21: Chest Tube Placement (Assist)

Published on 07/03/2015 by admin

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Last modified 07/03/2015

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PROCEDURE 21

Chest Tube Placement (Assist)

PURPOSE:

Chest tubes are placed for the removal or drainage of air, blood, or fluid from the intrapleural or mediastinal space. They also are used to introduce sclerosing agents into the pleural space to prevent a reaccumulation of fluid.

PREREQUISITE NURSING KNOWLEDGE

• The thoracic cavity, in normal conditions, is a closed airspace. Any disruption results in the loss of negative pressure within the intrapleural space. Air or fluid that enters the space competes with the lung, resulting in collapse of the lung. Associated conditions are the result of disease, injury, surgery, or iatrogenic causes.

• Chest tubes are sterile flexible vinyl or silicone nonthrombogenic catheters approximately 20 inches (51 cm) long, varying in size from 12F to 40F. The size of the tube placed is determined by the condition. Chest tubes inserted for traumatic hemopneumothorax or hemothorax (blood) should be large (36F to 40F). Medium tubes (24F to 36F) should be used for fluid accumulation (pleural effusions). Tubes inserted for pneumothorax (air) should be small (12F to 24F).2

• Indications for chest tube insertion include the following:

• A pneumothorax may be classified as an open, closed, or tension pneumothorax.

image Open pneumothorax: The chest wall and the pleural space are penetrated, which allows air to enter the pleural space, as in a penetrating injury or trauma; a surgical incision in the thoracic cavity (i.e., thoracotomy); or a complication of surgical treatment (e.g., unintentional puncture during invasive procedures, such as thoracentesis or central venous catheter insertion).

image Closed pneumothorax: The pleural space is penetrated, but the chest wall is intact, which allows air to enter the pleural space from within the lung, as in spontaneous pneumothorax. A closed pneumothorax occurs without apparent injury and often is seen in individuals with chronic lung disorders (e.g., emphysema, cystic fibrosis, tuberculosis, necrotizing pneumonia) and in young tall men who have a greater than normal height-to-width chest ratio; after blunt traumatic injury; or iatrogenically, occurring as a complication of medical treatment (e.g., intermittent positive-pressure breathing [IPPB], mechanical ventilation with positive end-expiratory pressure [PEEP]).

image Tension pneumothorax: Air leaks into the pleural space through a tear in the lung and has no means to escape from the pleural cavity, creating a one-way valve effect. With each breath the patient takes, air accumulates, pressure within the pleural space increases, and the lung collapses. This condition causes the mediastinal structures (i.e., heart, great vessels, and trachea) to be compressed and shift to the opposite or unaffected side of the chest. Venous return and cardiac output are impeded, and collapse of the unaffected lung is possible. This life-threatening emergency requires prompt recognition and intervention.

image Special applications: Chest tubes can be used to instill anesthetic solutions and sclerosing agents.

• Lung that is densely adherent to the chest wall throughout the hemithorax is an absolute contraindication to chest tube therapy.

• Use of chest tubes in patients with multiple adhesions, giant blebs, or coagulopathies is carefully considered; however, these relative contraindications are superseded by the need to reexpand the lung. When possible, any coagulopathy or platelet defect should be corrected before chest tube insertion. The differential diagnosis between a pneumothorax and bullous disease necessitates careful radiologic assessment.4

• The tube size and insertion site selected for the chest tube are determined by the indication.4 If draining air, the tube is placed near the apex of the lung (second intercostal space); if draining fluid, the tube is placed near the base of the lung (fifth or sixth intercostal space; see Fig. 20-1).

• When the tube is in place, the tube is sutured to the skin to prevent displacement, and an occlusive dressing is applied (Fig. 21-1). The chest tube also is connected to a chest drainage system (see Procedure 24) to remove air and fluid from the pleural space, which facilitates reexpansion of the collapsed lung. All connection points are secured with tape or zip ties (Parham-Martin bands) to ensure that the system remains airtight (Fig. 21-2).

• The water-seal chamber should bubble gently immediately on insertion of the chest tube during expiration and with coughing. Continuous bubbling in this chamber indicates a leak within the patient or in the chest drainage system. Fluctuations in the water level in the water-seal chamber of 5 to 10 cm, rising during inhalation and falling during expiration, should be observed with spontaneous respirations. If the patient is on mechanical ventilation, the pattern of fluctuation is just the opposite. Any suction applied must be disconnected temporarily to assess correctly for fluctuations in the water-seal chamber.

• Mediastinal tubes generally are placed in the operating room by a surgeon after cardiac surgery.

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