in the gastrointestinal tract and transported to the systemic circulation via the thoracic duct

Heimlich valve

a one-way flutter valve through which air can escape from the chest cavity but cannot re-enter it

Pleurodesis

a procedure that involves instilling a chemical agent, such as talc, into the pleural space to trigger an inflammatory response that creates scar tissue, improves adhesion between the pleural layers, and reduces the risk of recurrent pneumothorax

Talc slurry

a thin, watery mixture containing a soft, soapy powder and used for pleurodesis

A nurse is caring for a patient who has a chest tube in place attached to water-seal drainage. Which of the following observations about the drainage should be reported if found 5 hr after insertion?

About 150 mL/hr over the past 2 hours -after the first few hours, the nurse should report drainage that exceeds 70 mL/hr. Patients who lose as much as 100 mL of blood every 15 min might require autotransfusion within 6 hr.

Planning

Enhancing gas exchange and tissue oxygenation are the primary goals of closed-chest drainage. Strategies to optimize ventilation and oxygenation include positioning, pain management, and activity. Unless he cannot tolerate it, position the patient in Fowler's or high Fowler's position while he is in bed. These positions facilitate lung expansion. Develop a schedule for routine position changes to promote drainage and ventilation. Teach the patient to perform deep-breathing exercises and to use incentive spirometry. Assess his pain frequently and observe his ability to participate in deep breathing, incentive spirometry, and activities of daily living. Encourage him to ambulate or to sit in a chair throughout the day. The risks for infection and injury are also primary concerns. Planning should include proper care of the chest-tube insertion site and closed-chest drainage system and patient education. Develop a schedule for dressing changes using surgical asepsis. Collect the required supplies so that they are readily available when you need them. Maintain a closed system by checking the connections of the closed-chest drainage system routinely and teaching the patient how to avoid disconnecting the tubing. Teach him to keep the drainage system below the level of his chest when sitting or ambulating and to keep the chest tube free of kinks and away from objects or situations that might occlude it.

Implementation

Keep the head of bed at 30 degrees or higher. Remind or assist the patient to change position at least every 2 hr. Help him ambulate every 4 to 6 hr during the day when allowed to enhance lung expansion and drainage. Administer pain medication so that he can participate in deep breathing, incentive spirometry, and activities of daily living. Replace the dressing on a regular schedule, or when necessary, using surgical asepsis. Maintain a closed system by securing all connections. Secure the chest tube to the chest wall so that it doesn't dislodge during activity. Prevent kinking or occlusion of the chest tube during activity. Observe the patient during ambulation and activities to ensure that the chest tube remains free of kinks and occlusion

Assessment

Ongoing assessment is essential for monitoring your patient's response to impaired lung function and closed-chest drainage. Assess and document vital signs and respiratory status, including rate, depth, lung sounds, and oxygen saturation. Ask about chest pain and difficulty breathing. Note the patient's level of consciousness, skin color and temperature, and the rate of capillary refill in the extremities. Assess for the presence of pain. If the patient reports pain, assess the pain's severity, location, quality, and any relieving or aggravating factors. Observe the chest-tube insertion site for redness, swelling, pain, and excessive or unusual drainage. Palpate around the dressing site to check for subcutaneous emphysema (air in the tissues under the skin that produces a crackling sensation on palpation). Assess the functioning of the closed-chest drainage system by observing the characteristics and amount of drainage, the patency of the chest tube, tidaling of the fluid in the water-seal chamber, and oscillations within the air leak meter and suction-control chamber. When it is safe for the patient to ambulate, assess his ability to walk unassisted and provide assistive devices to ensure his safety.

Mediastinal chest tube

a tube inserted into the mediastinal space (the space between the right and left thoracic cavity that contains the heart, the mainstem bronchus, the thymus gland, and large blood vessels) to drain blood and fluid after cardiac surgery

Mobile chest drains

Patients who go home with a closed-chest drainage system intact or who require early ambulation can use a mobile chest drain. The Heimlich valve is a one-way flutter valve that allows air to escape but keeps it from re-entering the chest cavity. This device accommodates a small or partial pneumothorax and does not collect fluid. The arrow on the housing of the valve should always point away from the patient and the inner valve should move during exhalation, indicating air flow through the device. Another type of one-way valve attaches directly to the chest tube to collect fluid. Its trade name is the Pneumostat™ chest drain valve, and it is useful for patients with a pneumothorax who have small amounts of fluid. Although there are many different types of drainage systems, they all allow air to exit during exhalation and keep air from entering the pleural cavity during inhalation. The need for a drainage collection chamber or suction-control chamber varies with the patient and the reason for the tube. In any case, it is important to understand and feel comfortable with the equipment so that you can ensure the proper setup and maintenance, monitor the patient's status, and detect and manage any problems that might arise.

