ICU PROCEDURES: Chest Tube Management

ICU PROCEDURES: Chest Tube Management

ICU Procedures: Chest Tube Management – Nursing Management

Chest tubes are inserted into the pleural space to remove air, fluid, or blood and to restore normal intrapleural pressure, enabling full lung expansion. Nursing management of a chest tube is crucial to ensure patient safety, prevent complications, and ensure the chest tube is functioning properly.

Indications for Chest Tube Insertion:

1. Pneumothorax: Air in the pleural space causing lung collapse.
2. Hemothorax: Blood in the pleural space.
3. Pleural Effusion: Excess fluid in the pleural space.
4. Empyema: Pus in the pleural space due to infection.
5. Post-surgery: Following thoracic surgery or trauma to prevent fluid or air accumulation.

Nursing Management:

1. Initial Assessment:

• Vital Signs: Monitor heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature.
• Respiratory Assessment: Assess breath sounds, respiratory effort, and oxygen needs. Look for signs of respiratory distress such as dyspnea, cyanosis, and use of accessory muscles.
• Pain Management: Administer prescribed analgesics to minimize discomfort from the chest tube insertion.

2. Monitoring the Chest Tube System:

• Drainage System Components:
  1. Water Seal Chamber: Acts as a one-way valve, allowing air or fluid to exit but preventing air from re-entering the pleural space.
  2. Suction Control Chamber: Controls the amount of suction applied to the chest tube.
  3. Collection Chamber: Where fluid or air accumulates after being drained from the pleural space.
• Key Points to Monitor:
  1. Drainage:
     • Monitor the amount, color, and consistency of drainage.
     • Record the drainage every 1-2 hours initially, then as needed.
     • Report sudden increases (>100 mL/hour) or changes in drainage characteristics (e.g., bright red, purulent) immediately.
  2. Water Seal:
     • Tidal fluctuations (rise and fall of water in the water-seal chamber) should correspond with the patient’s breathing pattern. Absence of tidaling could indicate obstruction, re-expansion of the lung, or disconnection.
     • Bubbling in the water-seal chamber: Intermittent bubbling is expected in pneumothorax patients. Continuous bubbling may indicate an air leak.
  3. Suction:
     • Ensure the suction control chamber is set to the prescribed level (usually between -20 cm H₂O).
     • Monitor for gentle bubbling in the suction chamber if suction is applied.

3. Maintaining the Chest Tube System:

• Ensure proper positioning:
  • Keep the drainage system below chest level at all times to prevent backflow of fluid into the pleural space.
• Check tubing:
  • Ensure the tubing is not kinked, looped, or compressed, as this could impair drainage.
  • Avoid clamping the chest tube unless ordered by a physician (e.g., during tube removal or checking for an air leak).
• Secure the chest tube:
  • Ensure the chest tube dressing is clean, dry, and occlusive to prevent air from entering the pleural space.
  • Tape all connections to prevent accidental disconnection.

4. Patient Positioning and Mobilization:

• Encourage ambulation: If permitted, ambulation can help improve lung expansion and drainage.
• Frequent Position Changes: Turning, coughing, and deep breathing exercises should be encouraged to help re-expand the lung and promote drainage.
• Positioning: Patients can be positioned semi-Fowler’s to promote lung expansion and drainage.

5. Pain Management:

• Assess pain regularly and administer analgesics or other pain control measures as needed. Pain can inhibit deep breathing and effective lung expansion.
• Encourage deep breathing and coughing exercises, using incentive spirometry to help prevent atelectasis.

6. Recognizing and Managing Complications:

• Air Leaks:
  • Identified by continuous bubbling in the water seal chamber.
  • Check all connections for tightness and securement.
  • Notify the physician if the air leak is persistent or worsening.
• Tube Dislodgement:
  • If the chest tube is accidentally dislodged, cover the insertion site with a sterile occlusive dressing and tape it on three sides to allow air to escape and prevent tension pneumothorax. Notify the physician immediately.
• Infection:
  • Monitor the insertion site for signs of infection (redness, warmth, swelling, drainage). Use sterile technique during dressing changes and report any signs of infection to the healthcare team.
• Subcutaneous Emphysema:
  • This occurs when air leaks into the subcutaneous tissue, resulting in swelling and crepitus around the insertion site. Notify the physician if this is detected.
• Tension Pneumothorax:
  • If the patient shows signs of sudden respiratory distress, hypotension, tracheal deviation, or absence of breath sounds, it may indicate a tension pneumothorax, a medical emergency. The chest tube system should be checked for patency and the physician notified immediately.

7. Chest Tube Removal:

• Criteria for Removal: Once the underlying condition is resolved, and the chest tube drainage is minimal (<100 mL in 24 hours), the chest tube may be removed.
• Procedure:
  1. Premedicate the patient for pain.
  2. The physician will clamp the chest tube and remove the tube, often while the patient performs the Valsalva maneuver (forced expiration).
  3. Apply an airtight dressing over the insertion site.
• Post-removal Monitoring: Monitor the patient closely for signs of respiratory distress or recurrence of the original issue (e.g., pneumothorax).

Key Nursing Responsibilities:

• Monitor drainage: Regular assessment of the drainage system is vital for detecting changes in the patient’s condition.
• Maintain patency: Ensure the tubing and collection system are functioning properly to avoid complications like reaccumulation of air or fluid.
• Patient education: Inform the patient about the importance of deep breathing and coughing, and what to expect with the chest tube in place.
• Documentation: Keep accurate records of drainage, respiratory status, and any changes in the patient’s condition.

Effective chest tube management is critical for recovery, and vigilant nursing care can help prevent complications and ensure successful outcomes in patients requiring this intervention.