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Chest tube nursing care and placement is common procedure in many hospitals, yet nurses consistently rank them as one of the most overwhelming drains to care for.

A malfunction in a chest tube can be deadly for a patient in a matter of minutes. Many hospitals have recognized them as a common source of error and patient harm. For these reasons it is imperative that nurses understand how chest tubes function and how to care for them. In this course we will discuss the anatomy, indications, and care of chest tubes.

Introduction   

The ancient Greeks were the first to record techniques used to drain the pleural space (1). Though the process and equipment have evolved over the centuries, the basic principles  of chest tubes nursing care have not changed (1). Today, thoracostomy tube (more commonly known as a chest tube) placement continues to be a very common procedure.

Chest tubes are utilized for a variety of reasons, ranging from emergent placement to routine use after an elective surgery (1). They can be placed just about anywhere– the bedside, the operating room (OR), and interventional radiology.

Most nurses will encounter chest tubes at some point during their career– perhaps frequently, depending on where you work. Thus, it is essential for nursing staff to feel comfortable with chest tube management. Unfortunately, like anything else in healthcare, chest tubes are at risk for complication. Chest tubes nursing care is critical to overall health. Quick identification of potential complications could be the difference between life and death. This course aims to expand your knowledge and increase confidence in chest tube management.

Chest Tubes Nursing Care Basics – What Is a Chest Tube?

Licensed and retrieved from Adobe Stock

Let’s start with a quick refresher on the structure of our lungs. First comes skin (obviously). Beneath that is a layer of subcutaneous tissue, followed by muscle. Then we come to the ribs, which form the basic protective cage that holds our lungs, heart, and some very important blood vessels. Between each rib from top to bottom is a vein, artery, nerve, and more muscle (2). Behind the ribs lies the first layer of the pleural space, called the parietal pleura (2).

This membrane lines the entire chest cavity. Then comes the pleural space, which measures about 15-20 microns wide in its normal state (2). On the other side of the pleural space lies the visceral pleura, which is a membrane that covers the lungs, and then finally the lungs themselves (2).

What this means is that in a normal person, a small potential space exists between the lungs and the chest cavity, called the pleural space. When the pleural space becomes compromised and fills with extra fluid or air, the precarious negative pressure balance that keeps the lungs inflated is disrupted, forcing lung tissue to collapse.

A chest tube comes to the rescue. Known officially as a thoracostomy tube, the chest tube is a hollow plastic tube that is carefully placed by a licensed provider. The tube is driven through the outer skin and muscle, between two ribs and past the parietal pleura to rest inside the pleural space.

Its purpose is to drain the excess fluid or air out of the pleural space so the affected lung can reinflate. The tube is attached to a drainage system to facilitate the movement of the abnormal fluid/air out of the pleural space. The tube remains in place until the fluid/air is removed, the lung is reinflated, or becomes nonfunctional (3). 

According to chest tube nursing care experts, chest tubes are generally divided into three categories based on size and method of insertion: large bore, small bore, and tunneled.

Large Bore (Blunt Dissection Technique)

Generally greater than 20Fr in size, large bore chest tubes are placed using the blunt dissection technique (3). A quick aside here: the size “Fr” refers to “French” or the actual french word “Charrière”, which is the name of the frenchman who invented the sizing (3). The sizing is based on the diameter of a tube, with 1Fr = ⅓ mm (for example, a 12Fr tube is 4mm, 12÷3=4).

The blunt dissection technique requires a skin incision large enough to fit a finger (3). A clamp or forceps is used to bluntly dissect intercostal tissues. The tube is inserted and held in place with heavy suturing (3). This technique is more invasive. It also comes with some risks, including damage to surrounding structures, tube misplacement, bleeding, and increased pain.

Small Bore (Seldinger Technique)

Small bore chest tubes are generally less than 14Fr in size. They are placed using the Seldinger technique, which involves using an introducer needle to get access into the pleural space (3). A guidewire is threaded through the needle and the needle is removed. Then the chest tube is threaded over the wire and the wire is pulled out, leaving only the chest tube. The tube is held in place with a suture and/or adhesive dressing. Advantages include a smaller incision, less pain, and it’s less invasive (3). Conversely, they are more prone to blockage because they are smaller (3).

The decision to use a small or large bore chest tube is made by the provider. For the treatment of most pneumothoraces, research shows that small bore chest tubes are as effective as larger tubes and may be less painful (4). Large bore tubes are recommended to treat traumatic pneumothorax due to the need for removal of blood and air (4). In the past, providers used large bore chest tubes to drain thick fluid like blood and pus, but more recent research suggests that small bore chest tubes are also effective if they remain patent and are properly maintained (4).

