PROCEDURE Placement (Assist) 22 Julie Waters PURPOSE: Chest tubes are placed for the removal or drainage of air, blood, or fl uid from the intrapleural space. They also are used to introduce sclerosing agents into the pleural space to prevent a reaccumulation of fl uid.

PREREQUISITE NURSING unintentional puncture during invasive procedures, KNOWLEDGE such as or central venous catheter insertion). • The is a closed airspace in normal condi- ❖ Closed : The pleural space is penetrated tions. Any disruption results in the loss of negative pres- but the chest wall is intact, which allows air to enter sure within the intrapleural space. Air or fl uid that enters the pleural space from within the , as in spontane- the space competes with the lung, resulting in collapse of ous pneumothorax. A closed pneumothorax occurs the lung. Associated conditions are the result of disease, without apparent injury and often is seen in individuals injury, surgery, or iatrogenic causes. with chronic lung disorders (e.g., emphysema, cystic • Chest tubes are sterile fl exible polyvinyl chloride (PVC) fi brosis, tuberculosis, necrotizing pneumonia) and in or silicone nonthrombogenic catheters approximately young tall men who have a greater than normal height- 20 inches (51 cm) long, varying in size from 8F to 40F. to-width chest ratio; after blunt traumatic injury; or The size of the tube placed is determined by the indication iatrogenically, occurring as a complication of medical and viscosity of the drainage. 6 The side of the chest tube treatment (e.g., intermittent positive-pressure breath- usually has a radiopaque strip down the side to assist in ing, mechanical ventilation with positive end-expiratory visualization on chest radiographs. pressure). • Indications for chest tube insertion include the ❖ Tension pneumothorax: Air leaks into the pleural space following: through a tear in the lung and has no means to escape ❖ Pneumothorax (collection of air in the pleural space) from the , creating a one-way valve ❖ Hemothorax (collection of blood) effect. With each breath the patient takes, air accumu- ❖ Hemopneumothorax (accumulation of air and blood in lates and pressure within the pleural space increases, the pleural space) and the lung collapses. This condition causes the medi- ❖ Thoracotomy (e.g., open heart surgery, astinal structures (i.e., heart, great vessels, and ) ) to be compressed and shift to the opposite or unaffected ❖ Pyothorax or empyema (collection of pus) side of the chest. Venous return and cardiac output are ❖ Chylothorax (collection of chyle from the thoracic impeded, and collapse of the unaffected lung is pos- duct) sible. This life-threatening emergency requires prompt ❖ Cholothorax (collection of fl uid containing bile) recognition and intervention. ❖ Hydrothorax (collection of noninfl ammatory serous • Absolute contraindications: Lung that is densely adherent fl uid) to the chest wall throughout the hemithorax is an absolute 5 ❖ contraindication to chest tube therapy. ❖ Pleurodesis (instillation of anesthetic solutions and • Relative contraindications: Use of chest tubes in patients sclerosing agents) with multiple adhesions, giant blebs, or coagulopathies • Chest tubes inserted for traumatic hemopneumothorax or should be carefully considered; however, these relative hemothorax (blood) should be large (36F to 40F). Medium contraindications are superseded by the need to reexpand tubes (24F to 36F) should be used for fl uid accumulation the lung. When possible, any coagulopathy or platelet (pleural effusions). Tubes inserted for pneumothorax (air) defect should be corrected before chest tube insertion. should be small (12F to 24F). 2,6 The differential diagnosis between a pneumothorax • A pneumothorax may be classifi ed as an open, closed, or and bullous disease necessitates careful radiological tension pneumothorax. assessment.5 ❖ Open pneumothorax: The chest wall and the pleural • The tube size and insertion site selected for the chest tube space are penetrated, which allows air to enter the are determined by the indication.5,6 If draining air, the tube pleural space, as in a penetrating injury or trauma; a is placed near the apex of the lung (second intercostal surgical incision in the thoracic cavity (i.e., thoracot- space); if draining fl uid, the tube is placed near the base omy); or a complication of surgical treatment (e.g., of the lung (fi fth or sixth intercostal space; see Fig. 21-1).

