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22 Chest Tube Placement (Assist) 179 PROCEDURE Chest Tube 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 thoracentesis or central venous catheter insertion). • The thoracic cavity is a closed airspace in normal condi- ❖ Closed pneumothorax: 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 lung, 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 pleural cavity, 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 trachea) pneumonectomy) 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 ❖ Pleural effusion 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
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