The Pleural Space
In the thoracic cavity, the lungs are surrounded by two thin membranes. The membrane that wraps tightly against the lungs is called the visceral pleura, and the outer layer is called the parietal pleura. Between these membranes is a thin space filled with air called the pleural space. The pleural space is very important to the function of the lungs. This space is under negative pressure, pressure less than atmospheric air. The differences in pressure between the pleural space, lungs, and outside air are what create inspiration and expiration.
When there is a disruption in this negative pressure either by trauma, surgery, or a pathological process (like a tumor or infection), the negative airspace in the pleural cavity can fill with air or fluid. This upsets normal breathing as the lung is compressed or collapsed.
Indications for Chest Tubes
A chest tube is indicated to evacuate excess air or drain fluid when the pleural space is compromised. A chest tube is a flexible catheter inserted into the pleural space from outside of the chest wall. These tubes can be small bore, (14 French) or large bore (up to 42 French). In current practice, small bore chest tubes are used for both air and fluid evacuation, as they are less invasive and have fewer complications than large tubes. A large bore tube may be indicated if there is a concern that the tube may obstruct easily because of large amounts of blood or thick exudate.
A pneumothorax occurs when the pleural space fills with air. A pneumothorax can be caused by trauma or disease processes when the pleural space is compromised. When the pressure from the air leaking into the space becomes greater and greater (with every breath), a tension pneumothorax results and can cause the collapse of the lung and the compression of vital vessels, the heart, and trachea. This is a life-threatening emergency that must be treated with a chest tube.
Hemothorax and Pleural Effusion
A hemothorax is a blood collection, while pleural effusions are caused by the collection of transudates or exudates in the pleural space. These conditions can be caused by surgery or disease processes such as cancer or emphysema. Both may be treated by chest tube drainage. Some effusions are chronic and require palliative drainage several times a week using a special long-term chest drain.
Insertion of Chest Tubes
Chest tubes may be inserted in an operating room or at the bedside. This must be done using sterile procedure. The patient may be given local anesthesia and pain medication but is generally not sedated. The procedure is done by a physician (often a thoracic surgeon) or a specially trained advanced practice nurse. An incision is made in the chest wall, and the tube is inserted between the ribs and then sutured in place. A dressing is placed around the tube.
The nurse assists in the procedure by medicating the patient and providing education to the patient and family. He or she ensures that the sterile field is maintained and assists the physician as needed. The nurse will monitor vital signs and respiratory status during and after the procedure.
The nurse should connect the chest tube to the closed drainage collection device once in place, and apply suction if appropriate. The collection chamber should maintain a water seal at all times. A water seal is an area of water within the drainage system between the chest and the environment. It allows air to be expelled out of the pleural space but prevents atmospheric air from entering the pleural space and causing or exacerbating a pneumothorax. Some drainage collection systems do not use a traditional water seal, but instead have a special one-way valve. It is important to know which type of drainage system is being used.
The nurse should monitor cardiopulmonary status closely after the insertion of a chest tube until breathing stabilizes. This includes vital signs, oxygen saturations, and mental status. Signs of possible complications include tachycardia, hypotension, tachypnea, decreased breath sounds, decreased oxygen levels, fever, and decreased levels of consciousness. The nurse should assess and treat pain as needed.
Once stabilized, the nurse should continue to monitor the patient carefully. Assessments include auscultating lung sounds and monitoring respirations, lung expansion, and oxygen levels. The nurse must also monitor the area around the insertion site for bleeding and subcutaneous emphysema, the leaking of air beneath the skin that can be seen or felt with gentle palpation. Subcutaneous emphysema is often described as feeling like stiff paper crunching or crispy rice cereal popping when touched.
The nurse should also monitor and document the amount and type of drainage in the system and reports any changes.
The Drainage System
There are different types of drainage systems and the nurse should be familiar with the preferred system of the specific organization. A chest tube to a drainage system can be left to drain by gravity, or connected to vacuum suction depending on the physician order. The nurse should frequently assess that the collection system is functioning properly and that there is no leak in the system connections.
Most collection devices have a water seal chamber. Normal findings in this chamber include tidaling which is a gentle rise and fall of the water level with inspiration and expiration. Excessive bubbling in this chamber is likely the sign of an air leak.
The tubing between the chest and the drainage system should never be milked or clamped. This can cause excessive air pressure to the pleural cavity and result in a pneumothorax. The collection system should remain at a level lower than the chest at all times.
If the chest tube drainage collection system is broken or upset at any point, the entire system should be replaced. The tube should be briefly clamped while exchanging systems to avoid air entering the chest cavity. A bottle of sterile water should be kept at the bedside in case the drainage system is compromised, the tube can be placed in sterile water as a temporary water seal. Dressing supplies should also be at the bedside. If the tube dislodges from the insertion site, the site should be covered with a gauze dressing with tape to three sides.
Chest tubes are inserted for the treatment of various conditions such as pneumothorax, hemothorax, and pleural effusions. The nurse plays an essential role in assisting with the insertion procedure and the monitoring of the patient during and after chest tube placement. The nurse should perform frequent assessments of the patient's cardiopulmonary status and the condition of the drainage system itself.
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