Respiratory: Chest Tubes 101

You're listening to Nitty Gritty Nursing with Nurse M, where she breaks down the nitty-gritty basics of nursing concepts.

Hello everyone and welcome back to Nitty Gritty Nursing with No Sam. Today we're gonna talk about chest tubes and basically what is a chest tube and what is the nitty-gritty of the information about a chest tube that you need to know in order to be successful.

And essentially, just to kick this off a chest tube which is something that we insert into the pleural space of someone's chest cavity to either remove air or fluid. And it whole intent and purpose is just to re-expand the lung back to a normal size.

The interesting thing about the pleural space is that it's a negative pressure-based cavity. So when we do get an excess of fluid or air that enters that particular space, it does disrupt the normal pressure gradient and causes the lungs to essentially collapse kind of like a sponge. And there's many reasons that someone that you're taking care of might end up with a chest tube.

The big ones are gonna be like a pneumothorax, when air enters into the plural space from either some sort of trauma or it could just be spontaneous, like someone has uh, you know, a lung bleb, like a blister, it's but it's we call it a bleb and it just ruptures spontaneously uh and that can cause air to leak out from the lungs into this pleural space. It could be from a pleural of fusion where fluid enters that

pleural space, and then it could also be from like a hemothorax, which is blood, aka fluid that enters the pleural space. And people get hemothoraxes from again a traumatic injury, sometimes diseases like tuberculosis. Uh an empyema is when it's an infectious fluid in that plural space.

A chylothorax is when it's a lymphatic t fluid in the plural spice. And then anytime someone has any sort of open heart surgery or cardio surgery and it disrupts the negative pressure that's required for the expansion of the lungs, these people are gonna have chest tubes. And what there you know, you don't really need to know about how the chest tube is necessarily placed because that's what our provider's gonna do.

But what you need to really understand is like the chest tube drainage system. and that that that system itself returns negative pressure back to the intrapleural space to remove the abnormal accumulation of either air or fluid that's been trapped in there and that ultimately is just preventing that person's lung from properly expanding. Now most places

There's the chest tubes are all basically the same design. There's three parts to it. There's a drainage chamber where whatever's inside the patient that needs to come out, whether it's air or fluid, drops itself into this one collection chamber or bottle or column, whatever you wanna call it. And that column or bottle is then attached to a water seal bottle, which is maintaining the negative pressure inside the fluid collection chamber.

And the la last one is a pressure regulating system. And you can either have a wet suction or dry suction. You might have heard that at some point. Essentially wet suction is just regulated by the height of the water in a control chamber when it's connected to the wall.

And when you have a wet suction drainage system, what you wanna hear what's very relaxing for nurses when they're used to using these systems is we wanna hear and see bubbles when it's working. And the water does evaporate over time, so you have to add water. to the wet suction chamber in order to maintain

the pressure. And most chest tube systems, when you pull it out of the package, they're already set to like a negative 20 pressure gradient. And you just leave that. Don't mess with it. If the provider wants something else, they can come in and change that pressure system. Or if you're working in an ICU, again, you'll learn how to do that.

The dry suction chambers actually ha don't have a water column to control the suction, but they actually use like this orange bellow that can be uh you know moved uh up or down depending on how much pressure you want to elicit. This is this does offer higher pressure options because we can control it really, really well and the water doesn't evaporate over time because there is no water for our water.

control chamber. And in these particular ones, which are the ones that I'm most commonly seen, um, there's no bubbling, there's no water evaporation, which is why we've got way more control over how much suction we can elicit when we use those. Now some institutions are going um into fancier chest tube drainage systems that are all electronic and have digital readouts again, if that's something that you're seeing.

I would say uh read the manual and consult with that particular facility and those shops that have those because this is just about basic chest cheap sets setup.

So, with the nursing role specifically for someone who's got chest tube, like our job is to monitor the drainage system itself. And the key is keeping the whole drainage system below the patient's chest. If you have fluid inside of someone's pleural cavity that is preventing their lung from properly expanding and you lift the drainage chamber above their chest, uh it's just gravity. It's just gravitational pull. It's not gonna work. So keep those drain those drainage systems below the chest.

The tubing, the tubing that comes from the chest tube that's stuck into someone's chest wall, which is often sutured in place. Right. Keep it free from kinks or um, you know, uh bending over itself so that the flow doesn't work. You wanna make sure that it's basically draining freely, that there's no clots or like

stagnant fluid sitting in there that's going to prevent the negative pressure from shifting. And you want to make sure all of those connections are sealed. And there's three big places where you need to check the collections of the connections. The first is at the actual physical patient. When that chest tube goes in Right, that needs to be an occlusive dressing which is like an

oil pregnated dressing that goes around the chest tube side itself because that's a big area where air can escape in and out of the actual like surgically inserted wound. So you want to have an occlusive dressing there that is then covered with gauze and tape.

