Mikhael Earl S.

Tacorda
Group A- 1D
Chest Tube Thoracostomy (CTT)
A chest tube, chest drain or tube thoracostomy is a flexible plastic tube that is inserted through
the side of the chest into the pleural space. Chest tubes are made of clear plastic (vinyl or
silastic). They are available in varying diameters, sized in multiples of 4 on the French scale (eg.
Adult or Teen Male = 2832 Fr, Adult or Teen Female = 28 Fr, Child = 18 Fr, Newborn = 1214
Fr). They have multiple side holes to allow effective drainage and have length markers to help
note the distance of the lowest hole from the skin surface. A radiopaque strip lines the tube to
help easy visualization on chest radiography.

Some tubes are mounted on stylets or trocars that
act as guides to help insertion and proper placement of tubes.
Purposes
Drain fluid, air and lung effusions.
Re-expand collapse lungs
Normalize intra-thoracic pressure
To maintain equilibrium in respiratory system
Conditions requiring CTT
Pneumothorax
Hemothorax
Hydrothorax
Chylothorax
Empyema
Pleural Effusion
Penetrating lung injury
Post-operative modalities
Assessment for Emergency CTT
Dyspnea
Cyanosis
Restlessness & agitation
Chest pain
Tachypnea (grunting, nasal flaring and retractions in infants)
Tachycardia (initially but may become bradycardic as air leak worsens)
Jugular venous distension (JVD)
Hypertensive (initially but may become hypotensive as air leak worsens)
Tracheal deviation to the unaffected side
Decreased breath sounds to the affected side
Hypertympanic percussion note over the effected side
Unequal chest expansion
Difficulty ventilating patient (requiring high airway pressures)
Confirmatory test
X ray
Mikhael Earl S. Tacorda
Group A- 1D
Contraindications
Coagulopathy
Pulmonary bullae
Pulmonary, pleural, or thoracic adhesions
Loculated pleural effusion or empyema
Skin infection over the chest tube insertion site
Chest Drainage Canisters or Bottles
I. Chambers

Trap bottle/collection chamber traps blood and fluid from pleural space.
Water seal chamber - allow air to exit from the pleural space on exhalation and prevent
air from entering the pleural space on inhalation.
Manometer bottle regulates the generated pressure by suction.

II. Seal Drainage System

One bottle system
Two bottle system
Three bottle system

Nursing Responsibilities

1. Assess patient for respiratory distress and chest pain, breath sounds over affected lung
area, and stable vital signs
2. Observe for increase respiratory distress
3. Observe the following:
a. Chest tube dressing, ensure tubing is patent
b. Tubing kinks, dependent loops or clots
c. Chest drainage system, which should be upright and below level of tube insertion
4. Provide two shodded hemostats (clamp) for each chest tube. Chest tubes are only
clamped under specific circumstances:
a. To assess air leak
b. To quickly empty or change collection bottle or chamber; performed only physicians
c. To change disposable systems; have new system ready to be connected before
clamping tube so that transfer can be rapid and drainage system reestablished
d. To change a broken water-seal bottle in the event that no sterile solution container is
available
Mikhael Earl S. Tacorda
Group A- 1D
e. To assess if patient is ready to have chest tube removed (which is done by physicians
order); must monitor patient for recreation of pneumothorax

5. Position the patient to permit optimal drainage
a. Semi-Flowers position to evacuate air (pneumothorax)
b. High Flowers position to drain fluid (hemothorax)
6. Maintain tube connection between chest and drainage tubes intact and taped
a. Water-seal vent must be without occlusion
b. Suction-control chamber vent must be without occlusion when suction is used
7. Coil excess tubing on mattress next to patient. Secure with rubber band and safety pin or
systems clamp.
8. Adjust tubing to hang in straight line from top of mattress to drainage chamber. If chest
tube is draining fluid, indicate time that drainage was begun on drainage bottles adhesive
tape or on write-on surface of disposable commercial system
a. Strip or milk chest tube only per MD/PA orders only
b. Follow institutional policy for this procedure

Problems solving with chest tubes
Problem: Air leak
Problem: Continuous bubbling is seen in water-seal bottle/chamber, indicating that leak is
between patient and water seal
a. Locate leak
b. Tighten loose connection between patient and water seal
c. Loose connections cause air to enter system.
d. Leaks are corrected when constant bubbling stops
Problem: Bubbling continues, indicating that air leak has not been corrected
a. Cross-clamp chest tube close to patients chest, if bubbling stops, air leak is inside
the patients thorax or at chest tube insertion site
b. Unclamp tube and notify physician immediately!
c. Reinforce chest dressing

Warning: Leaving chest tube clamped caused a tension pneumothorax.

