Wednesday, October 5, 2011

Chest tubes and pleural drainage systems

Chest Tube and Pleural Drainage System Management

Pleural drainage systems have been around since 1967.  Back then the three bottle system was used, and today the system is a single unit.  The systems remove free air and/ or fluid from the pleural space via a chest tube.

Modern pleural drainage systems are single units
Once a chest tube is inserted you’ll want to make sure it’s properly connected to the pleural drainage system.  The system should then be checked during routine assessments to make sure it’s functioning properly. 

Indications for chest tubes: 

1.      Pneumothorax
2.      Hemothorax
3.      Pleural effusions
4.      Chest trauma
5.      Flail chest

Contraindications for chest tubes:

1.      Infection over insertion site
2.      Uncontrolled bleeding

Where is chest tube inserted?  On the side of the pneumothorax, mid-axillary line and usually the 4th or 5th intercostal space above the rib (arteries and nerves are located just below the rib). 

How is chest tube inserted:
      1.   Patient given conscious sedation and also localized anesthetic over area of
            insertion.  Time should be given for medicine to take effect.
      2.   Patient should lie on side with arm raised over head to help open up area where
            tube is to be inserted.  Soft restraints may be used to prevent patient from
            contaminating area.  This will prevent patient from flailing are in response to
            pain.
      3.   Physician will insert tube as far as he thinks is necessary.
      4.   Sutures will be inserted and dressing applied
      5.   X-ray should confirm placement

How to set up the system:  (if suction ordered, follow steps 1-5, if not ordered, follow steps 1 and 2 only)

1.      Connect the patient tube to the patient thoracic catheter
2.      Use a luer slip tip syringe to inject about 20cc into the Patient Air Leak Meter through the needleless injection site on top of the unit.  Fill to the 40cc “Fill” line
3.      Connect suction source to suction port
4.   Increase suction from source (wall) until the orange float appears in the suction
      control indicator window.
4.      Negative pressure pre-set at –20 cm H20 and, if ordered differently, it can be adjusted using the suction control. 

Suction Control:  This is the dial in the upper left.  It is pre-set at –20 cm H2O

Situations that may require higher suction pressures of –30 or -40 cm H2O include:
1.      Large air leak
2.      Empyema
Note how air flows through the pleurevac
3.      Viscous pleural effusion
4.      Reduction in pulmonary compliance

Note:  If you decrease this setting, you’ll need to depress the Filtered High Negativity Relief Valve.

Gravity Drainage:  If the doctor orders gravity drainage, you do not need to set up suction to the system.  In this case, the suction port should remain uncapped and free of obstruction because this is where air will drain out.  Suction may be discontinued during transport, and sometimes 24 hours prior to removal of chest tube. 

Collection Chamber:  This is where drainage from the chest will accumulate.  It can hold up to 2000cc.  Fluid overflows from one compartment to the next.  When 2000cc is reached, the unit needs to be replaced.  Clamp the tube and set up a new unit.  A new unit should be ready before tube is clamped so you can make the change quickly.

The Water Seal Chamber: 

1.  One-Way Seal:  A check valve provides the one-way seal which allows air to exit from the pleural space while preventing air from entering pleural cavity during inhalation.  Water is not required to achieve this one way seal.  This is a modern seal that replaces the old water seal systems.  It retains a seal even if the unit is tipped over.

Unlike a water seal system in which the seal may be lost when the unit is tipped, the dry seal protects the patient from atmospheric air.

2.  Air Leak Meter:  However, by placing fluid in one-way seal compartment you can use it for diagnostic purposes to measure negativity in the patient’s chest.  This is generally indicated if the chest tube is used for purposes of resolving a pneumothorax.  Bubbling during exhalation every 3-4 seconds indicates a leak.

The 3 bottle system was more complex than what we use today
1.  The meter is made up of numbered columns, labeled from 1 (low) to 7 (high).  The higher the numbered column through which bubbling occurs, the greater the degree of air leak.  By documenting the number, the clinician can monitor air leak increases or decreases.

If you see no bubbling in the air leak meter, the air leak (pneumo) is resolved and the chest tube can be removed.

3.  Calibrated Manometer:  The water seal chamber also has a calibrated manometer to measure the amount of negative pressure within the pleural cavity (this is the small arm to the right of the air leak meter). During spontaneous breathing, the water level should rise up the small arm during inspiration and fall during exhalation (this will be the opposite if a patient is receiving positive pressure breaths). 

Water going up the arm indicates pressure in the chest has become more negative.  If there is no leak, water should rise and fall with the patient’s respirations.  This oscillation is called tidaling and is one indicator of a patent chest tube. 

Negative Pressure Indicator:  The indicator window above the collection chamber should have the word “YES” if there is negative pressure in the collection chamber. 

Filtered High Negativity Relief Valve:  Should only be depressed if you decrease the suction control setting (like from -20cm to –10).  Pressure at the patient side of the unit will stay at the previously set level until this valve is depressed and negative pressure is relieved.  Pressure is automatically limited to –50 cm H2O.

Positive Pressure Release Valve:  This opens with increases in pressure to prevent pressure accumulation and to prevent a tension pneumothorax.  This should never be obstructed. 

Sample port:  It’s located on the patient tubing near the pleural drainage system.  It can be used to obtain a sample for lab testing.  Also, if ordered, you can add an anticoagulant into this port.  Use an 18 gauge or smaller needle. 

