Chest Tube Thoracostomy

CHEST TUBE THORACOSTOMY I – Definition: -is a surgical opening in the chest wall and inserting. A thoracostomy tube (chest catheter) is inserted into the chest wall above the area of the second or third rib. A local anesthetic (xylocaine 1% or 2%) is administered and an incision is then made into the pleural space of the chest wall. The tube is inserted, positioned, and clamped, and silk sutures are use to secure the chest tube in place. TYPES OF CHEST DRAINAGE CLOSED-CHEST DRAINAGE -known as the water seal drainage. -use to restore the negative pressure that has been lost inside the pleural space owing to pneumothorax, and to prevent additional air and fluid from entering the pleural cavity. The chest tube leads from the chest via plastic or rubber tubing to a glass container in which the end of the tube is attached to a glass rod submerged in water. An air vent allows the escape of air, which bubbles up through the water. this constitutes the water seal which prevents air from traveling up to the tube to the pleural space in which negative pressure must develop to re-expand lung. TYPES: • A Simple One - bottle system It provides water-seal gravity drainage. The gravity system allows the flow of air or water into the bottle when the pressure in the pleural space is sufficient to displace the water in the glass rod. The long glass rod is submerged about 2 cm below the water surface; an intrapleural pressure greater than 2 cm in the pleural space will be required to displace it. The reader may demonstrate this concept by taking a drinking straw and blowing in through the straw while it is submerge in a glass of water. More effort is required to blow air through the straw when it is at the bottom of the glass than when it is just slightly under the surface, because a longer column of water must be displace from the straw. Since the gravity water-seal drainage bottle is covered with a stopper, the short glass rod simply serves to allow the escape of air from the bottle. If this short glass rod becomes occluded, air pressure could build up within the bottle. This increase pressure pushes the water in the bottle up the long glass tube toward the chest, risking back flow of fluid into the chest.

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Two – bottle water – seal drainage system It involves the addition of a suction source and a suction-control bottle. These are added if gravity is not sufficient to clear the air or fluid from the chest. The suction-control bottle allows the entrance of air which bubbles through the column of water in the glass rod, reducing the amount of negative pressure from the suction source. This is sometimes called a suction-breaking bottle. When the force of suction exceeds that required to displace the water inside the glass rod, from the water level down to the end of the glass rod, room air will be drawn into the system to reduce the negative pressure applied to the chest. Failure of the breaker bottle to bubble means that the desired amount of suction has not been reached. The reasons for this should be investigated. Causes may include a leak within the bottle and tube system, an inadequate suction source, and a serious air leak into the pleura from ruptured bronchus or bronchopleural fistula. The physician may distinguish among them by briefly clamping the chest tube near the chest to determine whether bubbling will resumed. Resumption of bubbling indicates an intact drainage system. The problem then is an air leak into the pleura from a physiological source. The tube must not remain clamp as a tension pneumothorax will develop if the air leak into the pleural space has no egress. Air leaks into the pleural space may be localize by careful examination of the chest.

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A three-bottle system It involves the addition of a separate collection bottle so that the drainage may be separate collection bottle so that drainage may be measured and inspected as it comes from the chest. •

Pleur-evac It is a commercially available product incorporating all the features all ready discussed. It is a single light weight unit which indicates the amount of air bubbling through the suction chamber from the atmosphere. It calibrates the exact amount of negative pressure in the pleural space and has a client leak air flow meter to indicate the amount of air coming from the individual. II – Purposes:

• Remove excess air, blood, or fluid from the pleural cavity, • Reduce the size of the pleural space, and restore negative intrapleural

pressure to promote lung expansion. • Remove tumors of the lung, bronchus or chest wall • Repair or reverse structures contained in the thorax such as open heart surgery or repair of a thoracic aneurysm.

