chest tube question

[pinky11889]

I was working a night shift and taking care of a patient that needed a chest tube due to a pleural effusion; the order was to keep the chest tube to gravity drainage. After a couple hours I noticed the dressing became saturated so I called the pulmonary doctor and he told me to change the order to wall suction, 20cm. I set up the suction, changed the dressing, then reported off the day nurse. During the day the patient drained a large amount of fluid. I worked again that night and she only put out about 100.

I worked again today and noticed when looking at her I&Os that her chest tube output was significantly less during the 7p to 7a shift when compared with day shifts. I was wondering why this is happening, or is this just a random coincidence?

I was a pleur-vac sahara chest tube drainage system, the one that doesn't use water.

[Mischief47]

Generally a patient is less active during the night and if on free drainage then this would be quite understandable, but given that the patient is on suction then this should not really affect the output, unless the patient is kinking off the tube during sleep then it is possible that the build up overnight will increase drainage throughout the day. Hope this helps some. Maybe someone else has other ideas..

[pinky11889]

I had her during a night shift and I made sure we positioned her in a way that would not kink the tube. During night shift I felt that something was wrong almost, and that she should be putting more out. Maybe I'm thinking too much.

The patient was very elderly, but appear comfortable.

What would happen if the chest tube was set to wall suction, but was still leaking around the dressing. Would that mean the tube pulled a bit? Or the tube was clogged? Just wondering.

[Mischief47]

Always a good thing to check for leakage, because the suction is then not doing its job and could infact cause a pneumothorax if air gets in or it could also cause subcutaneous emphysema which is air in the subcutaneous space. This feels like bubble wrap on palpation. Check the suture is still intact and the tube should always be checked. Our tubes over here have cm/mm marked on them. Thats how we tell if there has been any movement of the tube, its checked at the measurement every shift and we only use underwater seal drainage on and off suction. Bubble and swing ensure that the tube is doing its job. That your tube is draining means its not clogged.

Don't overthink what your doing, check from patient to wall, as long as her vitals are stable it shouldn't cause any harm.

[Mischief47]

[nursej22, MSN, RN]

We see big differences in CT output on our OHS patients depending on the time of day as well. If you consider that the pleural fluid is dependent, then it's only going to drain when the drain tube is in the fluid. When your patient is upright, the fluid is around the drain tubing and be collected. When she is lying down, the fluid may pool behind the lung, away from the drain.

Depending on the nature of the fluid it can have a lot of fibrin and actually clog the little holes in the drain. We have used TPN in some patients to try to keep the drain patent. This is usually in cases of empyema, though.

And always check the tubing from patient to collection chamber to the wall. Even a little pinpoint hole can affect suction.

[Chestdoc]

To me it sounds like the chest tube is clogged. Sounds like many of the others agree. The tube is clogged so the fluid is being forced out around it. This means the doctor can try to suction the tube out, or flush it, or more likely, put in a new chest tube or take the patient to surgery for a thoracoscopy. That sounds extreme, but if you have a chest tube you want it to drain properly, which this one is not.

Chest tube clogging is not an uncommon problem. There is a new product that can prevent this, called the PleuraFlow. (The Active Tube Clearance System: A Novel Bedside Chest-Tube Clearance Device, Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery: January/February 2010 - Volume 5 - Issue 1 - pp 42-47). Might be worth checking into because this problem can lead to complicaitons and even infections, increased costs, etc.