Chest Tube Question
- 1Aug 3, '07 by TigerGalLEWe use LPNs on my floor. They cannot do IV pushes. So an LPN asked me give solumedrol and ativan to her patient. So I agree and head down to the room. When I get in the room the patient seems to be in quite a bit of respiratory distress. I don't know much about the patient so i question her if she has been SOB for long. She tells me she just returned from xray and she has been short of breath throughout her hospital stay but not this bad. I also hear a terrible sucking, burping type noise. I remember hearing something about a chest tube removal earlier in the shift. I ask her if she had a chest tube removed today and she said she did. I grab a set of vitals and an O2 sat. Her O2 sat was 82% on 2L and I bumped her up to 5L where she came up to 92%.
Remember I know nothing about this pt. I call for her primary nurse to come to the room. I see her outside the room and she says she just picked up the pt at 1500 and she hasn't seen her yet b/c she'd been in xray.....
Anyways she reinforces the dressing and we get a stat portable CXR. She calls the physician and i go back to my patients...
My questions is.. why was it making that terrible sucking noise?? I know that can't be good and it has something to do with the air passing through the old chest tube site, but i don't quite understand why it would do that. And I hate to sound like an idiot. But the other nurses just told me it shouldn't be doing that.. But I was wanting a better explanation. If y'all could help that'd be great.
- 1Aug 3, '07 by KarenBecause each time the patient breathes it causes a vacumn and if air is being sucked through the old chest tube site it will make that sucking sound. It is exactly as it sounds. As air is sucked in it places pressure on the lung and it will recollapse, definitely an emergency. You did the right things, but checking the dressing immediately is important because you can prevent more air from being sucked in by perhaps repositioning it or if it is totally off, placing a gloved hand directly on the opening.
- 1Aug 3, '07 by GilaRRTSounds like a sucking chest wound. Did she have a fall or some kind of trauma following the removal of the tube? Typically, a purse string or other similar type of suture method is utilized upon insetion. Then, after the tube is pulled, the suture is used to close the wound. If she did not develop dyspnea right after the removal, I would suspect something happened that compromised the site.
In many cases we will apply an occlusive dressing secured on three sides to the wound. The rationale is to allow for the escape of air through the open side and thus prevent a tension pneumothorax; however, if there is a large communicating open area, then air would have a difficult time building up. So, I would not fault you for reinforcing the dressing. Did you note SC emphysemia, JVD, tachycardia, or hypotension?
- 3Aug 3, '07 by FlyingScotThat terrible sucking noise was air being sucked into her chest cavity when she took a breath. I'm not sure where you are in your nursing career so if you know the following info all ready please forgive me. When we breathe our diaphragm muscle flattens and drops while the muscles in our chest rise pulling the ribs up and out. This causes negative pressure in the chest and draws air into our lungs like a bellows. Another way to demonstrate this is put on a glove at work sometime and leave it on till it sticks to your hand. Once it has stuck turn your hand palm up and pinch the glove in the center of your palm and pull up. What happens? Well you'll notice that air comes in and that is exactly how the lungs work. So when you have a patient with a wound that penetrates into the chest cavity whether by choice (chest tube that has been removed) or accident (stabbing) it is imperative that you frequently assess the dressing covering it because it must be occlusive. If it is not occlusive then every time your patient takes a breath air from the room will rush into the chest cavity and will eventually collapse the lung. We call this a "sucking chest wound" and it is a true emergency. In the future if this should happen again the first thing you do is clamp your hand (wearing gloves of course) over the wound if the dressing is off or over the dressing itself. When I say clamp I mean really press on it because you want to stop the air from coming in and yell like hell for help. If you are allowed at your facility place the patient on 100% with a non-rebreather mask. A stat CXR is warranted to see if the chest tube has to go back in. This patient then needs close monitoring. She was very lucky that you remembered the chest tube removal. This could have had disastrous results. You and your coworker did the right thing. Hope this helps. BTW.what happened to the patient?
- 0Aug 3, '07 by TigerGalLEShe was tachycardic (around 115), but her BP was high 170ish/90ish. I don't remember seeing and JVD. My main goal was to get the primary nurse and get the physician notified. It wasn't my patient so once the patient's O2 sat was stable and she was no longer in acute distress I had to go back to my patients... So I'm not sure what the portable CXR showed or what became of the situation.
I think however, that the physician was on the way to possibly suture the site. After reinforcing the dressing the sucking stopped, however like I said I'm not sure what the CXR showed. I wish now that I knew. Everything was so crazy on our floor this afternoon that I didn't have a chance to stop and find out.Last edit by TigerGalLE on Aug 3, '07
- 0Aug 3, '07 by NREMT-P/RNYep, sucking chest wound.
Good catch, sounds like you may have saved the patient and the LPN.
Some days you get the BEAR!
Bet you (and the LPN) will never forget this experience. I always watch chest tube patients closely - when I place the tube, while the tube is in and (in the facility) after removal. Clinical presentation of the patient AND integrity of the tube-site-sutures-dressing.
Good job for the Patient! You did just what you should have done!
- 0Aug 4, '08 by juan de la cruz, MSN, RN, NP Guidewhen disconnecting a CT pt from suction for transport, do you leave the suction tubing open to air or clamp it, and why?
You should never clamp a chest tube without a physician's order, even when transporting the patient. When you clamp a chest tube you leave no room for air to escape out of the water seal system. You may cause problems by doing this such as air being sucked back into the pleural cavity causing a pneumothorax. When you leave the suction tubing open, you create a one-way flow of air allowing it to still escape out of the closed water seal system but at the same time preventing atmospheric air to enter the other direction through the chest tube into the pleural cavity.
In our cardiothoracic surgery practice, we never order a patient with a chest tube on wall suction to leave the unit unless necessary. If the patient needs an x-ray, I order a portable unit. Leaving the chest tube off suction can sometimes cause the lung to drop. Because of that, I usually order a chest x-ray six hours after placing the chest tube on water seal (other term for removing the wall suction). Placing the chest tube on water seal can be used as a trial run for a chest tube removal the next day in most lung surgery patients as well as those who ended up with a chest tube because of a pneumothorax.
There are indications for clamping the chest tube. One is when the physician performs a pleurodesis. That is when an irritant substance (such as talc or an antibiotic solution such as Doxycycline) is injected into the pleural cavity to cause local irritation around the pleura and cause the lung surface to stick to the visceral pleura to prevent recurrence of a pneumothorax. Typically the chest tube is only clamped for 4-6 hours and then released later.