• Repair trauma to the chest or chest wall, such as penetrating chest wounds or crushing chest injuries. • Sample a lesion for biopsy. III – Procedure: 1. Assess Chest Drainage. Measure and document the amount of drainage coming from the pleural space in the collection chamber. This record helps determine the amount of blood loss and flow rate of drainage from the pleural space. Disposable plastic systems are manufactured with a marked write-on surface on which to record the amount of drainage rates and amounts are used in planning blood replacement therapy and assessing client’s status. As much as 500 to 1000 ml of drainage may occur in the next 24 hours after chest surgery. Between 100 and 300 amount of drainage may accumulate during the first 2 hours; after this time, the drainage should lessen. Excessive drainage or a sudden large increase may require further surgery to determine its cause. Normally, chest drainage is grossly bloody immediately following surgery, but it should not continue to be so for more than several hours. Assess blood loss by monitoring the rising fluid level in the collection chamber. Suspect hemorrhage if the pulse rate becomes rapid and the blood pressure drops. Check fluid in the drainage collection chamber. If the fluid level has not risen, check the tunes for patency. Notify the surgeon if (1) the drainage remains frankly bloody for longer than the first few postoperative hours, (2) bleeding recurs after it has slowed, or (3) there are any other manifestation of hemorrhage. 2. Asses Water-Seal Function. A water seal provides a one-way valve between atmospheric pressure and sub-atmospheric (negative) intrapleural pressure. It allows air and fluid to leave the intrapleural space but prevents the back-flow of atmospheric air into the chest. On expiration, air and fluid in the pleural space travel through the drainage tubing. The air bubbles up through the water seal and enters atmospheric air. On inspiration, the water seal prevents the atmospheric air from being sucked back into the pleural space (which would collapse the lung). The fluid in the water-seal compartment is not drawn into the chest cavity because the negative pressures generated during inspiration in the intrapleural space are not high enough to pull the fluid through the

drainage tubing. However, fluctuation of the fluid occurs during respiration; this fluctuation is called tidaling (tidal movement) or vacillation. Observe the water-seal. Fluid in the water-seal compartment should rise with inspiration and fall with expiration (tidaling). When tidaling is occurring, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has re-expander or if the chest drainage tubes are kinked or obstructed. If tidaling does not occur: Check to make sure the tubing is not kinked or compressed. Change the client’s position. Have the client deep breath and cough. If indicated, milk the tube If these measures do not restore tidaling, notify the surgeon. (Note: Tidaling may not occur or may be minimal in systems not using suction.) Observe for bubbling in the water-seal compartment. Bubbling in the water-seal compartment is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent bubbling is normal and indicates that the system is accomplishing one of its purposes, that is, removing air from the pleural space. Continuous bubbling during both inspiration and expiration, however, indicates that air is leaking into the drainage system or pleural cavity. Because air entering the system also enters the pleural space, this situation must be corrected in the following manner: Locate the source of the air leak, and repair it if you can. Begin by inspecting the chest wall where the catheters are inserted. If a chest catheter is loose or has been partially removed, gently squeeze the skin up around the catheter or apply sterile petrolatum gauze around the insertion site. Determine whether this measure stops the continuous bubbling in the chamber. If the air leak continues, check the tubing, inch by inch, and all the connections. A break in the tubing or a loose connection may be found that can be sealed with tape. If the leak still cannot be located, it may be necessary to replace the drainage system.