Um, the second big connection point is where that chest tube exits the patient, is where the tubing from the actual chest tube drainage system and the chest tube connect. And oftentimes you'll see uh providers and healthcare staff that are used to working with it really putting on either an occlusive dressing or some sort of really strong tight dressing so that that connection does not become loose or just flat out come undone. And then the next connection is actually to the physical drainage.

system. Um and so we wanna monitor in that drainage collection system the uh amount of fluid that's coming out. If someone's got a pneumothorax and it's just full of air Are we gonna see fluid in there? No, we're not. It's because it's air. We can't see it. But what we can see is in that water seal chamber where it's preventing the any air or fluid from going back to the patient'cause it's got that negative pressure.

right? We're gonna see it fluctuate with with how they're breathing in and out, in and out, in and out. That's good. What we don't wanna see is like the continuous like bubble bubble like a babbling brook. That's bad. Babbling brook bad. So some mild fluctuation is good. Now, if the water seal in that if the water in the water seal chamber isn't fluctuating at all, it only means one of two things.

Either one, the lung has completely re-expanded and it doesn't need to fluctuate because the lung is actually now doing its proper job. Yay! Or there's a kink. Boo and it's preventing the fluctuation from actually occurring. So if you look at the water seal chamber and it's not doing anything, either A, the lung has re-expanded, or B, there's a kink somewhere and start looking for that. Now. For air leak monitoring.

excessive continuous bubbling means that there's an air air lake. So when you've got that babbling brook of a blah blah blah blah blah of the water that's just bubbling continuously, it means you've got an air lake somewhere. And so you need to now start to go back through and try to figure out where that air lake is occurring.

at one of those three points, either at the patient, at the connection between the chest tube and the chest and the connection tube to the drainage system, or at the drainage system to the connection tube that again is then attached to the chest tube coming out of the patient.

The caveat to this is that if there's a pneumothorax, if it's just pure air inside someone's chest cavity, you're gonna see intermittent bubbling. We expect that because as the air escapes, we would expect to see a few bubbles. Imagine you swimming underneath the water.

And you're holding your breath, and every once in a while you let a little bit of air out and you see a few little bubbles go up. That is what we call intermittent bubbling, versus if you just go underwater and you just expel all of the air that you've just taken. that it would be considered like excessive bubbling. So we don't want excessive bubbling, intermittent bubbling, totally fine if it's an emothorax.

Now, if it's a hemothorax, we shouldn't be seeing a whole lot of bubbling because we just want to get the fluid out and there's not any air inside the chest cavity that we're trying to get out of the person.

Now nursing care for patients who do have chest tubes. It's it's f it's straightforward. Don't overcomplicate this, okay? The first thing is monitor your patient. Firstly, monitor your patient. Because we have a chest tube inside their pleural cavity, logic would serve just listen to their lung sounds. Okay, if your patient has a chest tube, you should be listening to their lung sounds, because we want to make sure that the lung is actually re expanding.

On top of that, as you're listening to the lung sounds, like watch their rate of breathing. Are they having difficulty breathing? Do they have the dyspnea is what we call it? You know, that difficulty with breathing. And at what point is it? If they've got dyspnea with breathing and you've just now you've

Just inserted the chest tube, like that's not as concerning as the chest tube's been in for a day or two and they've now got dyspnea. That's concerning. You also want to monitor that insertion site and make sure that it doesn't get infection. And when you're monitoring the insertion site of the chest,

Right. You want that occlusive dressing around the insertion site, but you're also like just watching to make sure that there's no like air that's escaping into the skin. We call that subcutaneous crepitus and it feels like this crackling like a snap crackle pop sensation.

underneath the skin. That means that there's air in that subcutaneous tissue around it and that means that there's an air leak. And then the other big thing is encourage your patient to take deep breaths and cough. Now it's gonna hurt like

A lot. It's gonna hurt a lot. They're not gonna wanna do it. So you know what? Part of that nursing care is maybe keep them well medicated so that they do take a cough and deep breathe. Because the more they do that, the more they're gonna push out the fluid, the more they're gonna push out the air and re-expand their lung. And then the sooner we can take the chest tube out. So think logically about this. The other thing is about is about their positioning, like

Don't have them be lying on the chest tube's side. That's A gonna be super freaking uncomfortable for them, and B, you're have a higher likelihood of maybe kinking the tube somewhere. So make sure that they are positioned in a good position, whether that's supine or supine and slightly elevated at forty five degrees.

Something that is comfortable for them. Now the big problems with the chest tube, right,'cause we put something in, we know kinda how to monitor it, like make sure you watch the drainage chamber, keep it below the patient, no kinks, make sure that you've got three site uh occlusive dressings at the incession site. But now let's say that it gets pulled out from the patient. So directly at their chest, you know, they decide to get themselves out of bed. Happens, right?

And they put their hand on their chest tube tube and as they sit up they like rip out their stitches and that chest tube comes right on out. What are you gonna do? As a nurse, what are you gonna do? You now have a hole from the outside directly into their pleural cavity. Cover it with a piece of plastic. I don't care what you have available right then and there, but you want to cover it immediately with an occlusive dressing typed on three sides.

I mean if you've got the luxury of a sterile dressing there, yes, I'm gonna say use that for infection prevention. But the reality is that if a chest tube comes out of someone's chest, you now have the potential for an emergency to occur if they get too much air back into their chest. And then they develop attention pneumothorax, which is a life threatening emergency.