Tunneled (Indwelling)

(Retrieved from Cleveland Clinic Journal of Medicine, 2016)

Indwelling chest tubes are indicated for long-term chest drainage, primarily as a treatment for malignant pleural effusion (3). These tubes consist of a special catheter equipped with a cuff that remains under the skin and acts as an infection barrier (3). The Seldinger technique is used to get access into the pleural space, along with a “peel-away” dilator that allows the tube to be tunneled under the skin. Two small incisions are required for placement. A special vacuum bottle is attached periodically to collect the drainage (3).

Current Practice in Chest Tubes Nursing Care

Bedside chest tube placement has become increasingly routine. Thus, bedside nursing staff may be directly involved with the initial chest tube placement (5). 

The nurse may be asked to gather the necessary supplies for placement, ensure patient consent is obtained, and assist with patient education regarding the procedure (5). The nurse may assist the provider during the procedure by participating in a pre-procedure “time-out” and monitoring the patient’s vital signs, comfort, and response to the procedure. Afterward, the provider will order a chest x-ray to verify placement and to confirm the absence of complications from the chest tube insertion. As always, the nursing staff is responsible for ensuring any post-procedure orders are carried out.  

Once the chest tube is in place, verified by x-ray, and attached to a drainage device, nurses are tasked with monitoring the patient and the drainage device. This would include monitoring vital signs as directed, observing for pain and signs of infection, and assessing the tube and drain system (5). An important part of monitoring includes recording the amount and color of chest drainage. How often this is done depends on nursing judgement, facility policy and the provider’s written orders.  

Perhaps the most intimidating aspect of chest tube management is ensuring proper function. It is the nurse’s job to look for signs that there may be a problem. Rest assured, these signs and symptoms will be discussed in detail later in the course.  

There will also be orders for the nurse to change any dressings and provide necessary wound care. This includes routine observation of the chest tube insertion site. Depending on how long the chest tube is in place, nurses may also have to change out the drainage system if it becomes full of fluid.  

Patients with chest tubes may ambulate, if appropriate, and travel to other departments within the hospital for other procedures. Chest tubes nursing care staff (most nurses) are responsible for ensuring the chest tube is properly packed up and stowed away for every adventure. This includes removing the chest tube from suction if suction is ordered and leaving the drainage system lower than the patient’s chest. Remember, it’s okay, the water seal will keep anything from entering the patient during transport and/or the procedure. 

Indications for Chest Tube Placement

A chest tube may be indicated for the following reasons: pneumothorax/hemothorax, pleural effusion, empyema, chylothorax, and post-operatively after cardiac/thoracic surgery (1).

Pneumothorax/Hemothorax

A pneumothorax, also known as a “lung collapse”, occurs when the normal negative pressure gradient within the lungs is compromised (6). Air is introduced into the pleural space where it is not welcome. A pathway to the pleural space may form on the inside of the body when lung tissue is damaged. The connection typically forms at the airway or alveoli (the little air sacs in the lungs that encourage gas exchange) (6).

For example, a patient with COPD or chronic bronchitis may develop enlarged, weakend alveoli called blebs that are prone to rupture. When this happens, air flows into the pleural space because of the difference in pressure, forcing the lung tissue to shrink or collapse in response to the expanding pleural space (6).

A pneumothorax may also occur from an outside source if an abnormal connection forms between the pleural space and the chest wall (6). For example, during a lung biopsy, a needle is introduced into the lungs from the outside. Sometimes a pathway forms, allowing air from the environment to flow into the chest. In an attempt to equalize the pressure, air rushes into the pleural space.

A pneumothorax may also be spontaneous in a condition known as primary spontaneous pneumothorax (PSP) (6). PSP usually occurs in tall, thin young men between the ages of 10-30 (6). The risk is significantly increased with current or past smoking (6).

Finally, a hemothorax is diagnosed when blood becomes trapped within the pleural space. It often occurs with pneumothorax. Hemothorax may result from trauma, abnormal coagulation, spontaneously, or after certain medical treatments (such as a biopsy) (7).

Symptoms of pneumothorax and hemothorax include acute chest pain and shortness of breath (dyspnea). The pain may be worse during inhalation and localized to the affected side (6). The degree of dyspnea is often proportional to the size of pneumothorax (bigger pneumo = more pain), but not always- a small percentage of people are asymptomatic (6).

Licensed and retrieved from Adobe Stock

Pleural Effusion

In a healthy person, the pleural space contains a small amount of serous fluid (about 5-10 ml) that is secreted by the parietal pleura and reabsorbed by the lymphatic system (8). When this carefully balanced system is disrupted, extra fluid can accumulate, known as a pleural effusion.

Pleural effusion is the result of leaky capillaries. Capillaries leak for two reasons: changes in pressure or damage to the vessels themselves (8). Congestive heart failure and cirrhosis are the two most common causes of pressure changes. Capillary damage is most commonly caused by pneumonia, pulmonary embolism, cancer, and GI disease (8).