Evaluation

Respirations should remain unlabored, with a rate within the expected range. Maintain oxygen saturation above 90% and remind the patient to report any chest pain or dyspnea. Expect lung sounds to be clear bilaterally with a symmetric chest rise on inhalation. The patient's skin should remain pink and warm and have a quick rate of capillary refill. Decide with the patient on a specific pain level that he finds manageable for performing deep breathing, incentive spirometry, and activities of daily living. The chest tube site should remain free of infection. The chest drainage system should function continuously within the closed system. Chest tube drainage should decrease over time. The patient should be able to ambulate and perform activities without complications, and his level of endurance should increase over time.

What is the first thing to manage any complications?

Start by checking the patency of the chest tube and looking for loose connections between the patient and drainage system. Determine if the chest tube is clamped, kinked, or occluded by following the length of the entire tubing. If the tubing has disconnected from the drainage unit, instruct the patient to exhale and cough. This rids the pleural space of as much air as possible. Submerge the end of the chest tube in 1 inch of sterile water until you can cleanse the tips of the tubing and reconnect them quickly. Tighten any loose connections and tape them securely or use a locking plastic tie.

While providing care for a patient who has a chest tube in place attached to a closed-chest drainage system, the nurse accidentally disconnects the chest tube from the system. Which of the following should the nurse do to prevent a serious complication while preparing to reconnect the system?

Submerge the end of the chest tube in 1 inch of sterile water -This action creates a water seal and prevents air from entering the pleural space through the open end of the chest tube when the patient inhales

Maintaining a closed-chest drainage system (general)

The level of monitoring it takes to ensure safety and functioning of a Closed-Chest Drainage system varies with the amount of drainage and with the patient's status, level of activity, and response to closed-chest drainage. For patients who have respiratory or cardiovascular instability or copious amounts of chest-tube drainage, monitor vital signs including oxygen saturation and pain level frequently. Auscultate their breath sounds and observe their color and respiratory effort. Diminished or absent lung sounds generally indicate that the lung hasn't re-expanded. Assess pain and provide analgesia to help optimize the patient's oxygenation and ability to perform activities. Check the chest tube dressing at least every 4 hours. Palpate the area surrounding the dressing for crepitus or subcutaneous emphysema, which indicates that air is leaking into the subcutaneous tissue surrounding the insertion site. If you see drainage on the dressing, note the dimensions of the stain so that you can monitor for additional drainage. Using surgical asepsis, change the dressing over the chest tube site as necessary or according to your facility's policies and procedures.

Water-seal or one-way-valve

The middle chamber is typically for the water seal; it allows air to exit the pleural space on exhalation and keeps air from entering the pleural or mediastinal space on inspiration. When setting up a closed-chest drainage system, follow the manufacturer's directions for filling the water-seal chamber with sterile water or the recommended sterile fluid, typically up to the 2 cm line. To maintain an adequate seal, keep the drainage system upright at all times and make sure the fluid in the water-seal chamber is at the recommended level (because water evaporates). Expect the water level in the water-seal chamber to rise with inhalation and return to baseline with exhalation, called tidaling, but keep in mind that continuous bubbling in the water-seal chamber indicates an air leak. Newer closed-chest drainage system designs include an air-leak meter with numbered columns indicating the degree of air leak. The higher the numbered column that has bubbling, the greater the air leak. The water seal chamber also has a calibrated manometer to measure the amount of negative pressure within the pleural cavity. The water level in the small arm of the water seal rises as the intrapleural pressure becomes more negative. If there is no air leak, the water level should rise with inhalation and fall with exhalation. If the patient is receiving positive-pressure ventilation, the reverse is true: The fluid level falls with inhalation and rises with exhalation. This oscillation indicates a patent chest tube. On some systems, the superior surface has a button to use to release pressure from the system when the negative pressure becomes too high, as indicated by a rising level in the small arm of the water seal. Be careful to release the pressure only when necessary, as this can cause pneumothorax when the pressure within the system is normal. Other closed-chest drainage systems have a one-way valve that replaces the traditional water seal. For these systems, the one-way valve performs the same functions of the water seal. However, it maintains the seal even if the unit is tipped over.