So if you've got a patient that the chest tube just comes right on out, you s slap a gloved hand over it, get a piece of plastic, ha get Something to cover that hole, tape it on three sides because then as the patient breathes out and that intrathoracic pressure decreases, that

that d dressing will basically suck into that hole and prevent air from getting in and then the vice versa when they breathe in and they increase that thoracic pressure, it allows the extraneous air, if it's there, to escape, but not to come back in.

So that's a big thing. If it c if it gets dislodged from your patient, cover the site with an occlusive dressing and tape it down on three sides. This prevents that tension pneuma from occurring and then you know what? Immediately notify the provider. Now Let's say that the chest tube stays in the person, but your whole system breaks. Like someone walks in, doesn't see it, and kicks your drainage chamber over and it gets a big crack in it.

Right, and because of that now there's an air link. So what are you gonna do in that instance? So one of the things that you should always have at the bedside to someone with a chest tube is sterile water. A bottle of sterile water, um I I mean me personally, I'm gonna have make sure that there's a bottle of sterile water s water sitting around and that I've got

gauze for like an occlusive dressing sitting around something like that. And so If that happens and your whole system like falls over, cracks and breaks, I'm actually gonna take the tube directly from the drainage system and stick it in like an inch of sterile water and I've just now created a water seal. This means that the w the air is not going to come back out. The air's not going to come back

into the patient, it's gonna stay out. And the fluid, every time that patient takes that deep breath and increases that intrathoracic pressure, they can still get air and fluid out. It's just you're not going to have this direct conduit. of this chest tube directly into the chest to refill it with air. Don't do that. Now once you've gotten the tube secured in some water, then go get a new system and hook it back up. Okay?

The other big things that they're saying nowadays is they don't recommend milking or stripping the tube where you know, you grab a portion of the tube where there might be sediment and you really start to like like you strip it out of it where you clamp down and you hold it and then you s bring your thumb down.

They're saying don't do that because it is increasing pressure in the system. Um, honestly, like you need to know your hospital's protocol for that. Now, you know, like massaging it a little bit, not properly stripping it. You know, I still see some nieces in practice doing that. And then the other big thing is that the clamping. Do we clamp, do we not clamp? And the reason the big thing I've always been taught is do not clamp the chest tube. Don't clamp it.

The reason being because when we clamp it we now are not allowing air to escape or air fluid whatever they have. you know, the cup the lymphatic fluid or whatever, to escape out and this can has the potential to increase the risk of attention to thorax.

to develop. And so we never do a clamping without a physician's order. I mean, I think once in my career I clamped it when I was working in the emergency room and the reason why was because I had a patient with an empyema, which is just a you know, the plural space was just full of like

pus based perulent drainage material. And when we put that chest tube in, he had so much fluid inside that chest cavity that when the fluid started to come out It came out at such a fast rate, I think, you know, immediate output was like six or seven hundred, eight hundred milliliters that the fluid came out so

So fast that we caused such a severe pressure shift that he then started to develop essentially a pulmonary edema from the lung trying to re-expand too quickly and not like slowly accommodating.

At that moment, I had a physician that said clamp the tube and we allowed for his lungs to then reacclimate and then I would unclamp it and allow two or three hundred milliliters to come out and then clamp it again. And we went through this process until, you know, not such an exorbitant amount of fluid was coming out at any given time.

So those are chest tube problems that can occur. Now the best part is when we get to remove a chest tube, patients get very excited about this, A because they're not going to have a giant piece of plastic sticking out the side of their chest. and B, it means we're on the trajectory of healing. So the big thing for us with Nurses as we do a chest tube removal is really to make sure you've gathered all the supplies potentially necessary. Sterile gloves, s

dressing supplies, occlusive based, masks, suture rem removal kits, etcetera. And a provider is usually the one that will remove the chest tubes. Nurses don't remove chest tubes. But we monitor the chest tubes to be like, hey, there's not been any fluctuation, not been any drainage, they are breathing much easier, it might be time for it to come out. You would then get a chest x ray and verify that. But

When we go to do the chest tube removal, one thing that the nurses can do is we really want to talk to your patient about the valsalvas maneuver. And that's to be done during the removal. And so basically if you think about like bearing down and val salving it like the gym. It increases Right, the intrathoracic pressure and it prevents air from entering the pleural spice as the tube comes out. Now before you r remove a chest tube, it hurts like the dickens.

Medicate your patient if ordered. If there's no pain medication ordered, you should probably ask the provider like, Hey, can we medicate them? Your patient will love you forever. Okay. And then after the tube has been removed Put an occlusive dressing, well, the provider should be putting an occlusive dressing over this site, and then you as the nurse are going to monitor for the respiratory status.

We will also often take a chest x-ray just to make sure that like nothing crazy happened during the chest tube removal. Again, totally dependent per facility. So this is chest tubes just in a short nitty-gritty format. If you have additional questions, make sure you reference like your books, things like that, your other faculty, you know, your nursing school stuff. Um and from there, keep learning.