Pleural effusion in the pediatric population usually stems from congenital heart disease, pneumonia, and cancer (8).

 Large right-sided pleural effusion Licensed and retrieved from Adobe Stock

Empyema

Empyema is the development of infected, purulent fluid inside the pleural space (8). Pneumonia is the usual suspect, but empyema can also form from a lung abscess, bronchopleural fistula (an abnormal tract/pathway between the bronchus and the pleural space), esophageal perforation, or complications of trauma and surgery (8).

The development of empyema may begin with just a small amount of extra, sterile fluid that accumulates in the pleural space (8). When an infectious agent is introduced, inflammation brings white blood cells and even more fluid. Eventually, the infected material can grow into the pleural walls and cause tissue thickening, prohibiting lung expansion (8).

Purulent drainage associated with empyema can be thick and therefore difficult to drain. Fibrinolytics (medicines that dissolve blood clots) can be directly administered through the chest tube into the pocket of infection to help break it down and improve drainage (2). tPA is the medication of choice. A small amount of tPA is diluted in saline and infused through the chest tube, which is clamped for a while (1-2 hours) before drainage is resumed (2). The dose may be repeated if necessary.

Symptoms for pleural effusion and empyema include dyspnea, pleuritic chest pain, cough, fever & chills if infection is present, and weight loss. If a large volume of fluid collects, cardiac function may be impaired: the heart cannot pump effectively if there is no room (8).

Post-Operative

Chest tubes are often placed after heart or lung surgery because of the risk for developing pleural effusion or pneumothorax during recovery. They are inserted while the patient is still sedated prior to leaving the operating room.

In chest tubes nursing care, chest tubes are routinely placed following open heart surgery, including cardiac bypass and valve replacements. They are also indicated in major thoracic surgeries, such as pneumonectomy, lobectomy, lung transplants, segmentectomy, and wedge resection.

Patients with chest trauma may require a chest tube in the presence of pneumothorax or hemothorax.

Patient Considerations for Chest Tubes Nursing Care

When considering chest tube placement, it is important to evaluate the patient. Because the indications for chest tubes range from routine post-op care to life threatening emergency, the presentation of these patients varies significantly. In all cases, patient or family consent is paramount and should be obtained prior to the procedure.

The only exception to this is a true emergency, the process for which is outlined in your facility’s policies (all the more reason to be familiar with policy!).

Contraindications in chest tube placement should be considered as part of a risk/benefit analysis. For example, there are no contraindications for using chest tubes in the treatment of tension pneumothorax (1).

Tension pneumothorax is a medical emergency. It occurs when a pneumothorax or hemothorax becomes so severe that air can no longer escape from the pleural space. The pressure increases within the chest and forces the mediastinum (heart, great vessels, etc.) to shift out of the way, compressing the remaining unaffected lung.

These patients are at high risk of going into shock or cardiac arrest. Signs and symptoms of tension pneumothorax include decreased breath sounds, hypotension, tachycardia, hypoxia, and tracheal deviation to the contralateral side of tension pneumothorax (16). A tension pneumothorax can be diagnosed from a bedside ultrasound or chest x-ray (16).  

Relative contraindications to chest tube placement include abnormal coagulation or infection at the insertion site (2). Abnormal coagulation puts the patient at higher risk of bleeding. The parameters for placement will vary between facilities, but generally speaking, prospective patients should have an INR < 1.5 and platelets > 50,000 (2).

Infection at or near the insertion site increases the risk of infection in the chest cavity (3). In many cases, an alternate insertion site is available and should be utilized. For patients seeking elective or semi-elective chest tube placement, these relative contraindications should be resolved prior to placement, if possible.

A chest tube is considered elective if the patient is stable. The American College of Chest Physicians (ACCP) guidelines state that a patient is clinically stable with a respiratory rate less than 24 breaths/min, pulse rate 60-120 beats/min, normal blood pressure, and oxygen saturation greater than 90% on room air (6).

The ACCP recommends that all patients with a large pneumothorax (great than 3 cm apical length) get a chest tube (6). Ultimately, the ordering provider will decide if a patient requires a chest tube as an elective procedure or an emergency.

Potential Complications

When preparing a patient for chest tube placement, it is important to be aware of potential complications. Chest tubes can be lifesavers but they are not without risk: when placed at the bedside or during an emergency, it is essentially a blind procedure.

Injury to Surrounding Structures

Gastrointestinal Tract. Although rare, it is possible to for chest tubes to be placed beneath the diaphragm into the abdominal cavity. Insertion into the abdominal cavity poses risk for injury of the stomach, bowel, liver, spleen and other abdominal structures (1).

Though the overall risk is <1%, a third of all chest tubes that find their way into the abdomen result in injury to the patient (1). Signs of abdominal placement include the presence of stomach contents within the tube or peritonitis (1). An x-ray would confirm that the chest tube is located below the diaphragm. Inserting the chest tube no lower than the 5th intercostal space helps prevent this problem (1).

