Chest Tube LCS

MunoRN, RN · May 22, 2021

We use the generic term "chest tube" for tubes that serve different purposes, the purpose of the tube along with what's going on with the patient that necessitates a tube is what determines what could happen by being off suction.

A chest tube used to evacuate drainage from a surgery, such as mediastinal tubes after open heart, is only on suction (if it is at all) to keep the drainage from stagnating in the tube and potentially clogging the tube. The suction is mainly helpful when the patient is in bed since there is less help from gravity to keep the drainage moving down the tube.

A chest tube that is placed to treat a pneumothorax, whether it's spontaneous, traumatic, or due to surgery such as a wedge resection is more critical to be on suction continuously, since without suction the lung could drop. Typically, if this type of tube has an air leak then you know that without suction a pneumo will develop. If there's no air leak then that suggests the suction of the chest tube is not actively preventing a pneumo and the patient could be off suction without a problem, although if when off suction or when the tube is clamped the patient suddenly becomes dyspneic or has other signs of a pneumo, then the patient should immediately be placed back to suction.

Typically the physician should be specifying what their expectations are for chest tube suction.

Hannahbanana, BSN, MSN · May 22, 2021

As Muno points out, it depends on why the chest tube is in there. This is a tutorial for how to think about that :).

Chest tubes, pneumothorax, and tension pneumos made clear
This little tutorial started out with a few sample NCLEX questions someone
posted. I answered this one....
<< On the way to an x-ray examination a client with a chest tube becomes
confused and pulls the chest tube out. The nurse's immediate action should
be to:
1. Place the client in Trendelenburg position
2. Hold the insertion site open with a Kelly clamp.
3. Obtain sterile Vaseline gauze to cover the opening.
4. Cover the opening with the cleanest material available.>>
As always in NCLEX-land (and in real life), you're looking for the answer that
keeps the patient safest. I know you'd rather cover that hole with
something sterile, but what is a greater immediate danger to this
unfortunate fellow, an infection (which may not even develop) or a great
honking pneumothorax (which certainly will)?

And while we're at it, let's talk about how you know whether to clamp or not
to clamp a chest tube that has been disconnected from its drainage device
(but is still in the pleural space). To understand this, let's look at the
differences between a tension pneumo and a pneumo that isn't a tension
pneumo .

Respiratory mechanics first ! When you breathe in, you're not actually
pulling air into your lungs with your muscles. You're actually making a suction
inside your chest with them (I know this may seem like a distinction without
a difference, but stay with me), and the air enters the lungs thru the route
provided for it to do so-- your trachea, via your nose or mouth (or trach
tube, if you aren’t so lucky).

Your lungs are covered with a slippery membrane called the visceral pleura.
The inside of your chest wall has one too, the parietal pleura. They allow the
lungs to slip around with chest wall motion, like you can slip two wet glass
plates around that are stuck together. Like the two glass plates, they're
hard to pry apart due to the surface tension of the wet between them, and
that's why the lungs fill the chest cavity and stay there. But just as you can easily pop those glass plates apart if you get a teeny bit of air between them, you can pop the bond between the two pleural layers with air, and if you do, the natural elasticity of the lung will cause it to collapse down to about the size of a goodish grapefruit.

How does the air get in the pleural space where it doesn’t belong? Well, you
can do it two ways. One is to play rough with the bad boys (or have surgery,
which is, after all, only expensive trauma) and have a sharp object puncture
your chest wall and admit air into the pleural space. How does it get in
there? Well, you make suction in your chest when you breathe in, and now air
has TWO routes to get inside your chest-- down the trachea into the lungs,
and thru the hole in the chest wall into the pleural space. This is called a
pneumothorax, air in the chest that is outside of the lung. The lung will tend
to collapse because the surface tension between the wet layers is now
interrupted (remember how the pieces of wet glass can be separated by
introducing air between them?) and the lungs are naturally elastic.