Mikhael Earl S. Tacorda
Group A- 1D
Problem: Bubbling continues, indicating that leak is not in the patients chest or at the insertion
site
a. Gradually move clamps down drainage tubing away from patient and toward
suction-control chamber, moving one clamp at a time
b. When bubbling stops, leak is in section of tubing or connection distal to the clamp
c. Replace tubing or secure connection and release clamp
Problem: Bubbling continues, indicating that leak is not in tubing
a. Leak is in drainage system
b. Change drainage system

Problem: Tension pneumothorax is present
Problems: Severe respiratory distress or chest pain
a. Determine that chest tubes are not clamped, kinked, or occluded. Locate leak
b. Obstructed chest tubes trap air in intrapleural space when air leak originates
within patient
Problem: Absence of breath sounds on affected side
a. Notify physician immediately
Problems: Hyperresonance on affected side, mediastinal shift to unaffected side, tracheal shift to
unaffected side, hypotenstion or tachycardia
a. Immediately prepare for another chest tube insertion
b. Have emergency equipment (oxygen and code cart) near patient
Problem: Dependent loops of drainage tubing have trapped fluid
a. Drain tubing contents into drainage bottle
b. Coil excess tubing on mattress and secure in place
Problem: Water seal is disconnected
a. Connect water seal
b. Tape connection
Problem: Water-seal bottle is broken
a. Insert distal end of water-seal tube into sterile solution so that tip is 2 cm below
surface
Mikhael Earl S. Tacorda
Group A- 1D
b. Set up new water-seal bottle
c. If no sterile solution is available, double clamp chest tube while preparing new
bottle
Problem: Water-seal tube is no longer submerged in sterile fluid
a. Add sterile solution to water-seal bottle until distal tip is 2 cm under surface
b. Or set water-seal bottle upright so that tip is submerged




















Mikhael Earl S. Tacorda
Group A- 1D
Name: __________________________________ Date: __________
Encircle the letter of the best answer. Relax while taking the exam and enjoy. Goodluck.
Situation: Mr. X a 78 year old client was brought by the Quezon CityEmergency Response Team
to the Emergency Unit of East Ave. Medical Center after he was hit by a car. Upon the arrival at
the hospital Nurse Mikhael assesses him and noted; dyspnea, generalized cyanosis, hypertensive
and unequal lung expansion. After the assessment the physician immediately diagnosed
Pneumothorax and ordered Chest thoracostomy tube.
1. Based on the understanding the procedure. Nurse Mikhael would prepare what size of
chest tube?
a. Fr38
b. Fr12
c. Fr32
d. Fr18
2. The following sign and symptoms are the assessment for emergency CTT except:
a. Hypertension
b. Hypotension
c. Apnea
d. Eupnea
3. The following are the function of CTT except:
a. To provide comfort
b. To normalize intra-thoracic pressure
c. To drain secretions
d. To drain lymphatic fluids
4. Which of the following laboratory test confirms chest tube placement?
a. Pulmonary Function Test
b. Arterial Blood Gas Studies
c. Radiographic Studies
d. Bronchoscopy
5. What is the best position for CTT?
a. Tredelenburg position
b. Supine position
c. Prone position
d. Semi-fowlers position
After the physician performed CTT, Mr. X was continuously assessed by Nurse Mikhael.
6. What would be the best possible indication of inappropriate tube placement?
a. Intermittent bubbling at water chamber
b. Respiratory rate of 15cpm
Mikhael Earl S. Tacorda
Group A- 1D
c. Blood pressure of 110/70
d. X-ray showing CTT tube in abdominal cavity
7. What indicates air leak?
a. Respiratory rate of 12cpm
b. Respiratory rate of 13cpm
c. Intermittent Bubbling of water
d. Continuous Bubbling of water
8. After noting that the water chamber is bubbling intermittently what should Nurse
Mikhael do?
a. Clamp the tube
b. Notify physician
c. Ask for x-ray
d. Do nothing
Nurse Mikhael shift is done. Before going home, he endorsed his client Mr. X to Nurse Romeo.
During the endorsement they both noticed absence of breath sounds on affected side of the lung.
9. What should they do first?
a. Check for airway
b. Perform chest compressions
c. Check for carotid pulse
d. Call the physician
10. After performing answer on no. 9 what is the best thing theycan do?
a. Nurse Mikhael will check for circulation
b. Nurse Romeo will administer Epinephrine
c. They will do nothing
d. Nurse Mikhael will go home and sleep and Nurse Romeo will monitor Mr. X