Chest tube management doesn’t have to terrify you

chest tube managementThere you are, getting report on your clinical assignment, and you see that your patient has a chest tube. OH NO! Suddenly, a crowd of thoughts enter your head. What if it becomes dislodged? What if it tips over? What if it stops working? What if it gets clogged? What if, what if, what if.

First of all, good for you for even THINKING that chest tubes might be serious business…because they most certainly are. But with a little bit of guidance, you’ll walk into your patient’s room with confidence and maybe say, “What if I totally rock this clinical day?”  Let’s make sure you do.

What is a chest tube?

A chest tube is essentially a device used to drain air or fluid from the pleural space in order to restore the lungs to normal function. The PleurEvac is a commonly used chest tube system which contains three chambers: 1) the collection chamber; 2) the water seal chamber; and 3) the suction control chamber.

How does a three-chamber system work?

Understanding how chest tubes work goes a long way toward making them less scary. When you know what you’re looking at, you’ll be more adept at troubleshooting and less likely to panic when something goes wrong.

  • The collection chamber simply collects any fluid from the lungs. This can be sanguineous to serous fluid and everything in between.
  • The water seal chamber uses water as a seal that prevents any air from going back in toward the patient, while allowing both air and fluid to come FROM the patient.
  • The suction control chamber does just that…controls the amount of suction.

Because there are a variety of types and brands of chest tube drainage systems, we won’t go over the specifics of each one…this is one of those things that is much easier to learn if you can actually touch the product with your own hands. This is the type we use, if you want to check it out!

When is a chest tube used?

A chest tube is used in a variety of situations, but mainly falls into a few categories:

  • After any surgery that opens the chest wall. When the surgeon cuts into the chest wall, air enters that space which leads to a loss in negative pressure. If you recall from your physiology course, the lungs work on a negative pressure system…if there’s not enough negative pressure, then the lung can collapse. Surgery (such as a thoracotomy) can also lead to blood residing in the pleural space as well…we want to get that out of there and a chest tube helps us do that!
  • Any introduction of air into the pleural space. This can be due to trauma or pneumothorax. A pneumothorax can occur spontaneously in patients with lung cancer, COPD, cystic fibrosis, HIV associated pneumonia, tuberculosis and pneumonia. Trauma can also cause a pneumothorax, namely a penetration trauma (knife, spear, bullet) or a fractured rib.
  • Blood in the pleural space. This is called a hemothorax. Common causes also include trauma, cancer and TB…but can also be a result of thoracic or cardiovascular surgery. Other causes include tears in the vessel wall due to central line insertion or even severe hypertension.
  • Empyema (purulent fluid in the pleural space), pleural effusions (common in cancers) and even lymphatic fluid in the pleural space.

How do I manage a chest tube?

If your patient has a chest tube, your job is to make sure it is functioning properly at all times. Sounds simple enough, right? Here are some basics you’ll want to implement with every single chest tube patient, every single time:

  1. Have your safety equipment ready! This includes: two clamps (without teeth), a bottle of sterile water and an occlusive dressing.
  2. Perform a full respiratory assessment at appropriate intervals (this may depend upon your institution and patient acuity). Could be as often as every hour, though it is important to note that you will be eyeing that chest tube system Every Single Time you enter the patient’s room, as well as doing a quick focused respiratory assessment with each interaction (work of breathing, skin signs, oxygen saturation level, respiratory rate, level of consciousness).
  3. Ensure the insertion site is clean, dry and intact. As my coworker Darren says, you’ll “tape the snot out of it.” Those chest tubes are not meant to come out inadvertently!
  4. Check for crepitus (subcutaneous air). Mark the border where the crepitus ends so you can easily ascertain if it worsens (or improves). If the crepitus is new, make sure the MD is aware. Not sure what it feels like? Check out this post.
  5. Ensure the tubing is draining freely; try to avoid dependent loops and watch for clots.
  6. Assess the amount and quality of drainage. Average drainage amount for an adult is about 70 ml/hr. If it’s more than 100/hr or you notice a sudden increase in the amount of drainage, call the doc (for kiddos, the usual amount you’d call about is greater than 5mls/kg in 1 hr or greater than 3mls/kg for 3 hrs.)
  7. Ensure that the amount of suction matches the MD order. This is a no-brainer. A typical order is 20cm H2O, but can vary. You may also see an order to drain by gravity. This means that you will NOT be hooked up to wall suction. Instead, there is a port on the top of the device that is to be unclamped and uncapped. If you see a glove over this…remove it! Not sure why anyone would do that, but I saw it on a nursing school quiz once :-).
  8. Encourage the patient to cough and deep breathe, which helps facilitate chest tube drainage and aids in lung expansion.
  9. Assess for fluctuation/tidaling…if tidaling is present, then your chest tube is patent…yay! Note that tidaling will cease when your patient’s lung has fully expanded (and will not be present in mediastinal tubes…but that’s another topic for another day). However, a lack of tidaling can also be because something is going wrong (so, let’s get this straight…a lack of tidaling could mean my patient is fine OR they’re really, really not fine…this isn’t confusing at all!). Look for dependent loops, inadequate suction or clots in the tubing, all of which can negatively affect tidaling. Note that when assessing for tidaling, the water will RISE on inspiration and DROP on expiration. HOWEVER, if the patient is on a ventilator, this will be reversed (recall that mechanical ventilation switches your patient from negative pressure ventilation to positive pressure ventilation). Science!
  10. Check for air leaks. You’ll want to keep an eye on the water seal chamber…a constant bubbling (not associated with respiration) could be a sign of tension pneumothorax or a few other problems which you can remember with the mnemonic DOPE: dislodgement, obstruction, pneumothorax and equipment failure. None of them are good. A normal air leak will coincide with the patient’s exhale or with a good cough.