The other way to get air into your pleural space is from having blebs/bullae
on your lung surfaces, and pop one (or more), or have some other hole in your
lung (sharp things again). Then air gets out of your lungs thru the hole(s) and
disrupts that pleural side-to-side thing, and there you go again, a
pneumothorax. This, however, is called a TENSION pneumothorax, because
that air increases with every exhalation (the lung now having two routes to
exhale air out of, the trachea and the hole in the lung itself). This allows the
lung to collapse on that side, and soon enough pressure (tension) will develop
in that half of the chest to push the chest contents over to the other side,
compromising blood flow and air exchange in the other lung & heart when it
does so. (This is when you see the "tracheal shift.") This is also a bad thing.

So: now both of these fine folks have bought themselves chest tubes. The
guy with the chest wall trauma has had his trauma hole sewed up, so when he
takes a deep breath air enters his trachea only. He has a water seal on his
chest tube so he can't pull air into his chest thru the tube-- the water seal
acts like the bend in your sink drain and prevents continuity of the inside
and outside places. The suction on the chest tube setup has done its job of
removing the air from the pleural space where it didn't belong--it was seen
bubbling out thru the water seal and then couldn't get back in. (When all the
air is gone from his pleural space, there will be no more airleak in the water seal compartment.) Now, if he disconnects his Pleurevac (or other copyrighted device), he can again take a deep breath and pull air thru the open tube into his pleural space, where it doesn't belong, collapse his lung, and start all over again. THEREFORE, when this guy disconnects his tube,
you clamp it IMMEDIATELY, to prevent air from entering the pleural space.
He should ALWAYS have those two big old chest tube clamps taped to his
Pleurevac (so they go with him to xray and all), just in case he does this.

However, the other guy, with the ruptured blebs and the intact chest wall?
Well, his chest tube is pulling air out of the pleural space, but more is still
getting in there since he still has a hole in his lung. The idea of the CT suction is to
pull it out faster than he can put it in, and allow the hole to heal up, at which
point he will no longer collect air in his pleural space and be all better.
Meanwhile, though, you see air bubbling in the waterseal chamber, showing
you that there is still air being pulled out of his pleural space. He has “an air
leak.” What happens to him if his chest tube gets disconnected?

Well, remember, he still puts air into his pleural space, because there's still
a hole in his lung. You put a tube in there to take it out, remember? OK, so
what happens if you clamp his tube (or remove it from suction)? Bingo, air reaccumulates in the pleural space all over again, his lung collapses, and things go to hell in a handbasket.
This guy should NEVER have clamps at his bedside (or go off suction for more than a minute), because some fool may be tempted to clamp his tube before his airleak seals, and he'll get in
trouble all over again. If he pulls his tubing setup apart, have him breathe
slowly and shallowly (to minimize the air leaving the hole in his lung and
getting trapped in his pleural space) while you quick-like-a-bunny hook him up
again to a shiny new sterile setup. But do NOT clamp his tube while your
assistant gets it set up for you.

Hope that helps with an overall perspective.

LovingLife123 · May 22, 2021

It honestly depends. Usually we use a portable suction to transfer patients if they have chest tube that requires suction. I’ve had a couple of times when I was traveling to CT and asked if it was OK to take off suction for a short period of time. I got an order from a physician to do that.

Most of the time, when a pt in transferring to the floor their chest tubes are set to water seal at that point. But if they are still maybe a day away, and are able to go to the floor I would use a portable suction. Is there a reason this wasn’t used? Was there a physician order to transfer the patient off suction?

Also, any chest tube I have ever worked with had a setting of either 20 or 40 of wall suction. I think this depends on your orders, and what the morning CXR looked like. I deal with mostly pneumos and hemos.

