Thoracic cavity, pleural space
Conditions requiring chest
drainage_1
Air between the pleurae
is a pneumothorax
Occurs when there is an
opening on the surface of
the lung or in the
airways, in the chest wall
or both
The opening allows air to
enter the pleural space
between the pleurae,
creating an actual space
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Conditions requiring chest
drainage_2
Blood in the
pleural space is a
hemothorax
Lateral decubitus
X-Ray
Conditions requiring chest
drainage_3
pleural effusion
Transudate
Exudate
Empyema:
open vs closed pneumothorax
Open pneumo
Opening in the
chest wall (with or
without lung
puncture)
Closed Pneumo
Chest wall is intact
Rupture of the lung
and visceral pleura
(or airway) allows
air into the pleural
space
Photo courtesy trauma.org
tension pneumothorax
Tension pneumothorax
occurs when a closed
pneumothorax creates
positive pressure in
the pleural space that
continues to build
That pressure is then
transmitted to the
mediastinum (heart
and great vessels)
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mediastinal shift from a tension
pneumothorax
Mediastinal shift
Mediastinal shift occurs
when the pressure gets
so high that it pushes
the heart and great
vessels into the
unaffected side of the
chest
These structures are
compressed from
external pressure and
cannot expand to
accept blood flow
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Clinical Manifestations
of a collapsed lung
SOB
Chest Pain
Cough
Absent or decreased breath sounds
on affected side
Shallow Respirations
Asymmetrical chest movement
Decreased O2 saturation
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Treatment for pleural conditions
1. Remove fluid & air as promptly as
possible
2. Prevent drained air & fluid from
returning to the pleural space
3. Restore negative pressure in the
pleural space to re-expand the lung
Remove Fluid &/or Air:
chest tube insertion
Chest tube tray with an
appropriate size tube
Surgical prep, sutures,
sterile gloves
Lidocaine, needles,
syringes, alcohol preps
Vaseline gauze, 4x4s &
tape
CDU = Chest drainage
unit
Suction and sterile water
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RN Role
Educate patient and family
Administer pain meds
Set up chest drainage unit
Obtain consent
Assists with insertion PRN
Verify occlusive dressing is intact
Tape all connections from CT to
drainage system to prevent air leaks
Assess the patient and document
appropriately
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2. Prevent air & fluid from
returning to the pleural space
Chest tube is attached to a drainage
device
Allows air and fluid to leave the chest
Contains a one-way valve to prevent air
& fluid returning to the chest
Designed so that the device is below the
level of the chest tube for gravity
drainage
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3. Restore negative pressure in the
pleural space
Tube to
vacuum
source
Tube open to
atmosphere
vents air
Tube from patient
Straw under
20 cmH2O
Fluid
drainage
Suction control
2cm fluid water seal
Collection bottle
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Restore negative pressure in the
pleural space
The depth of the
water in the suction
bottle determines
the amount of
negative pressure
that can be
transmitted to the
chest, NOT the
reading on the
vacuum regulator
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How a chest drainage system
works: summary
Expiratory positive pressure from the
patient helps push air and fluid out of
the chest (cough, Valsalva)
Gravity helps fluid drainage as long as
the chest drainage system is below the
level of the chest
Suction can improve the speed at
which air and fluid are pulled from the
chest
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Collection Chamber
This chamber
allows monitoring of
volume, rate and
nature of the
drainage
Measure output per
hospital policy
Most systems are
considered full at
2500ccs
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Water Seal Chamber
Water creates a
one-way valve that
prevents air or fluid
from returning to
the patients chest
Monitor this
chamber for:
air leaks (bubbling)
tidaling (fluctuations
in fluid level)
increased negative
pressure
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Suction Control Chamber
regulates the
suction level
acceptable for
thoracic drainage
Suction increases
drainage rate
Suction is controlled
by water level
Regulate wall
suction until gentle
bubbles appear
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Monitoring air leak
Water seal is a window
into the pleural space
Not only for pressure
If air is leaving the chest,
bubbling will be seen here
Air leak meter (1-5)
provides a way to
measure the leak and
monitor over time
getting better or worse?
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Air Leaks
Continuous bubbling initially - OK
Bubbling when pt coughs or exhales.
How to troubleshoot:
Crepitus (subcutaneous emphysema)
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Tubing from chest drainage
system
Make sure connections are tight and
taped
No Dependant loops
Milking or Stripping- only done if clot
is suspected
Controversial : may cause damage to
lung tissue as increased negative
pressure is exerted
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Transporting a patient with a chest
tube
Keep the drainage system lower than
the patients chest
May open suction end to air which
equals a water seal
Mayo clamps (rubber tipped
hemostats) should be kept at the
bedside
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Assess the patient
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Then: Assess the CDU
Check
Check
Check
Check
the dressing
tubing - dependent loops
drainage in tubing & collection chamber
water seal chamber
Bubbling
tidaling
Check level of water
Water seal chamber
suction control chamber
Check tubing CDU to wall suction: open?
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Accidental disconnection of tube
and drainage system
Reconnect ASAP or
Place end of tube in a sterile water
bottle until new system arrives
Monitor patient for s/s of resp
distress
Notify physician
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Accidental DC of Chest Tube
Seal off insertion site dry, sterile
dressing or, petroleum gauze
dressing
secure on 3 sides
Notify physician
Assess patient prepare to assist with
reinsertion
Watch for tension pneumothorax
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Termination of Chest Tube
Assess for signs of reexpansion
Minimal drainage
Minimal bubbling / fluctuations in
water seal chamber
Chest x-ray shows re-expansion
MD may leave to gravity 24
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Termination of Chest Tube
Explain procedure to patient
Equipment
Suture removal kit, gloves, Vaseline gauze,
4x4s, tape, towels
Tube should be pulled at the end of full
inspiration.
Some physicians prefer coughing or
holding breath to increase intrathoracic
pressure
Occlusive dressing
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