Chest Tube Management

Note: At 00:22, Nicole mentions that she is filling the water seal chamber with the syringe included in the packaging, but she’s actually filling the suction control chamber on this Atrium model. Always check the model and refer to the manufacturer’s instructions, and the physician’s orders for proper chest tube set up.

Overview

Purpose
1. Chest tubes are placed to:
  1. Drain fluid, blood, or air
  2. Establish negative pressure
  3. Facilitate lung expansion
2. The system is setup and maintained by the nurse
  1. Chest tube itself – secured with suture – placed by provider
  2. Drainage system
    1. Collection chamber
    2. Tubing
    3. Water seal chamber
    4. Suction port and pressure dial
  3. Occlusive dressing
    1. Usually vaseline gauze covered with dry gauze and tape
  4. MUST remain upright, below patient’s chest

Nursing Points

General

Supplies needed
1. Drainage system
  1. Should include a syringe of water for the water seal chamber
2. Suction setup
  1. Regulator
  2. Tubing
3. Vaseline gauze and other dressing supplies
4. Permanent marker

Assessment

When assessing an existing chest tube, follow the mnemonic TWO AA’S
1. Tidaline
2. Water Seal Level
3. Output
4. Air Leak
5. Ability to breathe
6. SpO2
See Chest Tube Management lesson in Respiratory Course

Therapeutic Management

If an air leak is discovered
1. Use the cross-clamp technique to identify the source
2. If the chest tube itself or the site are the source – notify the provider
If the tube is accidentally removed
1. Cover the site with occlusive dressing, taped on 3 sides immediately
2. Notify provider

Nursing Concepts

Steps and Nursing Considerations
1. Explain procedure to patient
2. Perform hand hygiene
3. Don clean gloves
4. New chest tube placement
  1. Open Pleur-Evac or other drainage system package
  2. Remove the syringe of water from the back
  3. Insert the syringe into the water seal port and inject the water
  4. Set up your suction regulator and tubing
  5. Attach suction tubing to suction port and set dial to ordered pressure
    1. If the provider orders “water seal” – do not attach suction
  6. Open the feet or hangers of drainage system to stabilize below the bed
  7. Remove the tubing from the package
  8. In a sterile fashion, remove the cap and assist the provider to attach the chest tube to the tubing
  9. Tubing should be coiled in bed to prevent dependent loops
  10. Make note of the volume of drainage expelled in the first hour by marking it with a permanent marker
5. Checking an existing chest tube
  1. Assess your patient
    1. Are they breathing okay?
    2. Lung sounds
    3. SpO2
  2. Check for tidaling in the tubing – should move with respirations
  3. Check for bubbling in the water seal chamber – which would indicate an air leak
    1. Also make sure there is enough water in the chamber (2cm)
  4. Assess the output
    1. Color, character
    2. Quantity – measured every 4-8 hours
    3. Mark level on chamber
6. For SAFETY
  1. Never clamp except when troubleshooting for an air leak
  2. Never strip the tubing
  3. Keep at the bedside:
    1. 2 hemostat clamps
    2. Sterile water/syringe for water seal
    3. Occlusive dressing and tape
7. Discard trash and used supplies
8. Remove gloves
9. Perform hand hygiene
10. Document procedure, findings, and patient response

Patient Education

Purpose for chest tube drainage system
Symptoms to report to the nurse ASAP

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Transcript

In this video we’re going to look at the initial setup of a chest tube drainage system and how you manage it periodically for the patient.

First, let’s start with the initial setup. The end of the tubing is sterile, but this doesn’t have to be done with sterile gloves. Start by taking the system out of the package.
Now you’ll locate the syringe of water – it’s usually on the back of the system, just pop it off.
Then find the water seal port – usually on the top or the side – and inject the water into that port. You’ll see it go into the water seal chamber.
Now you can attach your suction tubing if your doctor has ordered for it to be to suction – the port is usually on the top.
Use the dial to set it to the appropriate suction pressure. If your doc just ordered water seal, then don’t attach any suction at all.
Now you’re ready to hand the tubing to the provider once he has placed the chest tube – just make sure you keep the very end of the tubing sterile.
Once the tubing is attached, make sure you coil it in the bed to prevent any dependent loops.
You also want to use the hooks or feet on the drainage system to make sure it stays upright and below the patient’s chest at all times.
At first, you’ll want to monitor the output hourly, but, once your patient has had the chest tube for a bit, we’re going to check it every 4 hours. And you’re going to use the mnemonic TWO AA’S.
The T stands for Tidaling – you want to see if the fluid moves back and forth with respirations, which is normal – if you’re just draining air, you won’t see that.
The W and one of the A’s stand for Water seal and Air leak – you want to check the water seal chamber to make sure there’s enough water and to look for any bubbling that could indicate an air leak. You may have to kink the suction to confirm this
The O stands for output – look at the color and characteristics. Is it bloody? Is it yellow and clear? Are there clots in it? Then look at the amount. Usually we’ll mark the amount every 4-8 hours and document that in output.
Now, the last A and S stand for Ability to breathe and SpO2 – in other words, assess your patient. The goal of the chest tube is to facilitate lung expansion – is it working? Are they struggling? You may want to listen to their lungs? How’s their O2 level? Honestly, I usually start with this assessment – I’m looking at my patient the moment I walk in the room.

There’s a whole lesson on Chest Tube Management and what any abnormal findings might mean, as well as what to do about them inside the Respiratory course – so make sure you check that out as well.

We love you guys. Go out and be your best self today! And, as always, happy nursing!