Diaphragm. Many chest tubes are placed at the bedside without imaging guidance. Improper placement poses a risk for injury to the diaphragm (1). Laceration, perforation, and muscle injury are the most common injuries (1). Certain conditions increase the risk of diaphragmatic injury, including diaphragm paralysis, late pregnancy, obesity, ascites, and abdominal tumors (1).

Lungs. The lungs are at highest risk of injury during chest tube placement, especially if a patient suffers from decreased lung compliance or pleural adhesions (1). Lung injury is commonly missed because it cannot be visualized on imaging and patients may be asymptomatic (1).

A rare complication of chest tube placement is infarction of the lung. Excessive suction causes aspiration of lung tissue into the chest tube, leading to infarction and tissue death (1). Providers must also beware of lung perforation and accidentally puncturing the pulmonary artery (as evidenced by rapid blood loss, massive hemoptysis, shortness of breath, tachycardia and hypotension) (1).

Cardiac Structures. If the chest tube is advanced too far, the tip may rest too close to the mediastinum, resulting in compression of nearby structures (1). Although rare, it can lead to hemodynamic instability (1). There have also been cases of penetration of cardiac structures.

Other Potential Complications 

Pain- Some pain is associated with chest tube placement. At the very least, providers will provide local anesthetic to numb the area while the tube is inserted. Sometimes, patients are also given IV pain medicine or sedation during placement. Patients may also experience pain while the chest tube is in place, so providers will often prescribe PRN analgesia to improve comfort. Some studies have suggested that large bore chest tubes are generally more painful than smaller ones (4). Remember to encourage mobility. A patient’s pain will need to assessed, managed, and controlled.

Fistula- Bronchopleural fistula is both an indication for and potential complication of chest tube placement (1). A fistula is an abnormal pathway or tract that forms between two structures, in this case between the pleural space and the bronchial tree. A chest tube may benefit a patient if a bronchopleural fistula already exists (1). However, if a fistula forms as a result of the chest tube itself, it is associated with high morbidity and mortality (1). Patient symptoms of fistula include dyspnea, hypotension, cough, and persistent air leak (1). Timely chest tube removal can help prevent the formation of a fistula because it limits tube erosion (1).

Bleeding- Providers must be careful when placing chest tubes because the space between each rib contains a vein, artery, and nerve (1). Although rare, cases of hemorrhage and death have been reported as a result of chest tube placement. Luckily, abnormal bleeding is usually apparent right away. However, early diagnosis can be missed if the tube compresses the artery in such a way that it prevents any bleeding while in place (3).

Recurrent Pneumothorax- One of the worst complications is recurrent pneumothorax, simply because it means the chest tube has failed. A new pneumothorax is more likely to occur when the tube is pulled too early and the lung has not properly re-expanded (1). It can also be caused by an air leak or if air enters the pleural space during tube removal (1). If the recurrent pneumothorax is small and the patient is asymptomatic, it can typically be managed with follow-up imaging and close observation. Otherwise, the chest tube will have to be reinserted. 

Chest Tubes Nursing Care Basics – Where Are Chest Tubes Placed?

As previously mentioned, there are several different techniques used to place chest tubes: the blunt dissection technique for large bore tubes, Seldinger technique for small bore tubes, and the Seldinger technique with a peel-away dilator for tunneled chest tubes. Interestingly, these chest tube techniques can be performed just about anywhere: the OR, IR, and the patient’s bedside.

Operating Room

Chest tubes are usually placed in the OR after cardiothoracic surgery. The tube should be positioned no lower than the 5th intercostal space along the midaxillary line to avoid injury to the diaphragm (1). The second intercostal space at the midclavicular line is an alternate site. However, it is never the first choice because the tube must be driven through the pectoralis muscle (ouch) and it is more likely to produce an ugly scar (3).

Mediastinal chest tubes are commonly placed after cardiac surgery to facilitate drainage of blood and other fluid from the pericardial and pleural spaces (1). The goal is to prevent cardiac tamponade and pleural effusion. These tubes are easy to identify because they emerge from the mediastinum.

Interventional Radiology (IR)

Interventionalists have the advantage of using imaging to assist with chest tube placement. Ultrasound, CT and fluoroscopy (live x-ray) may be used. Imaging allows the provider to observe the chest tube as it enters the body, which helps ensure proper placement.

When placing a chest tube for the treatment of pneumothorax, the provider often uses fluoroscopy for guidance. The pneumothorax is visualized on the monitor while the tube is positioned. Using the Seldinger technique, the final catheter is threaded over the wire to rest in the pleural space.