I’ve got an air leak. Where is it coming from?

Excellent question! Remember those clamps you got from central supply so you’d have them at the bedside at all times in case of an emergency? Well, grab one of those…and with your RN standing by (and ensuring you are covered by hospital policy or an MD order), you’re going to clamp the tubing at the insertion site and assess the air leak. If it STOPS when you clamp it, then the leak is coming from inside the patient. If it DOES NOT stop, then the leak is coming from elsewhere in the system.

To check if it’s coming from the system, you’ll progressively clamp the tubing at 8-12″ intervals all the way back to the collection device and note where the leak is occurring. You’ll notice that the air leak stops when you clamp between the location of the leak and the water seal. If the leak is coming from your tubing or collection device, then the fix is as easy as getting a replacement. You’ll also want to check all your connections at this point…make sure they’re taped together securely, that there are no tears or holes in your tubing and that the tubing is connected securely to the collection device. BE SURE TO WATCH YOUR PATIENT WHILE YOU ARE CLAMPING THE TUBING! If he shows signs of respiratory or hemodynamic compromise…stop and alert the MD. Note that clamping the system to check for air leak is something that varies by facility. Always check your facility’s policy as you may need an MD order to do this form of troubleshooting.

What if the leak is coming from the patient? In a pneumothorax, you’re going to have an air leak coming from the patient…because there is air IN the patient and we want it OUT! So, you’ll want to watch this to see if it gets better or worse. The chest tube systems we use have a numbered chamber ranging from 1-7. An air leak present at level 1 is mild, whereas a leak at level 7 is severe. Over time, your patient’s air leak should improve as their pneumothorax improves. If it doesn’t, then that’s a conversation for you and the doc to have (remember to use your SBAR!).

Chest tube managementAnother consideration is that the air leak could be coming from the system, very close to the patient, underneath the dressing. So…if you think the leak is coming from the insertion site, you’ll need to take down the dressing and look at the tubing. If the eyelets are outside the chest wall, alert the MD. If you can’t see any obvious signs that the leak is coming from the insertion site or the tubing at the insertion site, then it’s likely coming from the lung. Replace the dressing and carry on.

Now, what about all those “what if scenarios?”

I always say that if you know what to do in an emergency, it probably won’t happen (knock on wood). And if it does happen, you’ll know how to deal with it without an undue measure of panic.

  • What if the chest tube becomes dislodged? 
    • This is where your safety equipment really comes into play! If the tube comes out of THE PATIENT, most facilities’ policies dictate that you should slap an occlusive dressing over the site and alert the MD.  Easy!
  • What if the chest tube becomes disconnected?
    • If the tubing becomes disconnected, most institutions’ policies indicate for you to quickly insert the patient end of the tubing 1-2 inches into the bottle of sterile water to create a water seal while you get a new system set up. Easy!
  • What if the collection device tips over? 
    • Most chest tube drainage systems have one-way valves to prevent the various fluids in the chest tube chambers from going where they aren’t supposed to. The worst that could happen is that your drainage spills over into another column, which would make it a little difficult to do your drainage calculations…but not impossible. If it’s going to be a problem for you, simply replace the device. Easy!
    • In a water-seal system, check the water-seal chamber…you may need to add more water to ensure it remains at 2cm. Piece of cake!
  • What if there’s a clot in my tubing?
    • DO NOT “milk” or “strip” the tubing without an order as this can drastically increase the negative pressure in the pleural space. If you spot a clot, one method is to squeeze it gently toward the collection chamber, making sure to release the tubing completely in between squeezes. Make sure your facility’s policy covers this, and if you are unsure, ask the RN you are working with, or the MD managing the patient and the chest tube. Easy!
  • What if I have a sudden surge of red drainage? 
    • This could potentially be a hemorrhage. Alert the MD STAT and prepare for surgery. Not as easy, but totally do-able!
  • What if drainage suddenly stops? 
    • This could mean you have a clot or kink in the tubing. Check all of your tubing carefully, remove kinks and gently squeeze out the clots, if allowed by your facility. If your patient is deteriorating rapidly, let the MD know STAT…he or she may write an order to “milk” the tubing. You got this!
  • What if my patient suddenly crumps?
    • Crump means to crash, deteriorate, spiral downward…and it can happen quickly in patients with chest tubes. If you note sudden onset respiratory or hemodynamic compromise, suspect a tension pneumothorax. Check that the tubing is free of kinks or clots and notify the MD STAT!

And before we call it a day, one question that comes up ALL THE TIME, is if the chest tube should be clamped if you are transporting the patient from one area to the other (for example, to go to CT scan). I think you know the answer to this…but just in case, it’s NO!

Be safe out there and, as always, please defer to your facility’s polices and procedures where differences exist 🙂

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