DEFINITION: insertion of the tube into the pleural space to allow the blood, fluid, pus or air to drain and to allow the lung to reinflate.

Parietal pleura - lines the chest wall Visceral pleura - covers the lungs

Air between the pleurae is a pneumothorax

Blood in the pleural space is a hemothorax

Transudate or exudate in the pleural space is a pleural effusion

Lung abscessPost- op chest drainage

( thoracotomy procedures, coronary artery bypass graft)

1. Remove fluid & air as promptly as possible

2. Prevent drained air & fluid from returning to the pleural space

3. Restore negative pressure in the pleural space

4. Facilitate lung expansion

1. One-bottle system drains by gravity; combines drainage

and water-seal chambers in one. the easiest system to use but does not

allow suction control and can’t handle copious drainage.

2. Two- bottle system uses the 1st bottle for drainage and the

2nd bottle for water sealing. not to be used for excessive drainage

3. Three-bottle system Uses the 1st bottle for drainage, the 2nd

for water sealing, and the third for suction control.

Used for copious drainage

PREVENT AIR & FLUID FROM RETURNING TO THE PLEURAL SPACE This system works if

only air is leaving the chest

If fluid is draining, it will add to the fluid in the water seal, and increase the depth

As the depth increases, it becomes harder for the air to push through a higher level of water, and could result in air staying in the chest

Tube open to atmosphere vents air

Tube from patient

PREVENT AIR & FLUID FROM RETURNING TO THE PLEURAL SPACE

For drainage, a second bottle was added

The first bottle collects the drainage

The second bottle is the water seal

With an extra bottle for drainage, the water seal will then remain at 2cm

Tube open to atmosphere vents air

Tube from patient

2cm fluid

Fluid drainage

Tube to vacuum source

Tube open to atmosphere vents air Tube from

patient

Fluid drainage

Straw under 20 cmH2O

The straw submerged in the suction control bottle (typically to 20cmH2O) limits the amount of negative pressure that can be applied to the pleural space – in this case -20cmH2O

The submerged straw is open at the top As the vacuum source is increased, once

bubbling begins in this bottle, it means atmospheric pressure is being drawn in to limit the suction level

Higher negative pressure can increase the flow rate out of the chest, but it can also damage tissue

Choose site

Explore with finger

Place tube with clamp

Suture tube to chest

Fluid, like air, moves from an area of higher pressure to an area of lower pressure

Same principle as raising an IV bottle to increase flow rate

PRIOR TO PROCEDURE:1.Verify consent form is signed.2.Assess the client’s understanding of the

procedure and provide education as needed.3.Assess for allergies to local anesthetics.4.Assist the client into desired position.5.Prepare the chest drainage system in advance

per protocol (e.g. filling the water seal chamber)

6.Administer pain & sedation med as prescribed.7.Prep the insertion site with Betadine then

drape thereafter.

DURING THE PROCEDURE:1. Assist the physician with insertion of chest

tubes, application of a dressing to the insertion site, and set up of the drainage system.

The CT tip is positioned up toward the shoulder or down toward posterior side.

CT sutured to the chest wall and airtight dressing is placed over the puncture wound.

CT attached to drainage tubing that leads to a collection device

Place the chest drainage system below chest level with tubing coiled on the bed. Ensure that the tubing from the bed to the drainage system is straight to promote drainage by gravity.

2. Throughout the procedure, continually monitor the vital signs and client’s response to the procedure.

AFTER THE PROCEDURE:1.Assess the client’s VS and respiratory status @

least every 4 hrs.2.Encourage coughing and deep breathing every

2 hrs.3.Keep the drainage system below chest level

including during ambulation.4.Monitor CT placement and function. Check the water seal every 2 hours and

add water as needed. Document the amount & characteristics of

drainage

every 8 hrs by marking the date, time, and drainage level on the container at the end of the shift.

Report excessive drainage to the physician. Monitor the fluid in the suction control

chamber and refill as needed. Check for expected findings of tidaling in

water seal chamber and continuous bubbling in the suction chamber.

5. Routinely monitor for kinks, occlusions, or loose connection.

6. Monitor the CT insertion site for redness, pain, infection, and crepitus (indicative of air leaks)

7. Place the client in semi- Fowler’s position to promote lung expansion and to drain the fluid.

8. Administer pain medication as prescribed.9. Obtain chest X-ray to verify CT placement.10. Keep two covered hemostats, a bottle of

sterile water, and occlusive dressing visible at bedside at all times.

CHEST TUBE REMOVAL:1.Provide pain medication as ordered half an

hour prior to removal.2.Assist with suture removal.3.Instruct client to take a deep breath,

exhale, and bear down (valsalva maneuver) or to take a deep breath and hold it ( to reduce risk of air emboli) during CT removal.

4.Apply airtight sterile petroleum jelly gauze dressing.

5. Obtain chest X-ray as prescribed (to verify continued resolution of the pneumothorax, hemothorax, or pleural effusion.

6. Monitor the client for excessive wound drainage, signs of infection, or recurrent pneumothorax.

1. AIR LEAKS All connections should be securely

taped and check regularly. Monitor water seal chamber for

continuous bubbling. If observe, locate source of air leak and intervene accordingly ( tighten connection, replace drainage system)

2. ACCIDENTAL DISCONNECTION, SYSTEM BREAKAGE, OR REMOVAL

If the tubing separates, instruct the client to exhale as much as possible and to cough to remove as much air as possible from the pleural space. Clean the tips and reconnect the tubing.

If CT drainage system breaks, immerse the end of the tube in sterile water seal.

If CT is accidentally removed, an occlusive dressing taped on only 3 sides should be immediately placed over the insertion site (allows air to escape and reduces the risk for development of a tension pneumothorax.

3.TENSION PNEUMOTHORAXSucking chest wounds, prolonged

clamping of the tubing, kinks in the tubing, or obstruction may cause a tension pneumothorax.

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