Question

Identify indications for the use of chest tubes and accompanying signs and symptoms.

Describe the risks/complications associated with chest tubes and chest drainage units(CDUs).

Identify how to prepare/assist with the insertion of achesttube.

Describe the monitoring of chest tubes and chest drainage systems.

Describe considerations in caring for the patient who has a chest tube, including chest tube maintenance.

Identify factors that indicate when it is appropriate to discontinue the use of a chest tube.

Describe how to assist with discontinuation of a chest tube.

Answer 1

1 A chest tube is used to evacuate fluid and air from the pleural space and to restablish a negative intrapleural pressure so that the lung can reexpand.Chest tubes are generally placed for the treatment of pneumothorax and hemothorax in trauma and in nontraumatic conditions.Inaddition ,chest tubes are used for the drainage of large symptomatic or recurrent pleural effusions ,in the treatment of empyema and chylothorax and as drainage of the pleural space after esophageal rupture..

2 Older chest tubes may include a metal trocar ,which has been responsible for a large nuber of the perforation complications .if a trocar comes with the chest drain set ,it should be immediately discarded or only used with the chest drain set,it should be immediately discarded .Complications of chest tube placement include traumatic perforation of lung,heart chambers,inferior venacava,pulmonary artery,diaphragm, intra-abdominal organs and breast prosthesis.other complications are intercoastal neuralgia,bleeding from intercoastal vessels,reexpansion pulmonary edema,infection.

3 Chest tubes are placed in the fourth or fifth intercoastal space just anterior to the midaxillary line and directed apically in the chest cavity.The nipple line is generally used in males to estimate the fifth intercoastal spaceand the inframammary fold or crease in women.The area is prepared and draped.and local anaesthetic using1%lidocaine is administered. A smalll incision is made below the planned interspace and a tract for insertion is made by bluntly spreading the muscle using either a Kelly clamp or Mayo scissors.After entering the pleura ,a digital examination of the chest cavity should be performed to ensure proper position and to lyse any local adhesive bands that would prevent insertion of the tube.The tube then can be inserted using a blunt-tip clamp and directed to the appropriate location in the chest.The chest tube should be sewn in place with a single silk suture and connected to the drainage system.

4 The amount and character of fluid output should be monitored throughout the day .The presence or absence of an air leak should also be notedby looking for the presnce of bubbles in the water seal chamber during inspiration or coughing.When a continued airleak is noted ,it is important to ensure that the leak is not within the system itself.This can be checked by sequentially clamoing the tube before each connection and looking for an air leak.if there is leak from the system ,it must be replaced.it is also important to make sure that there is no leak where the chest tube enters the chest and to check thechest radiograph to see that the last hole in the chesttube is within the chest.

5 Acutely ,a drainage of 1500ml of blood or more from the hemothorax,which represents approximately 40% of the circulating blood volume ,should raise serious concerns that the haemorrage may require operative intervention.ingeneral more than 800ml in 1 hour ,400ml/h for 2 consecutive hours ,200ml/h for 4 consecutive hours or 800ml over 8 hours should also prompt consideration for operative intervention.During transport when suction is unavailable ,the patient should be transported on water seal and the water seal chamber should be kept atleast 2ocm H20 below the level of of the patient to prevent reflux of fluid up the tube with any high negative intrathoracic pressures that may occur.clamping the chest tube during transport could result in a tension pneumothorax if a significant air leak from the lung is present.

6 Chest tubes can be pulled when no air leak is noted on waterseal for 24 hours ,the drainage falls below 100 ml/day and the chest adiograph demonstrates complete expansion of the lung.Mechanical ventillation should not be a deterrent to removal of a chest tube because the risk of recurrent pneumothorax after chest tube removal in these patients is low .One exception is that when the tube has been placed for an empyema ,pulling a chest tube that is draining an empyema cavity may result in reaccumulation of the abscess cavity.

7 After taking down the dressing ,carefully cut the sutures holding the tube in place .Place a greased gauze pad on a 4*4 dressing and hold it over the chest tube exit site.Instruct the patient to take a large breath and perform a Valsalva maneuver,then rapidly pull the chest tube while covering the exit site with the greased gauze dressing .if great care is nit taken during the maneuver,a pneumothorax may occur,requiring replacement of the chest tube.