Introduction to Chest Tubes Nursing Management

Chest tubes are used to create negative pressure and allow expansion of a collapsed lung. They also restore the normal negative pressure in the pleural space.

Certain situations warrant a chest tube such as surgery, a pneumothorax (air in the pleural space), pleural effusion due to blood in the pleural space (hemothorax), empyema (infection in the pleural space) or chylothorax (lymphatic fluid in the pleural space).

A chest tube can be inserted into any of the four pleural spaces (left, right, anterior, or posterior) and can be placed in various ways: through an incision in the chest wall or through a needle puncture in the chest wall.

Insertion of a chest tube is not without risks. The three most common locations are: subxiphoid, intercostal, or supracostal.

The subxiphoid location is right below the xiphoid process at about the level of the 9th thoracic vertebra. It is a good access point for drainage because it’s easy to identify and doesn’t require much dissection. However, because it’s so close to major organs such as the liver and heart, there’s a higher risk of complications from placement.

The intercostal space is located between two ribs. It’s also called an “intercostal” drain because it drains toward the heart through intercostal spaces (the space between ribs).

The supracostal is located right above the sternum. This placement may be necessary if there are multiple wounds on both sides of the chest wall.

Types of Chest Tubes

Chest tubes are one of the most common types of medical equipment used in hospitals – so it’s crucial to know exactly when they are needed in client care.

Chest tubes typically come in two sizes: large-bore and small-bore. A large-bore chest tube is 20 French (Fr) (or larger), while a small-bore chest tube is smaller than 20 Fr. For long-term use, physicians frequently carefully insert them under the skin of the chest or tunnel them in a vein.

Another tube to mention is the Jackson-Pratt (J-tube). This kind of chest tube is inserted into the pleural space through an incision in the chest wall. The insertion site closes over time as it heals.

Chest Tube Chambers

Chest tube chambers are tubes that go into the lungs to drain fluid from them. They’re inserted through the skin and into the chest cavity, where they connect to a reservoir bag on the outside of the body. These include:

1. Suction control chamber – It’s generally gentle, steady, or continuous bubbling.
   • Memory trick: Think of a child sucking down a milkshake, we want gentle bubbling NOT vigorous.
2. Water seal chamber & Air lead monitor – It will remind you of a tidal wave (rise & fall). Continuous bubbling is not good.
   • Memory trick: Just think of a seal in the ocean for a water seal. Seals float up & down with the TIDE of waves & every time it takes a breath. This is good Tidaling, rising & falling with the TIDE.
3. Collection Chamber – Notify a HCP if you see bright red blood, or if their pulse is over 100 ml/hr (after 1st hour of placement).
   • Remember: Dark bloody drainage is normal, but document and monitor the client if you see old blood.

Chest Tube Drainage

Chest tubes insertion is a common procedure in hospitals. There are two main types of chest tubes: water seal drainage and closed drainage.

Types of Chest Tube Drainage Systems

There are three main types of chest tube drainage systems that you’ll encounter in any medical facility:

The gravity system is a simple design that allows fluid drainage with gravity alone. It’s useful for clients without intensive monitoring or needing their fluid output measured.

The pressure system uses a pump to actively remove fluid from the client’s chest cavity. This system is more expensive than the gravity system, but allows for more precise control over fluid output.

The vacuum system uses a vacuum pump to actively remove fluid from the client’s chest cavity. This type of device is usually reserved for clients with severe respiratory distress or heart failure, as it can have significant effects on blood pressure if used improperly or excessively.

Nursing Care for Chest Tubes

Here is a checklist for what nursing care management looks like with chest tubes:

• Assessment of lung sounds is vital to nursing care of a client with a chest tube.
• Monitoring the client’s vital signs (blood pressure and pulse) every fifteen minutes, their level of consciousness, and their ability to breathe on their own.
• Observing for signs of infection such as redness, swelling, or drainage from the insertion site. Also, look for hemolysis (RBC breakdown), such as increased heart rate or low blood pressure.
• Taking notes on fluid intake and output (how much fluid comes out through the tube).
• Providing comfort through positioning and pain relief measures, and applying ice packs if necessary. This also includes promoting mobility with range-of-motion exercises if necessary.

Chest Tube Removal

Although removing chest tubes is a surgeon’s responsibility, nurses have a role in helping the client to heal and manage their pain. In some cases, a nurse may be asked to help surgeons with this procedure.

This includes applying gentle suction (using suction tubing) while also helping to keep things sterile — making sure that nothing gets inside of where we need access for removing it.

Always have vaseline gauze at the bedside in case of accidental chest tube removal.
If a chest tube disconnects from the collection chamber itself, there are two options:

1. Placing the distal end into 250ml sterile saline.
2. Water seal chest tube damage.

Chest Tubes Conclusion

A chest tube is a hollow, flexible tube placed into the chest. It acts as a drain. Chest tubes drain blood, fluid, or air from around the lungs, heart, or esophagus. Nursing knowledge, critical thinking, and care are essential in clients with chest tubes.

Sources

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3423278/
https://lavascular.com/broviac-catheter-broviac-line/
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Chest_drain_management/