Interventional radiologists are commonly enlisted to place drainage tubes for the management of empyema or lung infection (8). CT is the modality of choice because it allows better visualization of surrounding structures than fluoroscopy. The provider will take frequent CT scans while a wire is guided into place, then thread the catheter over the wire into the infection (8). Small bore tubes have been shown to be effective in the drainage of thicker fluids, like pus (4).

Finally, approximately 50% of cancer patients develop malignant pleural effusion (8). Malignant pleural effusion is recurrent, usually due to diseased pleura, obstructed lymph channels, or atelectasis (8). Breast, lung, lymphoma, ovarian, and gastric cancers have been known to cause malignant effusion (8). At first, these recurrent effusions may be treated with thoracentesis, a procedure in which the interventional radiologist positions a small catheter into the pleural space, where it remains temporarily to allow pleural fluid to drain. After drainage has ceased, the catheter is removed and a dressing is applied.

Over time, malignant effusions require drainage more frequently, which can be hard on the patient (8). Thoracentesis provides only short term relief of symptoms. Tunneled chest tubes are a more long term alternative for malignant pleural effusion. The catheter contains a special cuff and is tunneled under the skin to minimize the risk of infection. Prior to placement, the interventional radiologist will use ultrasound to locate the effusion.

Bedside

Providers often insert chest tubes at the bedside. After discussing the risks and benefits of the procedure with the patient, providers should obtain informed consent. Nursing staff would be required to assemble the appropriate supplies and be available to assist as needed. Full aseptic technique is required, so medical staff should wear gowns, gloves, masks and use sterile drapes (3).

Chest tube insertion is made much simpler if the patient is positioned appropriately. The head of the bed should be raised to 45-60 degrees with the patient resting in the supine position and slightly rotated. The ipsilateral arm is placed behind the neck or head so it is out of the way, providing easy access to the chest (ipsilateral meaning “same side”).

For posterior fluid collections, the patient should sit on the side of the bed with the provider standing behind (3). The position can be made more comfortable by allowing the patient to rest his or her arms upon a side table. Bedside ultrasound will allow the provider to visualize any fluid collections.

Note: In all cases, post-procedure x-ray is required as soon as possible to confirm chest tube placement and to verify the presence or absence of complications from the insertion. 

Large Right-Sided Pneumothorax

Notice the lack of parenchymal (lung) markings on your left side. Remember that chest radiographs are flipped, thus this is the patient’s right side. This lack of lung marking is due to a pneumothorax- thus the lung is compressed by air in the pleural space. 

Licensed and retrieved from Adobe Stock

Chest Tube Drainage Systems

After a chest tube is in place, it must be attached to a drainage system to facilitate the removal of excess fluid and promote lung reinflation. There are four basic types of drainage systems: Heimlich valves, three-compartment systems, digital systems, and vacuum bottles.

Heimlich Valve

A Heimlich valve is a one-way valve shaped a bit like a thin cylinder that attaches to the distal end of the chest tube. It is called a one-way valve because air is permitted to flow only one direction: out.

The valve itself is composed of a rubber flutter that occludes with inspiration to prevent air from entering the chest. The flutter opens during exhalation to allow the trapped air to escape the pleural space. The pneumothorax shrinks slowly over time with each breath. Heimlich valves are more commonly used for ambulatory patients when suction is not required (3). Its small size allows patients to move freely. Figure 1 is an example of a Heimlich valve (11).

(Figure 1)

Three-Compartment System

The most commonly used drainage systems are three-compartment systems, such as Atrium® and Pleur-evac®.

Like the name suggests, they contain three interconnected chambers: the collection chamber, water seal chamber, and a suction chamber. The collection chamber fills with air or fluid that drains from the chest tube. The water seal uses a column of water to prevent air from flowing into the pleural space with inhalation (3). Finally, the suction chamber allows the provider to adjust the level of suction against the chest tube.

If needed, the drainage system is attached to a wall regulator to apply active suction (3). Alternatively, these drainage systems can also be set to drain by gravity if the device is positioned below the chest (3). These drain systems require careful observation for air leaks. Figure two is a drawing of a three-compartment system (11).

Figure 2: Drainage system

Digital Drain System

A more modern approach to chest tube management, digital systems use a computer to monitor drainage, air leaks, and pleural pressure (3). All measurements are calculated internally and displayed on a screen. They do not require wall suction, so patients may ambulate with ease (3). Because they are more compact and basically manage themselves, some patients are discharged with their chest tube in place, resulting in shorter hospital stays overall (3). Digital systems are typically used for patients who develop a pneumothorax after thoracic surgery.

Vacuum Bottle

Remember, tunneled catheters are commonly used to drain recurrent pleural effusions associated with malignancy. Instead of constant suction and drainage, pleural fluid is allowed to accumulate and then drained periodically as needed. Frequency of drainage ranges from occasionally to multiple times a week. The tunneled catheters are equipped with a special one-way valve that opens and drains when a vacuum bottle is attached (3).

