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Managing chest tubes: Air leaks and unplanned tube removal Enhanced knowledge of chest tubes helps you cope with dangerous complications. By Angela C. Muzzy, MSN, RN, CCRN, CNS-BC, and Amy K. Butler, BSN, RN

ONCE TREATED only in high-acuity lems during tube removal. (The au - placement of the current tube if it’s settings, patients with chest tubes thors assume readers have basic malpositioned. In some cases, now receive care in inpatient med - knowledge about chest-tube func - chemical or mechanical ical-surgical floors, outpatient pro - tion and care.) may be indicated. cedural areas (such as intervention - Assess for air leaks at least once al radiology), and other settings. Managing air leaks per shift and as needed, based on More recently, to help shorten hos - Although air leaks commonly re - your patient’s respiratory status. pital stays and reduce readmissions, solve without intervention, they Start by examining the air-leak de - patients are being discharged with must be evaluated fully before tection chamber in the water seal of smaller, more portable chest the drain age device. An air tubes. This allows them to leak presents as small air continue to recover from bubbles; the amount of thoracic at home bubbling indicates the de - or, in some cases, to re - gree of the leak. If you no - ceive palliative care. tice bubbling, determine A chest tube is indicated location of the leak. Leaks when negative pressure in can occur outside the pa - the pleural space is dis - tient’s body (such as with - rupted, as from thoracic in the drain or tubing con - surgery or unanticipated nections) or within the trauma. The tube helps re - patient (for instance, at the store negative pressure, tube insertion site or inside preventing further respira - the chest cavity). tory complications. (See To determine where the Chest-tube indications .) leak is, clamp the tubing Although they can save as close as possible to the lives, chest tubes can pose patient. If bubbling contin - significant risks unless as - ues, suspect a leak in the sessed and managed properly. To chest-tube removal to ensure ade - tubing or damage to the drainage help prevent complications, clini - quate restoration of negative pres - device (as from inadvertent lower - cians must be familiar with basic sure in the pleural space. Pro - ing of the bed onto the drain). thoracic and pleural anatomy, inser - longed leaks—those lasting more Commonly, air leaks occur at the tion-site care, changes, and than 5 days after thoracic surgery— point where the distal end of the proper chest-tube management. are more dangerous than acute tube connects to the drainage de - Even then, unanticipated events and leaks. They indicate that negative vice tubing. Check this juncture to complications can occur. pressure hasn’t been restored and ensure it hasn’t become loose. Con - This article can help you feel the isn’t resolving. Such leaks sider using securements, such as more confident when caring for pa - can increase hospital stays and lead plastic fasteners (zip ties), to help tients with chest tubes. It discusses to , , and other prevent accidental disconnection several complications and describes complications. The patient may re - here. how to prevent and manage prob - quire a long-term chest tube or re - (Continued on page 12)

American Nurse Today Volume 10, Number 5 www.AmericanNurseToday.com 10 Chest-tube indications

Pleural chest tubes commonly are placed to remove air and fluid from the pleural 2. To reduce pain caused by chest- space, thereby restoring normal negative pressures. Mediastinal chest tubes (less tube removal, premedicate your common) are inserted after open- surgery to allow evacuation of residual patient as ordered; allow ade - and fluids. The chart below lists specific indications for chest tubes. quate time for the drug to take Indication Description effect. (See Managing pain dur - ing chest-tube insertion and Injury to lymphatic drainage system removal .) 3. Know that chest-tube removal is Collection of blood in pleural space a sterile procedure. Gather need - Exudate or transudate in pleural space ed supplies, including a mask, sterile gloves, suture removal kit, Air trapped in pleural space petroleum gauze, dry gauze, Postoperative Done to drain postoperative blood and tape, hazardous waste bag, and (mediastinal chest tube) fluids from or restore negative disposable pad. pressure in pleural space 4. Explain the procedure to the pa - tient. Instruct the patient to prac - tice taking deep breaths and (Continued from page 10) determine when a chest tube is no holding them. To prevent air longer necessary— for instance, if from re-entering the pleural If bubbling disappears when you drainage has become minimal and space during tube removal, in - clamp the tubing, suspect an air leak no longer concerning or if an air leak struct the patient to hold the at the insertion site or from within or the initial indication for the chest breath or to hum as you remove the chest wall. Assess the insertion tube has resolved. If permitted by the the tube. site; if you detect a leak, apply pe - state board of nursing or facility poli - 5. After you’ve removed the dress - troleum gauze and a sterile occlusive cy, clinical nurses with dem on strated ing and sutures, clamp the tube. dressing to seal it off. If the leak per - competence in removing chest tubes Ask the patient to take one more sists, suspect it’s coming from air re - can perform this procedure. deep breath and hold it. With maining in the pleural space (an un - Here are the basic steps of chest- one hand, simultaneously re - resolved pneumothorax), a pleural tube removal: move the tube swiftly and place injury, an exposed tube eyelet, or in - 1. Discontinue wall suction from it on the disposable pad. Keep appropriate communication between the chest drainage unit. Some lit - your other hand at the insertion the bronchial and pleural spaces. erature suggests you should do site, covering the hole. If purse- With a significant internal air leak, this at least 24 hours before tube string sutures are present, tie you may be able to palpate sub cuta - removal to eliminate a possible them off into several square neous emphysema or “crackling” air leak. knots. If desired, ask a colleague under the skin. Whatever its source, to hold the sutures while you an air leak must be addressed and pull the tube out. If these sutures resolved before the chest tube is re - aren’t present, immediately apply moved. A large, persistent leak with Managing pain during an occlusive dressing, such as no evacuation outlet can lead to ten - chest-tube insertion petroleum gauze. Again, the goal sion pneumothorax, in turn causing is to prevent air from reentering —a life-threaten - and removal the pleural space. ing emergency. As you probably know, inserting or 6. Dress the site with a dry occlu - removing a chest tube can cause sive dressing and discard the Planned and unplanned chest- considerable pain. As ordered, pre - chest tube and drainage device tube removal medicate patient before the proce - in the hazardous waste bag. A chest tube can be discontinued in dure and then routinely, based on 7. Obtain a postremoval chest X-ray two ways—planned or unplanned patient complaints and response to if the physician has ordered it or (accidental). Unplanned removal pain-management interventions. facility protocol requires it. (How - can be considered an emergency, Perform frequent pain assessment. ever, know that increasing evi - As needed or ordered, use such tech - but with quick action you can pre - dence no longer supports rou - niques as a patient-controlled anal - vent patient harm. gesia pump, a local anesthetic patch tine postremoval chest X-rays.) or cream, relaxation techniques, and Planned removal ice packs to aid pain control. Unplanned removal Clinicians use various indicators to In an unplanned chest-tube re -

