Chest Tube Question

  1. 1 We 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.

    Thanks
    Tiger
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  3. Visit  TigerGalLE profile page

    About TigerGalLE

    From 'SC'; 30 Years Old; Joined Feb '07; Posts: 791; Likes: 944.

    19 Comments so far...

  4. Visit  Karen profile page
    1
    Because 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.
    TigerGalLE likes this.
  5. Visit  GilaRRT profile page
    1
    Sounds 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?
    TigerGalLE likes this.
  6. Visit  FlyingScot profile page
    3
    That 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?
    NRSKarenRN, TigerGalLE, and OLDCARTS like this.
  7. Visit  TigerGalLE profile page
    0
    She 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
  8. Visit  NREMT-P/RN profile page
    0
    Yep, 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!

  9. Visit  eagle1953 profile page
    0
    can anyone answer this......when disconnecting a CT pt from suction for transport, do you leave the suction tubing open to air or clamp it. and why? am getting conflicting answers on this one.......pls help
  10. Visit  juan de la cruz profile page
    0
    when 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.
  11. Visit  juan de la cruz profile page
    0
    ...oh by the way, you of course would need to clamp the chest tube momentarily while changing the closed water seal system when it needs to be changed.
  12. Visit  eagle1953 profile page
    0
    my question was, when suction tubing is disconnected (not the water seal tubing) do you leave it open to air - of clamp it..........
  13. Visit  eagle1953 profile page
    0
    the pleurovac on our unit has a shut off valve on the short suction tubing that connects it to the longer tubing to wall suction. If this short suction tubing is supposed to be left open to air when the system is to gravity, why is there a shut off valve there? The doc on our unit went ballistic when he saw it open to air -- don't understand his thinking.
  14. Visit  jlcole45 profile page
    2
    To respond to the original posting .....
    It sounds like the occlusive dressing that should have been on correctly was not - You said chest tube had been removed -- so what you heard was a sucking chest wound - air moving into the pleural space with each breath. This is not a good thing to hear!

    By the way a low sat O2 is a late sign of resp distress ... bumping up the o2 will help some, but really the problem was something else. All you can do is reinforce the dressing and stay with the patient while X ray is done and set up for another chest tube - because if the pt had a big pnemothorax then another CT should be inserted. If you have decreased breath sounds on the same side then you can bet money that they have developed a pnemo.

    Now to address some of the other postings related to chest tubes....
    First, I have to say that I'm a bit disturbed about some of the questions and answers I've seen here. If you're taking care of patients with chest tubes then it's your responsibility as a professional to know how to take care of them. You can get a patient into serious trouble FAST if you don't understand what you are doing.

    You NEVER leave a chest tube "open to air" - it will result in a pnemothorax!!! Because you are allowing air to enter into the pleural space which will cause the lung itself to colaspe - this is due to pressure changes.

    Chest tubes are treated 3 ways-- Either it is to water seal, water seal and suction, and or clamped - which is done sometimes prior to removal and only with a MD order. The only time you as the nurse would clamp the tube is to change the drainage system (the container is full and you need to hook up a new one).

    They only time you discontinue the suction to a CT is with a MD order, otherwise leave it on.

    You can trust what I am telling you because 1). I have many years experience and 2). I take care of chest tubes every day as I work with post op heart and lung patients - and every one of them has chest tubes after surgery.

    For all of you who caring for patients with chest tubes - PLEASE seek out your unit educator to learn how to properly take care of these patients.
    nurseme3 and eagle1953 like this.
  15. Visit  annmariern profile page
    0
    Quote from eagle1953
    the pleurovac on our unit has a shut off valve on the short suction tubing that connects it to the longer tubing to wall suction. If this short suction tubing is supposed to be left open to air when the system is to gravity, why is there a shut off valve there? The doc on our unit went ballistic when he saw it open to air -- don't understand his thinking.
    I think I know what you mean, the same question came up last week so we asked the surgeon; He said it doesn't matter, the valve is just to turn off suction while you top off the fluids when in use. When wall suction is off and its to water seal it doesn't matter, the water seal will prevent air from reentering the lung. Most of out CT pts go to radiology off suction, because they get a better film. Not sure why you doc was freaking out? Hope that helps.


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