Nurse Roles and Responsibilities: How to Manage Chest Tubes

It is the responsibility of the nursing staff to monitor chest tubes and report any potential malfunction. Because chest tube patients may reside in virtually any hospital department (or even as an outpatient), it is essential that nurses feel comfortable around them. Chest tube management includes observing and maintaining the insertion site, recording output, and managing the drainage system.

Observe the Patient

Perhaps most importantly, the nurse should observe the patient. Check vital signs as ordered by the provider or facility policy. Assess for pain. Some discomfort is expected after chest tube placement. Provide pain medicine as needed. Auscultate breath sounds frequently and encourage deep breathing, especially during the post-procedure period. Diminished breath sounds, changes in vital signs and increased work of breathing could indicate the re-accumulation of air or fluid in the pleural space.

Maintain the Insertion Site. Chest tubes are commonly sutured to the skin to hold the tube in place. The insertion site is covered with a dressing to protect the area. Dressing changes occur as ordered by the provider or are dictated by facility policy. Most chest tubes require an occlusive dressing, meaning the dressing should adequately cover the site and be well-secured, which reduces the risk of developing an air leak (1). Expect to change the dressing if it becomes soiled. Chest tubes nursing care nurses should observe the insertion site frequently for signs of infection, including fever, redness at or around the site, swelling, warmth, and purulent drainage.

Although they are sutured in place, there is a risk for dislodging the chest tube if it is pulled too hard. Securing the tube to the patient’s side with a piece of tape is one way to reduce the risk of dislodgement (9). Advise the patient to ask for help when getting out of bed.

Record Output. The nursing staff is also in charge of observing and recording chest tube output. The frequency of recording the output is dictated by nursing judgment and written orders from the provider or facility policy. Drainage fluid is often bloody, serosanguinous (pink), or purulent, depending on the reason it was inserted. Whatever the color, it should lighten in color and lessen its drainage amount over time. The most common type of drainage system is the three-compartment system, such as the Pleur-evac® or Atrium®. All drainage is contained within this system, meaning the container cannot be emptied. Instructions vary between facilities, but it is common practice to document the amount of drainage directly onto the container by marking the level of output with a pen or marker. When full, the drain system is removed and a new, clean one is attached. Check your facility policy of when to call the physician for excessive drainage. Always call the physician for excess drainage when there is a change in the patient’s vitals signs or signs of a worsening condition. 

Manage Drain Systems

Heimlich Valve. Nurses should assess that the Heimlich valve is securely attached to the distal end of the chest tube. The one-way flutter valve allows air to leave the chest but prevents air from seeping back inside. It does not require suction, so the patient may move around freely. Heimlich valves do not possess a true collection chamber, rather, any drainage will freely leak from the distal end of the valve. Thus, the Heimlich valve is not the system of choice for patients with significant drainage.

Three-Compartment System. Again, these are the most commonly used systems. They should be positioned below the patient’s chest at all times. The nurse is responsible for monitoring the three compartments: collection chamber, water seal, and suction. As discussed above, the nurse will simply document the drainage any drainage that collects in the collection chamber.

The water seal serves two functions: to prevent outside air from flowing into the chest and the detection of air leaks. An air leak within a chest tube may indicate a serious problem. The water seal should be easy to find. When the water seal is functioning correctly, the water level will fluctuate (rise and fall) with breathing. If the nurse observes intermittent or constant bubbling within the water seal, an air leak is present (1). The most severe type of leak is a continuous air leak which is observed throughout the entire respiratory cycle. All air leaks need to be reported to the physician immediately and the patient needs to be reassessed for further signs of respiratory distress. Digital draining systems are able to quantity the leak and display dynamic real-time pleural pressures (12). A persistent air leak can be caused by either an alveolar-pleural fistula or bronchopleural fistula (12). 

Chest tubes often require suction to help gently pull excess fluid and air from the body. Three-compartment systems are equipped with a dial that allows staff to set the level of suction, usually between 0 and -40 cm H2O. The provider’s orders or facility policy will dictate the level at which suction should be set. Part of the nurse’s assessment is verifying that the suction dial is set correctly. Additionally, nursing staff should check that the suction tubing is connected securely to the wall suction regulator.

Digital Drain System. Thanks to technology, digital drain systems are pretty easy to manage. The device collects and displays all of its data to the nurse, including the amount of drainage, intrapleural pressure, and the presence of any air leak. It simply needs to be recorded.

Tunneled Catheters. Tunneled catheters should be clamped unless they are being drained. These catheters contain a one-way valve that will not open unless a vacuum bottle is attached. Tunneled catheters are usually managed at home by a willing family member or trained home health provider, thus the patient and family may require extensive education prior to discharge.

