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Chest Tubes
What are they? A chest tube is a hollow, flexible
tube placed in to the chest that acts as a drain. It
is inserted between the mid-axillary and anterior
axillary lines over a rib that is below the
intercostal level and into the pleural space. Chest
tubes drain blood and excess fluid or air from
around your lungs which allow them to fully
expand. They can drain by gravity but are usually
attached to a suctioning device. This is often a
closed drainage system which allows the excess
fluid or air to be drained out while preventing
more air to be let in. Nurses are responsible for
maintaining the site clean and free of infection
and for replacing the suctioning device once filled or if complications arise.
Types of closed-chest drainage systems - For most disposable three-chamber
closed-chest drainage systems, the collection chamber is on the right side. The
chest tube connects directly to the collection chamber port so that all secretions
flow into the collection chamber. The collection chamber is calibrated for accurate
measurements of drainage and typically has a write-on surface for documentation
of the date, time, and amount of fluid.

Water-seal - The middle chamber is typically for the water seal; it allows air to
exit the pleural space on exhalation and keeps air from entering the pleural
or mediastinal space on inspiration. Expect the water level in the water-seal
chamber to rise with inhalation and return to baseline with exhalation, called
tidaling. The water seal chamber also has a calibrated manometer to
measure the amount of negative pressure within the pleural cavity. If there is
no air leak, the water level should rise with inhalation and fall with
exhalation.
One way valve- For these systems, the one-way valve performs the same
functions of the water seal. However, it maintains the seal even if the unit is
tipped over.
Wet-suction control - Traditional closed-chest drainage systems regulate the
amount of suction by the height of the water in the suction-control chamber,
which is typically located on the left side of the system. Note that it is the
water level in the suction-control chamber that regulates the amount of
suction transmitted to the pleural cavity and not the settings on the suction
source. So, monitor the fluid level of the suction-control chamber and replace
it as necessary to maintain the appropriate amount of suction.
Dry-suction control - Systems that use dry-suction control allow for higher
suction pressure levels, there is no need to replace fluid, and they are quieter
because of the absence of continuous bubbling sounds. Instead of using the
column of water to control the amount of suction, a self-compensating

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regulator, or automatic control valve, continuously balances the force of the

suction with the atmosphere.
Mobile chest drains - Patients who go home with a closed-chest drainage
system intact or who require early ambulation can use a mobile chest drain.
Heimlich valve is a one-way flutter valve that allows air to escape but keeps it
from re-entering the chest cavity. Pneumostat is a one way valve that allows
for collection of a small amount of fluid.

Indications:

Pneumothorax (open, closed, simple, or tension) collapsed lung.

Hemothorax blood accumulation in the pleural cavity.
Hemopneumothorax combination of both pneumothorax and Hemothorax.
Hydrothorax excess of serous fluid in the pleural cavity.
Chylothorax - lymphatic fluid (chyle) accumulating in the pleural cavity due to
either disruption or obstruction of the thoracic duct.
Empyema collection of puss in the pleural cavity caused by infection.
Any other type of pleural effusion (buildup of fluid in the pleural cavity).
Patients with penetrating chest wall injuries that are intubated or about to be
intubated.

Assessment

Respiratory status to include rate, depth, lung sounds and oxygen saturation.
Ask about pain or difficulty breathing; if the patient reports pain, assess
severity, location, quality and any relieving or aggravating factors.
Assess level of consciousness, skin color, temperature, and rate of capillary
refill in extremities.
Mark the level of drainage on the outside of the chamber or on tape noting
time and date.
Check the water level in the wet seal chamber to be sure the water level is
always at 2cm.
Check the air vent to ensure it is working properly, is not wet or blocked.
Occlusion of the air vent prevents drainage and can result in pressure buildup
and could cause tension pneumothorax.

Equipment

Closed water seal drain system

Sterile water
Suction
Gloves
Clamps
Tape
Gauze
Face mask

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Replacing a closed-chest drainage system

Verify that the close-chest system does not have an air leak by observing the
water seal chamber or the air leak meter (if there is an air leak, do not clamp
air drain system).
Raise bed to working level, perform hand hygiene, and done gloves.
Prepare the new unit; instill the sterile fluid into the water seal chamber until
it reaches the 2cm mark or the mark the manufacturer specifies.
Remove the cap from the suction control chamber and instill the sterile
solution until it reaches the 20 cm mark or the prescribed level and recap the
suction control chamber. If the unit includes an air leak meter add the sterile
solution up to the indicated level.
Turn the patient on his side and place a linen saver pad beneath the patient.
Remove the tape securing the old tubing and dispose of gloves.
Wash hands, don new gloves and put on face mask with shield.
Double clamp the tube close to the insertion site by placing the clamps in
opposite directions.
Disconnect the end of the chest tube from the old system and reconnect it to
the new system.
Remove clamps from the chest tube and secure the new line with tape.
Remove the suction tubing from the old system and reconnect it to the new
system.
Dispose of the old system according to hospital policy.
Hang the new system on a non-movable part of the bed.
Place patient back to original position and ask him to lean forward and take a
couple of deep breaths. Check for fluctuations in the water seal chamber as
the patient breaths. Observe the oscillation of fluid in the suction control
chamber and adjust the suction source as necessary to generate a gentle
bubbling.
Assess patients respiratory status.