178 22 Chest Tube Placement (Assist) 179

• Once the tube is in place, it should be sutured to the skin patient ’ s condition, the procedure, the expected benefi ts, to prevent displacement and an occlusive dressing should and the potential risks. It also allows time for questions be applied (see Fig. 21-2). The chest tube also is con- to clarify information and voice concerns. Explanations nected to a chest-drainage system (see Procedure 25 ) to decrease patient anxiety and enhance cooperation. remove air and fl uid from the pleural space, which facili- • Explain the procedure and the reason for the procedure, if tates reexpansion of the collapsed lung. All connection the clinical situation permits. If not, explain the procedure points are secured with tape or zip ties (Parham-Martin and reason for the intubation after it is completed. Ratio- bands) to ensure that the system remains airtight (see nale: This explanation enhances patient and family under- Fig. 21-3 ). standing and decreases anxiety. • The water-seal chamber should bubble gently immedi- • Explain that the patient ’ s participation during the proce- ately on insertion of the chest tube and during expiration dure is to remain as immobile as possible and to do relaxed and with coughing. Continuous bubbling in this chamber breathing. Rationale: This explanation facilitates inser- indicates a leak within the patient or in the chest-drainage tion of the chest tube and prevents complications during system. Fluctuations in the water level in the water-seal insertion. chamber of 5 to 10 cm, rising during inhalation and falling • After the procedure, instruct the patient to sit in a semi- during expiration, should be observed with spontaneous Fowler’ s position (unless contraindicated). Rationale: respirations. If the patient is on mechanical ventilation, This position facilitates drainage, if present, from the the pattern of fl uctuation is just the opposite. Any suction pleural space by allowing air to rise and fl uid to settle to applied must be disconnected temporarily to assess cor- be removed via the chest tube. This position also makes rectly for fl uctuations in the water-seal chamber. breathing easier. • Instruct the patient to turn and change position every 2 EQUIPMENT hours. The patient may lie on the side with the chest tube but should keep the tubing free of kinks. Rationale: • Caps, masks, sterile gloves, gowns, drapes Turning and changing position prevent complications • Protective eyewear (goggles) related to immobility and retained pulmonary secretions. • Antiseptic solution: 2% chlorhexidine or povidone- Keeping the tube free of kinks maintains patency of the iodine tube, facilitates drainage, and prevents the accumulation • Local anesthetic: 1% or 2% lidocaine solution (with or of pressure within the pleural space that interferes with without epinephrine) lung reexpansion. 1 ❖ 10-mL syringe with 20-gauge, 1 2 -inch needle • Instruct the patient to cough and deep breathe, with splint- ❖ 5-mL syringe with 25-gauge, 1-inch needle ing of the affected side. Rationale: Coughing and deep • Tube thoracostomy tray breathing increase pressure within the pleural space, facil- ❖ Sterile towels, 4 × 4 sterile gauze itating drainage, promoting lung reexpansion, and pre- ❖ Scalpel with No. 10 or 11 blade venting respiratory complications associated with retained ❖ Two Kelly clamps secretions. The application of fi rm pressure over the chest ❖ Needle holder tube insertion site (i.e., splinting) may decrease pain and ❖ Monofi lament or silk suture material (No. 0 or 1-0) discomfort. ❖ Sterile basin or medicine cup • Encourage active or passive range-of-motion exercises of ❖ Suture scissors the arm on the affected side. Rationale: The patient may ❖ Two hemostats limit movement of the arm on the affected side to decrease • Thoracotomy tubes (8 to 40Fr, as appropriate) the discomfort at the insertion site, which may result in • Closed chest-drainage system joint discomfort and potential joint contractures. • Suction source • Instruct the patient and family about activity as prescribed • Suction connector and connecting tubing (usually 6 feet while maintaining the drainage system below the level of for each tube) the chest. Rationale: This activity facilitates gravity • 1-inch adhesive tape or zip ties (Parham-Martin bands) drainage and prevents backfl ow and potential infectious • Occlusive dressing materials contamination into the pleural space. ❖ 4 × 4 gauze pads or slit drain sponges • Instruct the patient about the availability of prescribed ❖ Petrolatum gauze analgesic medication and other pain-relief strategies. ❖ Tape or a commercial securing device Rationale: Pain relief ensures comfort and facilitates Additional equipment, to have available as needed, includes coughing, deep breathing, positioning, range of motion, the following: and recuperation. • Ultrasound machine and ultrasound gel PATIENT ASSESSMENT AND PATIENT AND FAMILY EDUCATION PREPARATION • If time permits, assess the patient ’ s and family ’ s level Patient Assessment of understanding about the condition and rationale for • Assess signifi cant medical history or injury, including the procedure. Rationale: This assessment identifi es the chronic lung disease, spontaneous pneumothorax, hemo- patient ’ s and family ’ s knowledge defi cits concerning the thorax, pulmonary disease, therapeutic procedures, and 180 Unit I Pulmonary System