Clamping the Tube. With the exception of tunneled catheters, as a general rule, chest tubes should not be clamped unless it is necessary to replace the drain system or it is ordered by the provider (9). If an air leak is present, a clamped tube can lead to tension pneumothorax (9). There is no need to clamp a chest tube during patient transportation or ambulation. If the drainage system is positioned below the chest as indicated, it will continue to drain with gravity after suction is turned off (9).

Chest Tubes Nursing Care Troubleshooting: When to Call the Doctor

Like anything else, chest tubes are prone to complications. It is essential for nurses to be able to identify a malfunctioning tube quickly and know when to alert the provider. A worsening pneumothorax can lead to a longer hospital stay for the patient, or at worst tension pneumothorax and death.

Tube/Drain Malfunction

Chest tubes should be assessed regularly by nursing staff. The chest tube must be well-connected to the drainage system and wall suction (if necessary). If the chest tube becomes disconnected from the drainage system, the two ends should be cleaned well with an antiseptic, like alcohol pads, prior to being reconnected (1). You can also stick the open end of the chest tube into a bottle of sterile water or saline to quickly create a water seal (13). Do not clamp the tube in case there is an air leak, as the patient could develop a tension pneumothorax (1). If the tube is completely pulled out from the patients’ chest, immediately apply pressure and apply a sterile petroleum impregnated gauze over the site and call the physician immediately (13). 

Infection. Infection is always a risk when a foreign body is present. Because chest tubes allow direct access into the chest cavity, it is essential to watch closely for any signs of infection. Infection may develop at the insertion site or inside the chest cavity (empyema/abscess).

Signs of infection at the insertion site include fever, redness, swelling, warmth, or purulent drainage. The site needs to be kept clean and soiled dressings should be replaced quickly and efficiently.

Chest tube patients that also have pleural effusions are at higher risk of developing empyema (1). Chest tubes are considered a “clean contaminated” procedure, meaning the chest cavity is accessed cleanly, but a risk for contamination remains as long as the tube is in place (1). The risk of empyema after chest tube insertion is as high as 25% in some populations. A nurse might suspect the development of empyema/abscess if the patient exhibits symptoms of infection: fever, tachycardia, respiratory distress and purulent drainage from the chest tube. A prompt call to the provider is warranted.

Kinks & Clots. The smaller the chest tube, the more likely it is to become clogged or kinked. Sometimes it is easy to spot a problem with a simple inspection of the entire apparatus. Pay particular attention to areas of the tubing covered with tape, such as the insertion site or taped connections. Straighten out the the tubing when patients are lying in bed or sitting in the chair.

Pay close attention to the drainage system. A digital system or three-compartment syndrome will alert you if there is a problem. A digital system will literally sound the alarm in the event of a kink or clot because it monitors pressures. Three-compartment systems are not fitted with alarms, so they require closer observation to detect an issue. Earlier, it was mentioned that it is normal for the water seal in three-compartment systems to fluctuate with breathing or coughing.

Note: If the water seal is not fluctuating with breath, you may have a kink or clot. The water seal is not fluctuating because the tube cannot drain past the blockage.

Kinks are easy to fix: simply straighten out the tube or resolve kinked connections. Clots can be a little more difficult to handle. Luckily, ⅔ of clots resolve themselves (1). Historically, providers have used techniques such as milking or stripping the tube to help remove clots. The use of these procedures is questionable. Prophylactic milking/stripping has not shown any tendency to prevent clots from forming (1). Also, these techniques have actually been shown to cause harm by increasing pressure within the pleural cavity, resulting in increased bleeding, tissue entrapment, and dysfunction of the left ventricle (1). Thus, tube milking and stripping should probably be avoided altogether.

What do you do if you see a clot then? If the clot is located in the drain system tubing, simply replace the system. Attach a new Pleur-evac® or Atrium® system and remove the affected tubing. If that doesn’t resolve the problem, notify the provider. Chest tubes can also become kinked inside of the patient, so the provider may order a chest x-ray to confirm proper tube placement (2).

Loss of Suction. Ensure that the drain tubing is securely attached to the wall suction regulator and that the tubing is unclamped. The regulator should be turned on. Check that the suction dial on the drain system is set to the appropriate suction setting and that the suction is continuous, not intermittent. If all connections are appropriate, the wall regulator or drain system is malfunctioning and should be replaced. Maintaining appropriate suction is critical, as too little suction will prevent lung re-expansion, while too much suction can damage lung tissue (9). 

Drain System Malfunction. The best course of action is to replace the drain system and re-assess the problem. If it was truly an issue with the drain system it should resolve by replacing it.

Air Leak

The easiest way to assess for an air leak is to observe the drainage system. Again, a digital system will alarm if it detects a problem. With a three-compartment system, an air leak will cause intermittent or constant bubbling within air-leak detection compartment of the water seal. Air leaks are a concern because they allow air to flow back into the pleural space (1). The whole point of the chest tube is to get the air out of the chest. Air leaks can occur in a couple places: at the insertion site or within the tubing/drain system (1).