Documentation
Document all assessment information, the time and date of the closed-chest
drainage system replacement, and the patients response to the procedure.
Evaluation

Respirations should remain unlabored and within the expected range.

Oxygen saturation should be maintained above 90% and patient should
report any chest pain or difficulty breathing.
Lung sounds should be clear bilaterally with a symmetric chest rise on
inhalation. Diminished or absent lung sounds generally indicate that the lung
hasnt re-expanded.

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Patients skin should remain pink and warm with a quick capillary refill in
extremities.
Ensure the chest tube is secure to the chest wall so that it doesnt dislodge
with activity. Check the chest tube dressing at least every 4 hours. Palpate
the area surrounding the dressing for crepitus or subcutaneous emphysema,
which indicates that air is leaking into the subcutaneous tissue surrounding
the insertion site. If you see drainage on the dressing, note the dimensions of
the stain so that you can monitor for additional drainage. Replace dressing on
a regular schedule or when necessary, make sure all connections are secure.
Assist patient to change positions every 2 hours and ambulate every 4 to 6
hours during the day to allow enhanced lung expansion and drainage.
Observe the patient during activity and ambulation to ensure the chest tube
remains free from kinks and occlusion.

Managing Complications - The primary goal of closed-chest drainage is to

optimize ventilation and gas exchange by draining the air or fluid from the pleural
cavity. When the closed-chest drainage system is not working properly, patients
may show early signs of altered oxygenation, such as restlessness, hyperventilation,
and tachycardia. They may also report increased pain on the affected side. At this
point, it is essential to troubleshoot the equipment, quickly identify the problem,
and provide effective interventions.

Checking the patency of the chest tube - Look for loose connections between
the patient and drainage system. Determine if the chest tube is clamped,
kinked, or occluded by following the length of the entire tubing.
Disconnected tubing from the drainage unit - Instruct the patient to exhale
and cough. This rids the pleural space of as much air as possible. Submerge
the end of the chest tube in 1 inch of sterile water until you can cleanse the
tips of the tubing and reconnect them quickly.
Air leak - If you see excessive and continuous bubbling in the water-seal
chamber or the air-leak meter, especially if the system is connected to a
suction source look for a leak in the drainage system. Using rubber-tipped
clamps, try to locate the leak by clamping the tube momentarily at various
points along its length. Begin at the tubes proximal end, near the dressing.
Look at the water-seal/air-leak meter chamber. If the bubbling stops, the air
leak is at the chest-tube insertion site or inside the chest. Examine the chesttube insertion site quickly to see if the dressing is loose or the tube is
dislodged. If the dressing is loose, air may be entering around the tube as the
patient inhales. Ask the patient to cough to rid the pleural space of as much
air as possible, apply an occlusive dressing or reinforce the dressing if it is
intact, and monitor the patient to see if oxygenation improves.
If the bubbling continues after you clamp the tube momentarily near the
insertion site, place another clamp a little further down the tube about 20 to

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30 cm (8 to 12 inches) toward the drainage system and remove the first

clamp. Each time you clamp at the more distal location, check the waterseal/air-leak meter chamber. When you place a clamp between the source of
the air leak and the water-seal/air-leak meter, the bubbling will stop. That
indicates a leak in the tubing distal to the clamp. Replace the tubing or
secure the connection and release the clamp. If you clamp along the tubes
entire length and the bubbling doesnt stop, the drainage unit might be
cracked and you will have to replace it.
Chest tube is completely dislodged - Cover the site immediately with a sterile
gauze dressing. Stay with the patient and monitor his vital signs while
another staff member notifies the physician. Observe for signs of a tension
pneumothorax, hypotension, distended jugular veins, absent or decreased
breath sounds, tracheal shift, hypoxemia, weak and rapid pulse, dyspnea,
tachypnea, diaphoresis, and chest pain. Make sure the equipment for chesttube insertion and emergency equipment are nearby.
If the drainage system has tipped over or is disrupted or damaged, or the
drainage collection chamber is filled to its maximum capacity, replace it.