Wet-or-dry suction control

Traditional closed-chest drainage systems regulate the amount of suction by the height of the water in the suction-control chamber, which is typically located on the left side of the system. When setting up the system, fill the suction-control chamber with sterile water or the recommended sterile fluid to the prescribed level: typically the 20-cm mark for adults. That indicates application of a suction pressure of -20 cm water to the pleural cavity. Infants, children, and patients with fragile lung tissue may require lower levels. Connect the suction source to the suction-control chamber and adjust the amount of suction to create gentle bubbling. Note that it is the water level in the suction-control chamber that regulates the amount of suction transmitted to the pleural cavity and not the settings on the suction source. So, monitor the fluid level of the suction-control chamber and replace it as necessary to maintain the appropriate amount of suction. Systems that use dry-suction control allow for higher suction pressure levels, there is no need to replace fluid, and they are quieter because of the absence of continuous bubbling sounds. Instead of using the column of water to control the amount of suction, a self-compensating regulator, or automatic control valve, continuously balances the force of the suction with the atmosphere. This allows the system to respond and adjust to changes in air leaks and fluctuations in the suction source vacuum to deliver accurate suction pressure. Set the dial the front surface of the system to -10, -15, -20, -30, or -40 cm water. Some patients may need a high suction pressure level due to a massive air leak from the lung surface, empyema or viscous pleural effusion, or a reduction in pulmonary compliance. Adjust the suction source until the float ball appears in the suction control indicator window.

What is the optimal position for a patient who has a chest tube?

Upright positioning of a patient with a chest tube allows optimal lung expansion. The nurse should elevate the head of the bed at least 30° and preferably higher

Dependent loop

a coiled section of tubing that hangs lower than the rest of the tubing or system

Oscillation

a flow that changes direction periodically or rhythmically; used to refer to the rise and fall of fluid within a closed-chest drainage system with inhalation and exhalation, also called tidaling

What is second thing to do when managing any complications?

determine whether or not there is an air leak. If you see excessive and continuous bubbling in the water-seal chamber or the air-leak meter, especially if the system is connected to a suction source, look for a leak in the drainage system. Using rubber-tipped clamps, try to locate the leak by clamping the tube momentarily at various points along its length. Begin at the tube's proximal end, near the dressing. Look at the water-seal/air-leak meter chamber. If the bubbling stops, the air leak is at the chest-tube insertion site or inside the chest. Examine the chest-tube insertion site quickly to see if the dressing is loose or the tube is dislodged. If the dressing is loose, air may be entering around the tube as the patient inhales. Palpate around the chest tube site and listen for a crackling sound indicating subcutaneous emphysema, which can result from a poor seal at the chest-tube insertion site. Ask the patient to cough to rid the pleural space of as much air as possible, apply an occlusive dressing or reinforce the dressing if it is intact, and monitor the patient to see if oxygenation improves. The sound of hissing air, a large amount of new drainage at the insertion site, or visibility of the drainage holes at the proximal end of the chest tube suggest that the tube has dislodged. Notify the physician immediately and prepare for another chest-tube insertion. Have emergency equipment (oxygen, resuscitation cart, chest- tube insertion kit) nearby including a flutter (Heimlich) valve or a large-gauge needle for an emergency thoracostomy. If the bubbling continues after you clamp the tube momentarily near the insertion site, place another clamp a little further down the tube about 20 to 30 cm (8 to 12 inches) toward the drainage system and remove the first clamp. Each time you clamp at the more distal location, check the water-seal/air-leak meter chamber. When you place a clamp between the source of the air leak and the water-seal/air-leak meter, the bubbling will stop. That indicates a leak in the tubing distal to the clamp. Replace the tubing or secure the connection and release the clamp. If you clamp along the tube's entire length and the bubbling doesn't stop, the drainage unit might be cracked and you will have to replace it.

A nurse is preparing to transport to radiology a patient who has a chest tube and a closed-chest wet-suction drainage system. The provider allows disconnecting the drainage system from the suction source during transportation. Which of the following must the nurse do when detaching the suction source?

make sure the air vent is open -Some closed chest drainage systems and suction devices contain a vent from the water-seal chamber. This allows the drainage unit to remain vented without suction. -So, the nurse should make sure this exit vent is open when disconnecting the suction source. -Other systems allow air to exit through the suction-control tubing. With these systems, the nurse should keep the suction-control tubing uncapped and free from occlusion to prevent a buildup of air inside the pleural cavity.

Intraparenchymal

within an organ's parenchymal tissue, the functioning cells as opposed to the connective tissue and structural framework, nerves, and blood vessels