FutureNurse0201 · May 22, 2021

Thank you for your responses, these clarify some of the confusion about CT. My pt had CABG surgery three days ago, was transferred from ICU and in that process between transfer and our suction not working (and getting a new one from another room) it took max 45 min. It was the end and change of shift (pt arrived at 6.30). Well, the night nirse told the pt that “it is very very bad” freaked him out, reported me to the manager and made drama on the floor. So I was concerned about the pt and about being reported.

LovingLife123 · May 22, 2021

7 minutes ago, FutureNurse0201 said:

Thank you for your responses, these clarify some of the confusion about CT. My pt had CABG surgery three days ago, was transferred from ICU and in that process between transfer and our suction not working (and getting a new one from another room) it took max 45 min. It was the end and change of shift (pt arrived at 6.30). Well, the night nirse told the pt that “it is very very bad” freaked him out, reported me to the manager and made drama on the floor. So I was concerned about the pt and about being reported.

Did you contact the physician prior to going to CT about the portable suction being broken and asking if it was OK to go?

FutureNurse0201 · May 22, 2021

There was no portable suction. ICU transferred pt to us without one. Our suction wasn’t working, it looked like it was but it wasnt. I tried fixing it (nearly injured myself) and it was already 7 pm when I decided to ask night nurse to help me since everyone was busy with the report and this will be her pt anyway. She got mad and first said how being off suction is really really bad, then ran to charge nurse to report me, then to manager and came back to help me get it off the wall and fix it

LovingLife123 · May 22, 2021

3 minutes ago, FutureNurse0201 said:

There was no portable suction. ICU transferred pt to us without one. Our suction wasn’t working, it looked like it was but it wasnt. I tried fixing it (nearly injured myself) and it was already 7 pm when I decided to ask night nurse to help me since everyone was busy with the report and this will be her pt anyway. She got mad and first said how being off suction is really really bad, then ran to charge nurse to report me, then to manager and came back to help me get it off the wall and fix it

It’s hard to say without actually being there. I’m going to guess night shift was being a little dramatic but again I wasn’t there and not privy to every detail about this patient. If ICU transferred without portable suction, it probably wasn’t a big deal.

This also shows why you always need to assess your room before accepting a patient. I know ER always rolls their eyes when ICU says give me 10 minutes to get the room set up, but this is why. I need to ensure every aspect of my room is working and ready.

FutureNurse0201 · May 22, 2021

It is a practice at the hospital (possibly with exceptions) to transfer with no portable suction. So far all of the pts I received from ICU were without suction (actually I have never seen a portable suction). And there was that suction noise in the suction but when actually connected to the CT it does nothing. In meantime, my pt wanted pain pill right away but wasnt in the system yet, his wife was on the phone asking about his meds and 30 min just flew by.

Wuzzie · May 22, 2021

2 hours ago, LovingLife123 said:

I’m going to guess night shift was being a little dramatic

Ya think? ?

MunoRN, RN · May 22, 2021

4 hours ago, FutureNurse0201 said:

Thank you for your responses, these clarify some of the confusion about CT. My pt had CABG surgery three days ago, was transferred from ICU and in that process between transfer and our suction not working (and getting a new one from another room) it took max 45 min. It was the end and change of shift (pt arrived at 6.30). Well, the night nirse told the pt that “it is very very bad” freaked him out, reported me to the manager and made drama on the floor. So I was concerned about the pt and about being reported.

The chest tubes commonly placed after CABG aren't the ones where it's important to keep them to suction continuously, particularly if the patient is upright (walking or sitting in a chair / wheelchair). And by 3 days out the drainage should be serous enough that suction isn't really doing much.

The night nurse made a stink for no good reason.

amoLucia · May 22, 2021

Muno - as per usual, you info was very informative for me.

HB - you offer great info also, but this time, it was just toooooo much all at one time. I'll go back to catch up.

Have you ever thought of providing short articles here on AN that covers various topics??? Keeping it short & simple though - not in too much length or depth. I'd venture many of us retirees or those in other specialties, might find reading educational.