Chest tube drainage overview. Can someone give input?

decembergrad2011, BSN, RN · Oct 22, 2010

This is off the top of my head, but I had a patient with chest tubes last semester so here's what I remember.

The fluctuation shouldn't change while the tube is inserted because it's fluctuating due to normal ventilation. When all of the fluid has been drained, if fluid was the reason for chest tube insertion (there are others - look them up!) indicated by a decreasing amount of drainage in the collection chamber, the doctor will discontinue and remove the chest tubes if everything looks fine.

The most important nursing action, and the one that always seems to be tested on, is about what to do if the chest tube becomes detached from the chest wall (read: the chest tubes get pulled out, normally from patient or care provider stepping on the tubes while moving around and ripping them out - OUCH!). In this instance, the nurse's priority is to cover the open area with a gauze taped in three areas (basically a non-occlusive dressing) and notify the doctor. While waiting for the doctor to arrive, you should be monitoring your patient for signs/symptoms of tension pneumothorax. After reinsertion of a new chest tube system, the doctor should order a chest xray to confirm placement.

There are other issues as well, I would direct you to your textbook or to do an online search.

I'm not certain on the bubbling, and I don't have time to look it up, so maybe someone else can answer you more definitively on that.

chare · Oct 22, 2010

atrium refers to this as an air leak indicator in both their wet and dry collection devices. on the atrium devices there is a series of numbered columns of decreasing size as you moveg left to right. atrium states states that you should be able to gage the size of the air leak depending upon the number of the column that is bubbling, the larger the numbered chamber the larger the air leak. while i'm not certain i agree with that 100%, you can trend whether or not your air leak is increasing or decreasing by noting the chamber that is bubbling.

air bubbling in this chamber only indicates the presence of an air leak somewhere in the system. it could indicate a residual pneumothorax or a leak mechanical leak in the system. if the chest tube was placed as a result of the patient presenting with a pneumothorax or status post a thoracotomy, then bubbling would be an expected finding and should steadily decrease.

if your patient with a chest tube develops new bubbling or an acute increase in size and frequency or bubbling in the air leak indicator this requires further investigation to determine the cause. after assessing your patient and determining that he or she is still hemodynamically stable you can start trouble shooting to determine the.

first, look at the patient to determine that the chest tube is still intact. if the insertion depth was recorded verify that that has not changed either. after determining that the chest tube is intact, you can determine the location of the air leak by briefly and rapidly clamping and releasing the chest and drainage tube in various locations. start by clamping near the chest tube near where it exits the chest wall. if this stops the bubbling then there has been a change in the patient's condition or the chest tube has been partially dislodged and one of the suction holes along side of the chest tube has exited the chest wall. either way this is something that the physician needs to be notified of.

if clamping the chest tube near the patient's chest wall did not stop the bubbling then you have a leak in the system. this is the most common cause of a new leak in the system. to determine the location of the leak move distal of the closest connection and briefly clamp the tube again. when the bubbling stops you have identified the leaking connection.

the slight fluctuation that you might notice in the air leak indicator is called tidalling. as mentioned by decembergrad2011 if tidalling is present it is a normal physiological response, and if present will remain even after the lung has re-inflated. you might also notice this tidalling in the drainage tube if there any fluid has collected there as well. absence of tidalling does not always indicate that the chest tube has clotted or become obstructed.

if you are caring for a patient with a chest tube in place you must familiarize yourself with the facility's policy regarding care of the patient with a chest tube. this policy should provide information regarding emergency care for the patient who develops chest tube related complications. you should keep all emergency supplies at the patient's bedside, as well as take these emergency supplies with you any time you transport the patient.

as decembergrad2011 mentioned, if the chest tube is pulled from the patient you should cover the insertion site with an occlusive dressing. this should be a dressing that does not allow air movement through the dressing such as plastic film or some type of foil. some policies will state that this dressing should be sealed only on three sides. in theory this allows the pleural space to vent and prevent the development of a tension pneumothorax. at my facility we would place a tagaderm occlusive dressing over the site and seal all edges.

if the tubing is cut, or a connection in the system is lost and you are not able to reconnect that you could either clamp the tubing or insert the end into a bottle of either water or saline and provide a water seal at least.

while there are many manufacturers of chest tube collection devices, atrium is the one that i am most familiar with and that we use at my facility. however, the principles are the same regardless of manufacturer.

collection devices can be classified as either wet (or water seal) or dry. this does not refer to the presence of fluid in the air leak indicator chamber. regardless of which type of device you are using you do not regulate the amount of ordered suction by increasing/decreasing the amount of vacuum pressure set on your suction regulator.

if you are using a wet collection device this means that you must instill water to determine the level of suction provided. a wet collection device has a numbered column. for example, you your patient is ordered to have her or his chest tube placed to 10 cm h2o suction then you would fill this chamber to the 10 cm line. the atrium ocean is an example of a wet or water seal collection device.

if you are a dry collection device there will be an adjustable dial which you use to dial in the ordered amount of suction. the atrium oasis is an example of a dry collection device.

regardless of which of these devices that you are using, you do not need to instill water in the air leak indicator for these devices to work, although i have never worked in a facility in which they did not require that this chamber be used.

on their website they maintain the atrium university. you will find much useful information her, primarily under the following tabs: product support, interactive, and clinical update. if your school's skills lab does not have chest tube collection devices and educational material available, the nursing schools tab provides a form with which they can request material.

the following pdf publications are also available for download from the atrium website:

managing dry suction chest drainage

managing chest drainage

again, while these are written specifically for atrium products, the principles remain the same regardless of manufacturer.

you will occasionally find a provider or facility that still uses glass to create a drainage collection system. the emedicine clinical procedures website regarding tube thoracostomy, management has information regarding this. if you are not familiar with the site, emedicine is an excellent resource. the site requires a free registration upon the first visit.

i hope this information was helpful, and good luck in your schooling.

jcutler · Oct 22, 2010

Awesome post. thanks