American Nurse Today Volume 10, Number 5 www.AmericanNurseToday.com 12 Chest-tube complications

The chart below lists chest-tube complications with corresponding nursing interventions. rate and effort. A repeat chest X- ray (if indicated) may be done to Complication Nursing interventions compare to previous films and evaluate for presence or return of Incorrect tube placement • Confirm proper tube placement with chest X-ray, as ordered. a pneumothorax, an effusion, or other problem. Infection • Monitor for signs and symptoms of infection. • Use sterile technique for dressing changes and Other complications whenever a break in closed system occurs (for Other chest-tube complications also example, when changing the drainage unit). can be dangerous. These include Occluded chest tube • Routinely check tubing for kinking, dependent extremely high negative pressures loops, and obstructions. within the system caused by ag - • If occlusion is visible, gently lift tube so gravity can gressive tube stripping, as well as aid drainage, or massage tubing to help loosen the re-expansion clot. Avoid milking or stripping tube, which may phenomenon, which results from harm patient. rapid removal of large amounts of Prolonged air leak • Identify source of air leak. Confirm that all air or fluid. Rarely, inadvertent connections are tight. Apply occlusive dressing chest tube misplacement in the liv - at insertion site. er, , , or great vessel can • Other interventions depend on location of leak— occur on insertion. (See Chest-tube insertion site or inside chest cavity vs. system complications .) (drain or tubing connections). Enhancing your knowledge of Unplanned or accidental • Immediately ensure air doesn’t re-enter pleural chest tubes and gaining the skills chest-tube removal space. needed to manage them improve • Monitor patient for signs and symptoms of your confidence in delivering safe respiratory distress. patient care. *

Selected references moval, stay calm. With a gloved dislodged where it connects to the Burt BM, Shrager JB. Prevention and man - hand, immediately cover the open drainage tubing, immediately close agement of postoperative air leaks. Ann Cardiothorac Surg . 2014;3(2):216-8. insertion site and call for help while off the tubing to air with your staying with the patient. Ask for pe - gloved hand by crimping it or using Cunningham JP, Knott EM, Gasior AC, et al. Is routine necessary after troleum gauze to cover the site, a clamp, if readily available. Or chest tube removal? J Pediatr Surg . 2014; along with dry gauze and tape to place the end of the tube in a bot - 49(10):1493-5. complete the dressing. tle of sterile water, creating a water Dias OM, Teixeira LR, Vargas FS. Reexpan - If you didn’t witness chest-tube seal. Instruct a colleague to prepare sion pulmonary edema after therapeutic tho - removal and the patient appears to a new sterile chest-drainage collec - racentesis. Clinics (Sao Paulo) . 2010;65(12): be in respiratory distress, ask him tion device, or retrieve a new ster - 1387-9. or her to exhale forcefully as you ile connector while you safely re - Gorji HM, Nesami BM, Ayyasi M, Ghafari R, lift your hand off the insertion site. turn the patient to bed. Observe the Yazdani J. Comparison of ice packs applica - Before the patient’s next inhalation, patient for signs and symptoms of tion and relaxation therapy in pain during chest tube removal following cardiac sur - quickly cover the site again. Have respiratory decline. Then reconnect gery. N Am J Med Sci . 2014;6(1):19-24. the patient repeat this a few times. the chest tube to the new drain and Kane CJ, York NL, Minton LA. Chest tubes in If you suspect air entered the pleu - unclamp it. the critically ill patient. Dimens Crit Care ral space before you got to the Nurs . 2013;32(3):111-7. scene, the patient may be at risk for Postremoval nursing assessment Kirkwood P. Chest tube removal (perform). a tension pneumothorax, which can Whether chest-tube removal was In: Wiegand DLM, ed. AACN Procedure become life-threatening unless the planned or unplanned, monitor Manual for Critical Care . 6th ed. St. Louis, air is expelled from the pleural the patient closely for signs and MO: Saunders; 2011; 171-7. space quickly. Notify the practition - symptoms of respiratory compro - er, obtain a chest X-ray, and pre - mise, using such techniques as The authors work at the University of Arizona Medical Center in Tucson. Angela C. Muzzy is a pare for possible insertion of a new (Sp O ), end-tidal 2 clinical nurse specialist in the cardiovascular chest tube. carbon dioxide (ET CO 2) monitor - (CVICU). Amy K. Butler is a staff If you’re walking with your pa - ing, and breath sound auscultation. nurse in the CVICU and a research assistant in the tient and the chest tube becomes Monitor the patient’s respiratory College of Nursing. www.AmericanNurseToday.com May 2015 American Nurse Today 13