Rapid bubbling in the absence of an air leak indicates considerable loss of air, as from an incision or tear in the pulmonary pleura. When this occurs, notify the physician immediately so that appropriate measures can be taken to prevent collapse of the lung or mediastinal shift, such as (1) application of suction, (2) increase in the amount of suction, or (3) thoracotomy. 3. Suction. Suction at 10 to 20 cm H2O may be applied to a chest drainage system if gravity drainage is not adequate or if a client’s cough or respirations are too weak to force air and fluid out of the pleural space through the chest catheters. Additionally, suction may be applied to closed-chest drainage (1) if air is leaking into the pleural space faster than it can e removed by a waterseal apparatus or (2) to speed up the removal of air from the pleural space. Suction is regulated by the height of the water column in the suction chamber. The more fluid in the chamber, the more suction (subatmospheric pressure) is created. Most clients who require a chest tube postoperatively also need suction for 24 to 72 hours. If there was no water in the chamber, atmospheric air would go straight from the air vent into the suction source as fast as the suction was applied. Passage of the air through the water slows it, and the suction force is controlled. Increasing the source of suction only causes more air to travel through the air vent. The suction applied to the client remains stable. An occluded atmospheric air vent is dangerous because it causes the suction to be applied directly to the pleural cavity. A suction force greater than 50 cm H2O may cause lung damage. 4. Assess Suction Apparatus Function. Because most suction regulators can create potentially damaging amounts of suction, the amount of suction in the system must be controlled. Proper functioning of a wet suction control compartment is indicated by continuous bubbling in the suction control chamber. Vigorous bubbling does not increase the amount of suction; rather it causes the water in the bottle to evaporate more rapidly. Absence of bubbling in the suction control chamber means that the system is not functioning properly and that the correct level of suction is not being maintained. Possible reasons for malfunction of a mechanical suction apparatus include (1) large amounts of air leaking into the pleural space or into the drainage apparatus and (2) mechanical problems in the regulator (suction power source). The most serious problem is air leaking into the pleural

space. Check for leaks by briefly clamping the chest drainage tube close to the client’s body and observing the chamber. If bubbling begins in the suction control chamber, there’s nothing wrong with either the drainage apparatus or the regulator. The problem is therefore an air leak into the pleural space around the chest tubes. If the air leak cannot be sealed off (e.g., with petrolatum gauze), notify the surgeon immediately. If bubbling does not begin in the suction control chamber when the chest catheter is clamped, the problem is in the drainage connections or the regulator. Check the system carefully, looking for loose connections and for air leaks around the compartment tops and in the tubing (e.g., split tubing). Make sure that the tubing is not kinked, is correctly positioned, and has no dependent loops. If the suction power source appears to be causing the problem, obtain another suction canister and regulator. Because the chest catheter remains clamped during this inspection, observe the client closely for indications of tension pneumothorax (e.g., dyspnea, tachycardia, hypotension, tracheal shift). As soon as the problem is corrected, the fluid in the suction control chamber begins to bubble. Immediately remove the clamps on the chest catheter. Newer closed-chest drainage systems feature a dry suction column, which uses a spring or dial mechanism in place of a water column to control the suction level. The advantages include ease in setup, no noise of bubbling water, no evaporation of water over time, and provision of higher, more precise level of suction. An orange-colored indicator appears in a window to indicate suction is being applied instead of bubbling water in the suction control column. 5. Promote Chest Drainage. Closed-chest drainage systems must always be placed lower (preferably 1 to 2 feet) than the client’s chest. Drainage by gravity is thus maintained, and fluid is not forced back into the pleural space. Chest drainage systems must be placed upright on the floor or hung from the foot of the bed. If the drainage apparatus is on the floor, be careful not to lower a high- low bed or side rails onto it. If a client with closed chest drainage is to be moved, always keep the chest drainage system just below the level of client’s chest.

IV – NURSING CONSIDERATION: RATIONALE: Provide thorough instruction and preparation or hospital discharge:

Thorough understanding promotes compliance and enhances self-care capabilities.

Surgical wound and chest tube insertion site care

Wound care varies according to condition of incision and client.

Continuation of exercise program

Continued exercise increases activity tolerance and prevents complications

Precautions regarding activity and environmental irritants Clinical manifestations to be reported to health care professionals Importance of regular follow-up care. Community agencies that can provide resources, as needed

Heavy lifting should be avoided. Return to work depends on clients condition and type of job. However, it is usually possible to return to work within 4 to 6 weeks. Environmental irritants can cause severe coughing episodes. Evidence of infection, deteriorating respiratory status, or other complications should be reported promptly. The client should be monitored closely for manifestations or surgical complications, recurrence of malignancy and metastasis. Community resources can facilitate home management.