mechanism of injury. Rationale: Medical history or injury may provide the etiological basis for the occurrence Patient Preparation of pneumothorax, empyema, pleural effusion, or • Verify correct patient with two identifi ers. Rationale: chylothorax. Prior to performing a procedure, the nurse should ensure • Evaluate diagnostic test results (if patient ’ s condition does the correct identifi cation of the patient for the intended not necessitate immediate intervention), including chest intervention. radiograph and arterial blood gases. Rationale: Diagnos- • Ensure that the patient understands preprocedural teach- tic testing confi rms the presence of air or fl uid in the ings. Answer questions as they arise, and reinforce pleural space, a collapsed lung, hypoxemia, and respira- information as needed. Rationale: This communication tory compromise. evaluates and reinforces understanding of previously • Assess baseline cardiopulmonary status for the following taught information. signs and symptoms that necessitate chest tube insertion.4 • Obtain consent if circumstances allow. Rationale: Inva- Rationale: Accurate assessment of signs and symptoms sive procedures, unless performed with implied consent allows for prompt recognition and treatment. Baseline in a life-threatening situation, require written consent of assessment provides comparison data for evaluation of the patient or signifi cant other. changes and outcomes of treatment. • Ensure patient has a patent intravenous access. Rationale: ❖ Tachypnea This access provides a route for analgesics, sedation, and ❖ Decreased or absent breath sounds on affected side emergency medications. ❖ Crackles adjacent to the affected area • Consult with the practitioner for the appropriate-size chest ❖ Shortness of breath, dyspnea tube to be inserted. Rationale: Evacuation of air neces- ❖ Asymmetrical chest excursion with respirations sitates a smaller tube; evacuation of fl uid necessitates a ❖ Cyanosis larger tube. ❖ Decreased oxygen saturation • Assist the patient to a supine position with the ipsilateral ❖ Hyperresonance in the affected side (pneumothorax) arm abducted and fl ex the elbow so that the patient ’ s hand 2,8 ❖ Subcutaneous emphysema (pneumothorax) is comfortably positioned above his or her head. Ratio- ❖ Dullness or fl atness in the affected side (hemothorax, nale: This positioning enhances accessibility to the inser- pleural effusion, empyema, chylothorax) tion site for positioning of the chest tube. ❖ Sudden, sharp chest pain • Administer prescribed analgesics or sedatives as needed; ❖ Anxiety, restlessness, apprehension follow institutional policy for moderate or procedural ❖ Tachycardia sedation. Rationale: Analgesics and sedatives reduce the ❖ Hypotension discomfort and anxiety experienced and facilitate patient ❖ Dysrhythmias cooperation. ❖ Tracheal deviation to the unaffected side (tension • Administer supplemental oxygen as needed. Monitor pneumothorax) pulse oximeter or end-tidal carbon dioxide level. Ratio- ❖ Neck vein distention (tension pneumothorax) nale: Real-time assessment of patient ’ s respiratory status ❖ Muffl ed heart sounds (tension pneumothorax) during the procedure is provided.

Procedure for Assisting with Pleural Chest Tube Placement Steps Rationale Special Considerations 1 . HH 2 . PE 3. Open the chest tube insertion tray Reduces transmission of using sterile technique. microorganisms. 4. Assist with preparation of the Facilitates insertion of the tube. equipment. A. Check that all equipment is present. B. Pour antiseptic solution into basin or medicine cup with aseptic technique or open antiseptic swab packet and stand by. C. Open the chest tube package and empty it onto the open sterile tray. D. Assist to prepare a syringe with lidocaine. 22 Chest Tube Placement (Assist) 181

Procedure for Assisting with Pleural Chest Tube Placement—Continued Steps Rationale Special Considerations 5. Assist the physician or advanced Assists in preparation of area for Insertion site for air removal is right practice nurse with preparation of the insertion and proper placement or left second intercostal space. insertion site. of tube.8 Insertion site for fl uid removal is right or left fi fth or sixth intercostal space, midaxillary line. Incision site is one rib below insertion site (see Fig. 21-1 ). 6. Perform a preprocedure verifi cation Ensures patient safety. and time out, if nonemergent. 7. After tube insertion, connect the chest Ensures the tube is properly tube to the closed chest-drainage positioned. 3 system and check for rise and fall