If an air leak is observed in the water seal chamber, the next step is to find out where it is coming from. This is one case where clamping the tube (temporarily, of course) can help diagnose a problem. First, clamp the tube close to the patient (10). If bubbling within the water seal continues, this means there is a leak in the tubing or drain system. Although made of strong material, these drain systems are not infallible. Tubing can be cut or damaged accidentally, and it may not be easy to spot. Assess the tubing for cuts or holes. Ensure all connections are secure, as loose connections are an easy way for air to sneak inside. Replace the drain system if the tubing or container is damaged.

On the other hand, if you clamp the tube and the air leak disappears from the water seal, this means air is leaking near the patient (10). In this case, the leak stems from the insertion site or somewhere inside the chest (10). An air leak at the insertion site occurs because the dressing is insufficient or the hole is too big. This is why an occlusive dressing is a must. Apply new petroleum gauze and cover with a sterile, occlusive dressing at the site where the tube enters the skin (10). This prevents air from leaking into the chest at the skin.

Unfortunately, sometimes the skin site is too large relative to the tube itself, meaning the tube is too small for the skin incision that was created (1). The tube should fit snugly into the skin incision, without gaps. If you suspect the skin incision is too large, notify the physician. Often, a simple stitch can tighten any loose skin at the insertion site (1).

Finally, if you have accounted for all of the potential problems listed above and an air leak remains, the problem is likely inside the chest (10). Potential causes of persistent air leak include residual pneumothorax, pleural injury, a malpositioned chest tube, or fistula (10). Notify the provider right away if all attempts to resolve an air leak have failed.

Tube Dislodgement

Sometimes, the tube comes out despite every precaution. It may be pulled out partially or completely. After a partial removal of the tube, quickly and calmly secure the tube to the patient with a new dressing and tape. Obtain a set of vital signs and assess for pain and any new symptoms, such as shortness of breath or dyspnea. Notify the provider immediately. Follow up imaging (usually an x-ray) may be ordered to determine chest tube location and assess for any residual pneumothorax.

If the tube is pulled completely out, put on gloves and quickly cover the insertion site with your hand to prevent air from flowing into the chest (10). Stay with the patient and call for help. When help arrives, ask a coworker to get the necessary supplies for a new occlusive dressing: petroleum gauze, dry sterile gauze, and tape. Apply the dressing and notify the provider immediately. If the patient is in distress, call for help. Remember, chest tubes can be placed at the bedside pretty quickly in an emergency. And try to stay calm!

Under normal circumstances, chest tubes are removed once drainage has ceased, breath sounds return to normal, and/or imaging shows a resolution of the pneumothorax (9).

Conclusion

Chest tubes are a life-saving intervention for the patient with pneumothorax, hemothorax, chylothorax, pleural effusion, empyema/infection, and also those recovering from major cardiothoracic surgery. The technique for chest tube placement depends on the size: large tubes are placed using the blunt dissection technique and small tubes are inserted with the Seldinger technique. Radiologists use the Seldinger technique and a peel-away dilator to insert tunneled chest tubes.

Both small bore and large bore chest tubes are effective in treating pneumothorax, hemothorax, empyema/infection, and preventing complications after surgery. The size of the tube really depends on provider preference. There are advantages and disadvantages to either size. Large bore tubes are less likely to form kinks or clots, but may be more painful. Small bore chest tubes are less invasive, but form clots much more easily. Tunneled chest tubes are a great way to provide a palliative care to patients suffering recurrent malignant pleural effusions.

While there are no true contraindications for chest tube placement, a few relative complications exist. Sometimes, chest tube placement is a true emergency, such as the need to treat a tension pneumothorax. In these cases, the benefits outweigh the risks. For more stable patients of chest tube nursing care, providers should ensure that consent is obtained and the patient’s blood is coagulating appropriately prior to chest tube insertion.

When possible, patients and their families should be aware of potential risks with chest tube placement. Bleeding, damage to surrounding structures, bronchopleural fistula, recurrent pneumothorax, and pain are some potential complications of initial chest tube placement.

Chest tubes may be placed in the OR, IR, or even at the bedside. Once inserted, the tube should be connected to a drainage system to pull air out of the chest and prevent air from returning to the pleural space. Types of drainage systems include Heimlich valves, three-compartment systems, digital systems, and vacuum bottles for tunneled catheters.

Nurses are responsible for chest tube management after insertion. Roles and responsibilities include monitoring and recording drain output while continually assessing for signs of infection, air leaks, suction loss, or drainage system dysfunction. The ability to quickly identify a malfunctioning tube is essential for protecting our patients. Often, a problem found within chest tubes nursing care is solved with a quick fix, like replacing the drainage system if the tubing becomes damaged. However, persistent questions and concerns require a prompt call to the provider.

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