What to look for when checking the system:

1.   The pleural drainage system should be below chest level of the patient at all times, even while walking the patient.  This will promote gravity drainage*.  The unit can be hung on the rail, or you can use the floor stand that swings out.
2.   The clamp should be slid down the tubing as far away from the patient as possible to avoid accidental clamping.
3.   Tube should never be clamped unless changing the system or unless otherwise directed by physician.  In the event of an air leak, clamping the tube could lead to a tension pneumothorax because leaking air will have no where to go.
4.   Make sure there are no loops or kinks in the tubing.  Make sure it is clear of obstruction.  Make sure it’s not under the wheel of the bed. 
5.   If the system tips over and fluid flows from one drainage compartment to another, this can be restored by angling the unit and redistributing fluid to the appropriate compartment
6.   If the system is set up for suction, make sure the orange float appears in the suction control indicator window.  If not check the suction control regulator on the wall to confirm it is on, check the tubing for leaks, and make sure the pressure release valve is not obstructed.
7.   If using suction drainage, the Negative Pressure Indicator should have a “YES” in it at all times.  If Gravity Drainage is being used (no suction), the “YES” should appear during inhalation only. If not, check the suction control regulator on the wall to confirm it’s on, check tubing for leaks, and make sure the pressure release valve is not obstructed.
8.   If using suction drainage, make sure the suction tubing is not blocked or kinked, and make sure the suction is on.  If using gravity drainage, make sure the suction port is not capped or otherwise blocked.  Blockage will prevent air from getting out of the chest and will result in a tension pneumothorax.
9.   Check calibrated manometer to the right of the air leak meter.  Make sure water oscillates with respirations.  If it doesn’t, this indicates the chest tube is not patent.   Check tubing for kinks or loops.  Make sure tubing is not under the wheel of the bed or other object. 
10.  Should the patient exhibit clear signs or symptoms of pneumothorax, be sure to immediately notify 
      the physician and obtain both a thoracentesis kit and a tube thoracotomy tray.
11.  If bubbling in air leak meter is constant you’ll want to do some troubleshooting to see where the leak is coming from.  Squeeze chest tube with your fingers close to the insertion site to occlude the tube momentarily.  Check the air leak meter…
·        If bubbling stops, the air leak is coming from the patient or at the insertion site.  The chest tube may have been pulled out.  The doctor should be called.
·        If  bubbling persists, the leak is distal to the point where the tube is occluded.  Continue to assess for leak in system.  Make sure all connections are secure.  If unable to find reason and fix leak, replace system.  The doctor does not need to be called.
12.  If chest tube is accidentally removed, cover insertion site with occlusive dressing and tape on three sides.  This will create a flutter type valve effect.  Air is prevented from entering as the patient breaths in, but air can escape through the open end of the dressing during exhalation.
13.  Chest tube dressing should be changed when soiled or as ordered by physician.

Two signs patient is healing:
1.      Absence or slowing of drainage in the collection chamber
2.      Absence or bubbling in the water seal’s air leak chamber

Once chest tube is resolved patient is usually monitored for 24 hours.

How often to assess chest tube patients?  Patients should be assessed depending on severity of the patient.  In the emergency room they are often checked every 10 minutes.  If admitted on the patient floors assessments are done every 2-4 hours.

What should be assessed on these patients? 
1.      Check for signs of respiratory distress
2.      Assess level of chest pain
3.      Lung sounds
4.      Heart rate
5.      Make sure pleural drainage system is working properly
6.      Make sure tubing and suction control port patent
7.      Check dressing

When should you call the doctor?

      1.   Any signs of increased respiratory distress
      2.   New onset sub q emphysema (crepitice) or worsening of this
      3.   Signs of clogged chest tube (blood clot in tube)
      4.   Hypovolemic shock
      5.   Any signs of increased air leakage
      6.   Greater than 100cc drainage in an hour for 2 or more hours
      8.   Worsening vital signs (increased HR, RR, temperature)
     
Conclusion:  With basic information about pleural drainage systems it’s easy for any clinician to monitor the progress of the patient, and swiftly observe and trouble shoot any problems that may occur. 

References:
·        Teleflex.com video “Set-up Sahara,” http://www.teleflex.com/en/usa/prod_sahara.php
·        Teleflex.com slideshow “Setting up the Pleur-Evac Dry Suction Seal System,”  http://www.teleflex.com/elearning/pleurevac/splashscreen.html
·        Parklandhospital.com “Competency Evaluation:  Chest tube drainage insertion and maintenance,” 2009, http://www.parklandhospital.com/other_services/pdf/CHEST_TUBE_DRAINAGE_PRE_INSERTION_CHEST_TUBE_MAINTENANCE.pdf
·         Tube Thoracostomy:  How to insert a chest drain.”, British Journal of Hospital Medicine, Jan., 2006, Vol. 67, no. 1.
·        *St. Joseph Healthcare, “Going Home with a Chest Tube and Pleur-evac Drainage Unit,” http://www.stjosham.on.ca/media/PatientED/A-E/PD%203807%20Going%20Home%20with%20Chest%20Tube%20and%20Pleurovac%20Drainage-web%20version.pdf

2 comments:

Anonymous said...

Awesome! Thanks for the help, very well organized information! (Nursing Student)

Rick Frea said...

Thank you.