Advice on pt with open chest Please!

Maevish, ASN, RN · Oct 19, 2010

Usually bubbling is due to a leak somewhere, you just have to find out where it's coming from.

You can check all the connections to make sure they're not loose or off, if you check the tubing for leaks and the leak is in the tubing, then the unit should be replaced. Sometimes the leak can come from the insertion site so you can CAREFULLY remove the dressing and make sure you can't see the eyelets in the catheter and if you hear/hear anything from the site, then the leak is in the lung itself.

And check if the bubbling happens all the time or in spurts. Like, if it fluctuates when the pt breathes and they're not on the vent, it's probably coming from a leak in the lung.

Sometimes, though, the doc is aware of the leak and you should get that in report. The magnitude of the leak should be documented so you know if there are changes from the previous inspection.

HOWEVER, with a medicinal chest tube there should be NO bubbling or movement of fluid in the water seal chamber!

Otherwise, gentle bubbling is normal (unless the pt is vented, then you get crazy fast bubbling). When the bubbling is too fast, it increases vaporization of fluid which gives you less suction.

I hope this helped a little. We don't get open hearts at our facility, but the basics of CT operation would be the same, I would think.

Xoxo

sweetart4988 · Oct 19, 2010

When a pt has an open chest there is always bubbling in thier chest tubes, at the time the pt chest is open b/c they were unable to close the pt chest in surgery due to different circumstances. I just want to know what causes the bubbling if anyone knows! Thanks

Maevish, ASN, RN · Oct 21, 2010

Sorry, guess I misunderstood. The constant bubbling in an open heart (ore any open chest surgery as far as I understand--and someone please correct me if I'm wrong ) is because the air that got trapped in the chest for during the procedure is coming out, which is good, but with that pt, you have to be sure you check for leaks that could be in the drainage system itself. You wouldn't want to assume that, since there's bubbling, that everything's ok.

HyperTension · Oct 21, 2010

No..

And no... You have an air leak. (Give myself the Captain Obvious award for that statement alone). Causes for such are many, compounded with the fact your patient has an open chest (retracted open, or just not sutured?). Is this leak related to a communication through the dressing placed in the OR, secondary to lung injury (trauma, surgical, cancer, COPD bleb......)

Chest tubes placed into the mediastinum are done to drain blood postoperatively and to prevent cardiac tamponade.

Any time you have an air leak that was not noted in the OR at time of placement, you essentially start from the patient and work back. Make sure your dressings are secure, tube connections valid, no possibility of this communication of air is occuring outside the patient.

To be honest, it doesn't suprise me that a patient with an open chest has an air leak from the adjacent mediastinum being open. Everything that keeps their chest enclosed has been interrupted (either surgically and / or due to and now "patched" closed. It may not be "air tight". You may have a communication from the pleural cavity, I don't know given the level of information given with this post.

A good link to review / research: Go with the flow of chest tube therapy .

I apologize that this reply is not as linear as I'd like it to be, please post / PM if more information requested.

Maevish, ASN, RN · Nov 5, 2010

Yeah I've always heard that the mediastinal chest tubes can have bubbling anyways, but I'm glad you said something cause I don't have as much experience in this area as I would like (HATE CTs and trachs cause I don't get them too often and am not comfortable with them).

I've never had that constant bubbling, but I looked up some stuff and it said that when you have an open heart pt that that can/will happen.

I love learning so bring it on and thanks for the question:yeah:

xoxo!!

clementinern · Dec 1, 2010

You are correct that a pt with an open chest does bubble most of the time. It's precisely because the chest is open, so you pretty much always have a leak. Regarding Maevish's post about how there shouldn't be any leak in a mediastinal tube- while this is true, most of the time in open heart pts, they actually have a pleural tube in there as well. If they have just 2 tubes they're likely only mediastinal- if they have 3, the one on the pts left is a pleural tube to the left chest. If they have 4, they probably have 2 mediastinal and a pleural tube to each lung. So, you can see leaking because while it looks as though they are all mediastinal, really one or 2 are places in the lung.

So, it's pretty tricky to have an airtight seal with an open chest cavity, so you'll pretty much always have a leak. Hope this helps.

Ruby Vee, BSN · Dec 1, 2010

hi, i am new to the surgical intensive care unit. in a pt with an open chest what causes the constant bubbling in the medistinal chest tubes? what are complication i should look for in pt with an open chest?
thanks for your help

if the chest is open, that's most likely where your air leak is coming from. is it covered with esmark and ioban? it's pretty hard to get those absolutely air tight.

if your patient's chest is open, you're not going to want to let him wake up due to the danger of him thrashing about. think about what would happen if your patient flailed his arms or attempted to turn with an open chest! (shudder!) i've heard stories -- can't testify as to their truthfulness -- about a patient with an open chest who sat up and his heart got squeezed between the edges of his open sternum with fatal results. it may be just a story older nurses use to scare younger ones, but i keep hearing it.

infection and bleeding are real risks. usually the dressing is placed in the or and isn't changed until the patient goes back to or for a washout and/or closure. check constantly to make sure the ioban dressing covering the chest is concave. if it starts bulging, you may have a potential tamponade. if the surgeons have to re-open the chest at the bedside, they'll place new esmark and ioban dressings and once again, we don't change them.

hope this helps