Transcript Chest Tubes (PICU) - Lane Medical Library — Stanford

Chest Tubes and Drainage Systems
Deb Updegraff RN, CNS
PICU
LPCH
Chest Tubes
Correct life threatening conditions
caused by excess of fluid and/or air in the
intrapleural space
Pneumothorax
A collection of air in the pleural space.
Can occur with
• Central line placement
• Chest surgery,
• Trauma to the chest wall
• Traumatic intubation
• Mechanical ventilation
Tension-Pneumothorax
If air continues to collect in the chest, the pressure can rise and push
the whole mediastinum over to the other side
“Intra” pleural
Space
There are 2 pleural membranes
involved in respiration
• visceral pleura
• parietal pleura
The Parietal pleura lines the inside of the thoracic cavity. The visceral
Pleura adheres to the outside of the lung.
Pneumothorax
Hemothorax
A collection of blood in the pleural space
Can occur with:
•Chest surgery
•Central line placement
•Chest trauma
Hemothorax
Pleural Effusion
The accumulation of pathologic quantities of fluid in
the intrapleural space.
Maybe caused by:
• Liver and kidney failure
• Congestive heart failure
• Infection
• Malignancy blocking the lymphatic system
Empyema
Inflammatory fluid and debris within the
intrapleural space. Usually results from an
untreated bacterial pneumonia.
Other causes:
• Thoracic trauma
• Rupture of lung abscess into the pleural space
• Extension of mediastinal or abdominal infection
• Iatrogenic at time of thoracic surgery
Patient Positioning
Insertion Sites for Chest tubes
Pneumothorax: (AIR)
• The best position is supine or with
head elevated anywhere from low to high fowler’s.
• The chest tube will be inserted into the 2nd or 3rd intercostal space
anterior chest at the mid-clavicular line
Effusions: (FLUID)
• If patient able, best position is sitting on the side of the bed leaning
over a pillow placed on a bedside table.
• The chest tube is inserted between the 4th to 6th intercostal space
mid-axillary line
Insertion sites
How 3 chamber drainage system works
First Chamber
The Water Seal chamber
Fresh chest tube inserted, patient could suck air directly into chest.
The distal end must be controlled. The water seal chamber acts as
A one way valve. Air can get out and as long as the tube is long
Enough, water can not be sucked in. Bubbles moving through
This chamber means the patient has an air leak.
Second Chamber
Single chambers are fine if all you want to drain in air.
When there is fluid it’s time for a second chamber.
2
1
Third Chamber
Here’s an idea! What if the fluid is thick or just needs extra help to drain?
What if we could add suction? Time for a 3rd chamber.
2
1 water seal chamber
2 drainage chamber
3 suction chamber
1
3
1 Water seal chamber
2 Drainage chamber
3 Suction Chamber
3
1
2
Third Chamber –Suction Chamber
The strength of suction is directly affected by the
level of water. The MD will order this. In Pediatrics
the amount is usually 15cm.
You need regulated wall suction. The weight of the
water acts as the suction limiter. No matter how
Hard the wall suctions pulls, the actual suction delivered to
the patient is 15cm.
Now back to Air Leaks
First Chamber-Water seal chamber
This chamber shows an air leak. This is a
Good thing if you have just placed the tube
For a pneumothorax. It means the air is
Getting out of the patient.
This does not automatically mean that air is
Coming out of the chest.
The leak can be coming from anywhere in the
System and this can be bad.
1
1
If the chest tube is pulled and dislodged, the drainage holes can actually be
“outside of the patient” sucking air. Air can dangerously accumulate.
In addition to the bubbles in the air leak chamber you should be able to hear
this with a stethoscope.
What to do:
• Take dressing down wrap hole with Vaseline gauze
• Call for a stat CXR.
Clamping a Chest tube
• Clamping a chest tube is a very big deal
Only clamp if you are:
Changing a full pleurovac
Or if you are
Trying to determine if the system is
leaking.
Water Seal
• Usually this is ordered when the air/fluid
draining from the patient is assumed to be
pretty much over and done with.
• What carefully for signs of re-accumulation
It means to disconnect from wall suction