(tidaling) of the H2 O column. Apply ordered amount of suction. 8. Assist with suturing of the tube to the Secures the position of the tube. 4 Type of stitch used depends on the chest wall. Sutures should be snug to individual; the goal is to prevent prevent free air from passing displacement of the chest tube. into the subcutaneous tissue. 9. Apply occlusive dressing (see Provides cover for the wound Fig. 21-2 ). with the least damage to the A. May use slit drain sponge or surrounding skin. 4 × 4 gauze under and over top of the chest tube insertion site. Petrolatum gauze is used around the chest tube, or follow institutional standards.7 B. Secure with tape dressing. 10. Tape all connection points to the Creates an airtight system. Check that all tube drainage holes drainage system or secure with Airtight connections prevent air are in the pleural space. zip ties (Parham-Martin bands). leaks into the pleural space. 1,4 (Level E*) 11. Secure the tube below the dressing to Functions as a strain relief to the patient ’ s skin with a commercial prevent tube and dressing securing device or tape. dislodgement. 12. Confi rm tube placement with chest Chest radiograph confi rms Ensure that the distal drainage hole radiography. (Level E) placement of tube, expansion is within the pleural space. of lung, and removal of fl uid. 8 Document result of chest radiograph in the patient ’ s record. 13. Dispose of used supplies and remove PE . 14. HH

*Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.

Procedure continues on following page 182 Unit I Pulmonary System

Expected Outcomes Unexpected Outcomes • Removal of air, fl uid, or blood from the pleural space • Hemorrhage or shock • Relief of respiratory distress • Increasing respiratory distress • Reexpansion of the lung (validated with chest • Infection radiograph) • Damage to intercostal nerve that results in • Restoration of negative pressure within the pleural neuropathy or neuritis space • Incorrect tube placement • Chest tube kinking, clogging, or dislodgment from chest wall • Subcutaneous emphysema • Reexpansion pulmonary edema

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions. 1. Assess cardiopulmonary and vital Provides baseline and ongoing • Tachypnea signs every 1–4 hours and as assessment of patient ’ s condition. • Decreased or absent breath sounds needed. Abnormalities can indicate • Hypoxemia reoccurrence of the condition that • Tracheal deviation necessitated chest tube insertion. • Subcutaneous emphysema On the basis of the patient’ s • Neck vein distention clinical condition or physician • Muffl ed heart tones orders, vital signs may need to be • Tachycardia checked more frequently. • Hypotension • Dysrhythmias • Fever 2. Monitor chest tube output every Provides data for diagnosis. Higher • Bloody drainage greater than or 1–4 hours and record amount and drainage amounts require more equal to 200 mL/hr color. frequent assessment. On the basis • Sudden cessation of drainage of the patient’ s clinical condition or • Change in character of drainage physician orders, output may need to be checked more frequently. 3. Assess for pain at the insertion Pain interferes with adequate deep • Continued pain despite pain site or for chest discomfort. breathing. Pain at insertion site, interventions particularly with inspiration, may indicate improper tube placement. 4. Evaluate the chest-drainage Water level normally rises and falls • Absence of tidaling in water-seal system for rise and fall (tidaling) with respiration until lung is chamber or bubbling in water-seal chamber. expanded. • Persistent bubbling Check connections. Bubbling immediately after insertion signifi es that air is being removed from the pleural space; bubbling with exhalation and coughing is normal. Persistent bubbling indicates an air leak either in the patient ’ s lung or in the chest- drainage system.3 5. Assess insertion site and Skin integrity is altered during • Fever surrounding skin with daily insertion, which can lead to • Redness around insertion site dressing change for presence of infection. 3 • Purulent drainage subcutaneous emphysema and • Subcutaneous emphysema signs of infection or infl ammation. 22 Chest Tube Placement (Assist) 183

Documentation Documentation should include the following: • Patient and family education • Presence of tidaling and bubbling • Reason for chest tube insertion • Amount of suction • Respiratory and vital sign assessment before and after • Patient ’ s tolerance of procedure insertion • Postinsertion chest radiograph results • Description of procedure, including tube size, date and • Unexpected outcomes time of insertion, insertion site, and any complications • Nursing interventions associated with the procedure • Pain assessment, interventions, and effectiveness • Type and amount of drainage

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .