{"id":1109,"date":"2015-06-18T15:25:11","date_gmt":"2015-06-18T19:25:11","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/10-7-chest-drainage-systems\/"},"modified":"2019-09-19T18:03:29","modified_gmt":"2019-09-19T22:03:29","slug":"10-6-chest-tube-drainage-systems","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/10-6-chest-tube-drainage-systems\/","title":{"raw":"10.6 Chest Tube Drainage Systems","rendered":"10.6 Chest Tube Drainage Systems"},"content":{"raw":"<p style=\"text-align: left\">A <strong>chest tube<\/strong>, also known as a thoracic catheter, is a sterile tube with a number of drainage holes inserted into the pleural space (see Figure 10.8). The pleural space is the space between the parietal and visceral pleura, and is\u00a0also known as the pleural cavity (see Figures 10.9). A patient may require a chest drainage system any time the negative pressure in the pleural cavity is disrupted and causes respiratory distress. Negative pressure is disrupted when air, or fluid and air, enters the pleural space and\u00a0separates the visceral pleura from the parietal pleura, preventing the lung from fully expanding and collapsing. Small amounts of fluid or air accumulating in the pleural space are often absorbed by the body without a chest tube.<\/p>\r\nFigure 10.10 demonstrates a pneumothorax. A large amount of fluid or air cannot be absorbed by the body and will require a drainage system in order to optimize oxygenation (Bauman &amp; Handley, 2011; Perry et al., 2018). Another type of chest tube called a Heimlich valve is discussed later in this chapter.\r\n<table class=\" aligncenter\" style=\"border: 0px solid #000000\" width=\"500px\">\r\n<tbody>\r\n<tr style=\"border: 0px solid #000000\">\r\n<td style=\"width: 332.063px;border: 0px solid #000000\">\r\n\r\n[caption id=\"attachment_2696\" align=\"alignnone\" width=\"243\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/chest-tube-drainage-holes.png\" style=\"font-style: normal;font-weight: bold;font-family: inherit;font-size: inherit;text-align: left\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/chest-tube-drainage-holes.png\" alt=\"\" width=\"243\" height=\"208\" class=\"wp-image-2696 size-full\" \/><\/a> Figure 10.8 Chest tube samples; note the various holes[\/caption]\r\n\r\n&nbsp;<\/td>\r\n<td style=\"width: 331.063px;border: 0px solid #000000\">\r\n\r\n[caption id=\"attachment_2697\" align=\"alignnone\" width=\"300\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Lung_Pleurea.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Lung_Pleurea-300x226.jpg\" alt=\"\" width=\"300\" height=\"226\" class=\"wp-image-2697 size-medium\" \/><\/a> Figure 10.9 Chest wall structure; note the lung's pleura[\/caption]\r\n\r\n&nbsp;<\/td>\r\n<\/tr>\r\n<tr style=\"border: 0px solid #000000\">\r\n<td style=\"border: 0px solid #000000;width: 676.063px\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_2698\" align=\"aligncenter\" width=\"300\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Pneumothorax.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Pneumothorax-300x300.jpg\" alt=\"\" width=\"300\" height=\"300\" class=\"wp-image-2698\" \/><\/a> Figure 10.10 Pneumothorax[\/caption]<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nThe location of the chest tube depends on what is being drained from the pleural cavity. If air is in the pleural space, the chest tube will be inserted above the second intercostal space at the mid-clavical line. If there is fluid in the pleural space, the chest tube is inserted at the fourth to fifth\u00a0intercostal space, at the mid-axillary line. A chest tube may also be inserted to drain the pericardial sac after open heart surgery. These tubes are placed directly under the sternum and are referred to as mediastinal chest tubes (Perry et al., 2018).\r\n\r\nSome conditions that may require a chest tube drainage system include (Bauman &amp; Handley, 2011; Perry et al., 2018):\r\n<ul>\r\n \t<li>Pleural effusion<\/li>\r\n \t<li>Pneumothorax<\/li>\r\n \t<li>Hemothorax<\/li>\r\n \t<li>Spontaneous pneumothorax<\/li>\r\n \t<li>Tension pneumothorax<\/li>\r\n \t<li>Traumatic pneumothorax (stab or gunshot wound)<\/li>\r\n \t<li>Cardiac tamponade (accumulation of blood surrounding the heart after open heart surgery or chest surgery)<\/li>\r\n<\/ul>\r\n<h2>C<strong>hest Tube Drainage Systems<\/strong><\/h2>\r\nA chest tube is connected to a closed chest drainage system, which allows for air or fluid to be drained and prevents air or fluid from entering the pleural space. Because the pleural cavity normally has negative pressure, which allows for lung inflation and deflation, any tube connected to it must be sealed so that air or liquid cannot enter the space where the tube is inserted (Bauman &amp; Handley, 2011; Rajan, 2013). In a chest drainage system, a water seal provides that protection. Chest tube drainage systems are sterile and disposable and consist of either two or three compartments (see Figure 10.11). The traditional chest drainage system typically has three chambers (Bauman &amp; Handley, 2011; Rajan, 2013). Figure 10.12 illustrates how a chest drainage system works. Note how the three chambers are connected and the path that air (pneumothorax) or blood (hemothorax) would take if the chest tube were attached to such a system.\r\n\r\n[caption id=\"attachment_2735\" align=\"aligncenter\" width=\"472\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/09\/472px-Labelled_chest_tube_drainage_system.png\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/09\/472px-Labelled_chest_tube_drainage_system.png\" alt=\"\" width=\"472\" height=\"599\" class=\"wp-image-2735 size-full\" \/><\/a> Figure 10.11 Chest tube drainage system with labels[\/caption]\r\n\r\n[caption id=\"attachment_2701\" align=\"aligncenter\" width=\"450\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/wet-suction-water-seal-chest-drainage-system-001.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/wet-suction-water-seal-chest-drainage-system-001-300x243.jpg\" alt=\"\" width=\"450\" height=\"364\" class=\"wp-image-2701\" \/><\/a> Figure 10.12 Under water seal drainage system[\/caption]\r\n\r\nAlways review what type of system is used in your agency, and follow the agency's and the manufacturer's directions for setup, monitoring, and use. An explanation of the different chambers in is order:\r\n<ol>\r\n \t<li>Collection chamber: The chest tube connects directly to the collection chamber, which collects drainage from the pleural cavity. The chamber is calibrated to measure the drainage. The outer surface of the chamber has a \"write-on\" surface to document the date, time, and amount of fluid. This chamber is typically on the far right side of the system\u00a0(Teleflex Medical Incorporated, 2009).<\/li>\r\n \t<li>Water-seal chamber: This chamber has a one-way valve that allows air to exit the pleural cavity during exhalation but does not allow it to re-enter during inhalation due to the pressure in the chamber. The water-seal chamber must be filled with sterile water and maintained at the 2 cm mark to ensure proper operation, and should be checked regularly. Fill with additional sterile water as required. The water in the water-seal chamber may rise with inhalation and fall with exhalation (this is called <strong><em>tidaling<\/em><\/strong>), which\u00a0demonstrates that the chest tube is patent. Tidaling can also be seen in the drainage tube that connects the patient to the chest drainage unit. Note the differences between dry suction systems and wet suction systems in terms of what bubbling means (se<span style=\"color: #000000\">e Table 10.4<\/span>). Some chest drainage systems have a feature that allows for measurement of air leaks\u2014the higher the number, the greater the air leak. The water-seal chamber can also monitor intrathoracic pressure (Teleflex Medical Incorporated, 2009). Some systems have dry seal technology that serves the same purpose (Teleflex, 2018).<\/li>\r\n \t<li>Suction control chamber: Chest drainage systems can function either via wet or dry suction. Not all patients require suction. If suction is ordered, knowing the type of drainage system you have and how it works will allow you to ensure it is working correctly (Teleflex Medical Incorporated, 2009).<\/li>\r\n<\/ol>\r\nIn addition to the three chambers,\u00a0the drainage system has\u00a0many safety features to ensure that high negative pressures can be monitored and relieved quickly. To review these safety features and additional information regarding the chambers of a closed chest tube drainage system, visit the <a href=\"http:\/\/www.teleflex.com\/en\/usa\/ucd\/chest_drainage_systems.php\" target=\"_blank\" rel=\"noopener\">Teleflex Medical Incorporated website<\/a>.\r\n\r\nSometimes the prescriber will order a chest tube attached to suction to facilitate rapid drainage. In this case, the amount of suction should be prescribed. Chest drainage systems designs include dry suction systems and wet suction systems. Table 10.4 outlines the key differences between dry and wet suction units.\r\n<table style=\"border-collapse: collapse;width: 100%\" border=\"1\">\r\n<tbody>\r\n<tr>\r\n<td style=\"width: 100%\" colspan=\"2\">\r\n<h3 style=\"text-align: center\">Table 10.4 The Differences Between a Dry Suction Chest Drainage System and a Wet Suction Chest Drainage System<\/h3>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 50%\">\r\n<h4 style=\"text-align: center\">Dry Suction Chest Drainage System<\/h4>\r\n<\/td>\r\n<td style=\"width: 50%\">\r\n<h4 style=\"text-align: center\">Wet Suction Chest Drainage System<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 50%\">\r\n<ul>\r\n \t<li>Newer technology.<\/li>\r\n \t<li>Negative pressures are controlled by the unit's design (a system that includes a float ball, vents and controlled release system.<\/li>\r\n \t<li>One way valves reduce risk of\u00a0 fluid migration\u00a0 from one chamber to the next if the unit is tipped over.<\/li>\r\n \t<li>Water is only used to fill the water seal chamber therefore set up is quick.<\/li>\r\n \t<li>A silent system (bubbling isn't the norm like the wet suction system). In this type of system, bubbling indicates a leak.<\/li>\r\n \t<li>Light weight allows for easier transport than a heavy unit.<\/li>\r\n \t<li>The control dial on the chest drainage unit controls the amount of suction.<\/li>\r\n \t<li>Capable of higher levels of suction as compared to the wet suction system.<\/li>\r\n \t<li>Some dry suction units have an air-leak monitor feature.<\/li>\r\n \t<li>Suction is regulated by the suction dial on the unit and not the suction source (ie. wall or portable suction machine).<\/li>\r\n \t<li>Equipped with a negative pressure release valve to release\u00a0 pressure caused by vigorous coughing, chest tube stripping\u00a0 (not recommended), decreasing or disconnecting suction.<\/li>\r\n \t<li>If suction is discontinued, the suction port on the chest drainage system must remain unobstructed and open to air to allow air to exit and minimize the risk of development of a tension pneumothorax<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"width: 50%\">\r\n<ul>\r\n \t<li>Older technology.<\/li>\r\n \t<li>Water level controls the negative pressure transmitted to the chest. As the water level evaporates, the negative pressure lowers. As such water levels must be checked and topped up frequently.<\/li>\r\n \t<li>The weight of the fluid makes transport more challenging.<\/li>\r\n \t<li>Takes time to set up. Also has a water seal chamber.<\/li>\r\n \t<li>These units are noisy because of the bubbling in the water seal chamber. Bubbling is expected<\/li>\r\n \t<li>If using suction, increasing the suction at the regulator increases air flow through the system but has minimal effect on the amount of suction imposed on the chest cavity. Excessive suction at the regulator causes the system to be noisier (more bubbling) and quickens evaporation of the water in the water seal chamber.<\/li>\r\n \t<li>Some wet suction systems have an air leak monitoring feature.<\/li>\r\n \t<li>equipped with a negative pressure release valve to release\u00a0 pressure caused by vigorous coughing, chest tube stripping\u00a0 (not recommended), decreasing or disconnecting suction.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 100%\" colspan=\"2\">Sources: Atrium, 2009; Teleflex, 2018; Zisis et al., 2015<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nTable 10.5 provides a list of potential complications and interventions related to chest tube drainage systems.\r\n<table>\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\" colspan=\"4\">\r\n<h3 style=\"text-align: center\">Table 10.5 Complications and Interventions Related to Chest Tube Drainage Systems<\/h3>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000;width: 30%\" colspan=\"2\">\r\n<h4 style=\"text-align: center\">Complications<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 70%\" colspan=\"2\">\r\n<h4 style=\"text-align: center\">Interventions<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Potential pneumothorax\/respiratory distress<\/td>\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">This is the primary concern for a patient with a chest tube drainage system.\r\n<ul>\r\n \t<li>Signs and symptoms include decreased SpO<sub>2<\/sub>, increased work of breathing (WOB), diminished breath sounds, decreased chest movement, complaints of chest pain, tachycardia or bradycardia, hypotension.<\/li>\r\n \t<li>Notify health care provider.<\/li>\r\n \t<li>Request urgent chest x-ray.<\/li>\r\n \t<li>Ensure drain system is intact with no leaks or blockages such as kinks or clamps.<\/li>\r\n \t<li>Apply oxygen and take a set of vital signs.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Air leak<\/td>\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">An air leak may occur from the chest tube insertion site or the drainage system. Immediately:\r\n<ul>\r\n \t<li>check connections and ensure they are secure.<\/li>\r\n \t<li>assess insertion site. This may include removing the dressing to observe the insertion site.<\/li>\r\n<\/ul>\r\nYou can test the drainage system itself for a leak by\r\n<ul>\r\n \t<li>Using a booted (or padded) clamp, begin at the dressing and clamp the drainage tubing momentarily.<\/li>\r\n \t<li>Look at the water-seal\/air leak meter chamber. Keep moving the clamp down the drainage tubing toward the chest drainage system, placing it at 20 to 30 cm intervals. Each time you clamp, check the water-seal\/air leak meter chamber.<\/li>\r\n \t<li>When you place the clamp between the source of the air leak and the water-seal\/air leak meter chamber, the bubbling will stop. If bubbling stops the first time you clamp, the air leak must be at the chest tube insertion site or the lung.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Accidental chest tube removal or chest tube falls out<\/td>\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">A\u00a0chest tube falling\u00a0out\u00a0is an emergency. Immediately apply pressure to chest tube insertion site and apply sterile gauze or place a sterile petroleum gauze and dry dressing over insertion site and ensure tight seal. Apply dressing when patient exhales. If patient goes into respiratory distress, call a code. Notify primary health care provider to reinsert new chest tube drainage system.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Accidental disconnection of the drainage system<\/td>\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">A\u00a0chest tube drainage system disconnecting from the chest tube inside the patient\u00a0is an emergency. Momentarily but immediately clamp the tube and place the end of chest tube in sterile water or NS. The two ends will need to be swabbed with alcohol and reconnected.\r\n\r\nHave an emergency \"accidental chest tube removal kit\" at the bedside which includes: clamp, petroleum impregnated dressing, two sterile 4 \u00d7 4's; container of sterile normal saline or sterile water, occlusion dressing, alcohol swabs.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Bleeding at the insertion site<\/td>\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Bleeding may occur after insertion of the chest tube. Apply pressure to site and monitor.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Subcutaneous emphysema<\/td>\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Subcutaneous emphysema is painless tracking of air underneath the subcutaneous tissue. It may be seen in the chest wall, down limbs, around drain sites, or around the head or neck. When the skin is palpated, it feels similar to having tissue paper trapped beneath the skin. Subcutaneous emphysema is not life threatening but requires monitoring in the event it worsens. In the event of worsening symptoms suggesting subcutaneous emphysema, report to primary health care provider.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Drainage suddenly stops and respiratory distress increases<\/td>\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">The chest tube may be clogged by a blood clot or by fluid in a dependent loop.\r\n\r\nAssess the drainage system and the patient, and notify primary health care provider if required.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Sudden increase in bright red drainage<\/td>\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">This may indicate an active bleed. Monitor amount of drainage and vital signs, and notify the primary health care provider.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">The drainage unit has tipped over<\/td>\r\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Situate the unit upright. Immediately check the fluid level in the water seal for correct volume. Replace lost fluid and likewise withdraw any excess fluid. If all of the chambers are contaminated with blood, consider replacing the entire unit. Use the swing out floor stand that is a part of the drainage unit. Consider securing the unit to an IV pole.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000\" colspan=\"4\">Data source: BCIT, 2015c; Perry et al., 2018; Teleflex Medical Incorporated, 2009<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nChecklist 88 reviews the care and management of a person with a closed chest tube drainage system\r\n<table style=\"border-color: #000000\">\r\n<tbody>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;text-align: center\" colspan=\"4\">\r\n<h3 style=\"text-align: center\"><span style=\"color: #333333\"><a id=\"checklist88\"><\/a>Checklist 88: Care and Management of a Closed Chest Tube Drainage System<\/span><\/h3>\r\n<h5 style=\"text-align: center\"><em><span style=\"color: #333333\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;text-align: center\" colspan=\"4\">\r\n<h5 style=\"text-align: left\"><span style=\"color: #333333\">Safety considerations:<\/span><\/h5>\r\n<ul>\r\n \t<li style=\"text-align: left\">A chest tube may be inserted at the bedside, in procedure room, or in the surgical suite. Health care providers often assist physicians in the insertion and removal of a closed chest tube drainage system.<\/li>\r\n \t<li style=\"text-align: left\">After initial insertion of a chest tube drainage system, assess the patient at minimum every 15for at least an hour.\u00a0Once the patient is stable, and depending on the condition of the patient and the amount of drainage, monitoring may be less frequent. Always follow hospital policy for frequency of monitoring a patient with a chest tube.<\/li>\r\n \t<li style=\"text-align: left\">Prior to managing a patient with a chest tube, review reason for the chest tube, the location of the chest tube, normal volume of drainage, characteristics of the drainage, date of last dressing change, and any previously recorded air leaks measurements.<\/li>\r\n \t<li style=\"text-align: left\">Safety\/emergency equipment must always be at the patient's bedside and with the patient at all times during transportation to other departments. Safety equipment should include:\r\n<ul>\r\n \t<li style=\"text-align: left\">Two guarded clamps<\/li>\r\n \t<li style=\"text-align: left\">Sterile water<\/li>\r\n \t<li style=\"text-align: left\">Vaseline gauze (Jelonet)<\/li>\r\n \t<li style=\"text-align: left\">4 \u00d7 4 sterile dressing<\/li>\r\n \t<li>occlusive dressing or\u00a0Waterproof tape<\/li>\r\n \t<li>small container of sterile water or saline<\/li>\r\n \t<li>alcohol swabs<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t<li style=\"text-align: left\"><em>Never<\/em> clamp a chest tube without a prescriber's order or valid reason.\u00a0The tube must remain unobscured and unclamped to drain air or fluid from the pleural space. There are a few exceptions where a chest tube may be clamped; see special considerations below.<\/li>\r\n \t<li style=\"text-align: left\">Chest tube drainage systems are replaced only when the collection chamber is full or the system is contaminated.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center\" colspan=\"2\">\r\n<h4 style=\"text-align: center\">Steps<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center\" colspan=\"2\">\r\n<h4 style=\"text-align: center\">\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">1. Perform hand hygiene. Identify patient using two identifiers and explain assessment process to patient. Create privacy to assess the patient and drainage system.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.\r\n\r\nProper identification provides patient safety measures for safe care.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">2.\u00a0Complete respiratory assessment, ensure patient has minimal pain, and measure vital signs. Place patient in semi-Fowler's position for easier breathing.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Patient should be in a semi-Fowler's position, have minimal pain, have <em>no <\/em>respiratory distress, and have <em>no <\/em>evidence of an air leak around the insertion site, and <em>no<\/em> drainage from the insertion site or chest tube equipment.\r\n\r\nFrequent assessment of the respiratory status is important if the patient's condition is stable, resolving, or worsening,\u00a0and ensures that\u00a0the chest tube is functioning correctly.\r\n\r\nAssessment should be at minimum every 15 minutes for the first hour immediately following chest tube insertion\/ Continue until patient is stable. Increase monitoring if patient's condition worsens.\r\n\r\nChest tubes are painful, as the parietal pleura is very sensitive. Ensure patient has adequate pain relief, especially prior to re-positioning, sitting, or ambulation.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">3. Ensure the chest drainage unit is below the level of the insertion site, upright, and secured to prevent it from being accidentally knocked over.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_62652\" align=\"aligncenter\" width=\"146\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-6871.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-6871-300x215.jpg\" alt=\"Chest tube lower than insertion site\" class=\"wp-image-6267 aligncenter\" height=\"105\" width=\"146\" \/><\/a> Chest tube lower than insertion site[\/caption]\r\n\r\nThe drainage system must remain upright for the water-seal chamber to function correctly.\r\n\r\nThe chest drainage system must be lower than the chest to facilitate drainage and prevent back flow.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">4. Assess chest tube insertion site to ensure sterile dressing is dry and intact and that the chest tube is secured to reduce risk of it being pulled out.\r\n\r\nCheck insertion site for subcutaneous emphysema.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Dressing should remain dry and intact; no drainage holes should be visible in the chest tube.\r\n\r\nDressing is generally changed 24 hours post-insertion, then every\u00a048 hours. Chest tubes are generally sutured in place.\r\n\r\nThere should be no fluid leaking from around the site or sounds of air leaks from insertion site.\r\n\r\n[caption id=\"attachment_6265\" align=\"aligncenter\" width=\"154\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-677.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-677-291x300.jpg\" alt=\"Chest tube Insertion site\" class=\"wp-image-6265\" height=\"159\" width=\"154\" \/><\/a> Chest tube insertion site[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">5.\u00a0Assess the drainage system\u00a0to ensure the system is intact and to prevent accidental tube removal or disruption of the drainage system.\r\n\r\nEnsure tubing is not kinked or bent under the patient or in the bed rails, or compressed by the bed.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Know what kind of chest drainage system this is. If suction is ordered, ensure the unit is functioning (wet suction units bubble; dry suction units only bubble if there is an air leak).\r\n\r\nIf there is no suction, note any evidence of air leak. Note: when suction is on, air leaks are not demonstrated on the suction unit.\r\n\r\nAssess amount and character of the drainage and note if there is any significant changes.\r\n\r\nKinked or bent tubing could interfere with the drainage of the pleural fluid.\r\n\r\nDependent loops may collect fluid and impede drainage.\r\n\r\nThe long tube may be coiled and secured to a draw sheet with a safety pin (allowing enough tubing so that the patient can move in bed comfortably) to prevent dependent loops.\r\n\r\n[caption id=\"attachment_6266\" align=\"aligncenter\" width=\"136\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-687-003.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-687-003-277x300.jpg\" alt=\"Tubing free from kinks or dependent loops\" class=\"wp-image-6266\" height=\"147\" width=\"136\" \/><\/a> Tubing free from kinks and dependent loops[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">6.\u00a0Ensure prescribed suction is set at the correct level.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Dry suction systems: the amount of suction is determined by the suction control dial. Check that the \"float\" or 'bellow' appears completely in the viewing window.\r\n\r\nWet suction systems: the amount of suction is controlled by the water level. Ensure that the water level is correct and bubbling is evident.\r\n\r\n[caption id=\"attachment_6257\" align=\"aligncenter\" width=\"194\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-6781.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-6781-300x184.jpg\" alt=\"Suction set at -20cm\" class=\"wp-image-6257\" height=\"119\" width=\"194\" \/><\/a> Suction pressure set at - 20 cm. Note the float does not appear in the window. As such suction is not working.[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">7.\u00a0If suction is <em>not<\/em> ordered, ensure the suction port is left open to air.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_1102\" align=\"aligncenter\" width=\"194\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-115.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-115-300x199.jpg\" alt=\"Suction port on the top of a chest tube drainage system\" class=\"wp-image-1102\" height=\"129\" width=\"194\" \/><\/a> Suction port on the top of a chest tube drainage system must remain open when suction is not in use. At this point this port functions as a vent[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">8.\u00a0Check the water-seal chamber to ensure water level is to the dotted line (2 cm) at least once every shift. Add water as necessary.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Adequate water in the water-seal chamber prevents excess suction being placed on the delicate tissue.\r\n\r\nWater levels should be checked each shift as the water may evaporate.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">9. Assess the water-seal chamber and\/or the drainage tubing for tidaling (water moving up and down) with respirations.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Gentle bubbling is normal as the lungs expand in wet suction systems.\r\n\r\nAny bubbles in a dry suction system suggest an air leak.\r\n\r\nTidaling is not evident when the chest drainage unit is attached to suction.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">10.\u00a0Assess air leak meter according to the chest drainage unit's feature. On every shift, document the level of air leak and if the air leak occurs at rest or with coughing.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Bubbling in the air leak meter indicates an air leak (or suction is on in a wet suction unit).\r\n\r\nIf bubbling is NOT expected, measure and monitor.\r\n\r\n&nbsp;\r\n\r\nIf an air leak is suspected, look for the source of the leak:\r\n<ul>\r\n \t<li>Checking and tightening all connections.<\/li>\r\n \t<li>Testing the tube for leaks (see special considerations below).\u00a0If leak is in the tubing, replace the unit.<\/li>\r\n \t<li>If the leak may be at the insertion site, remove the chest tube dressing and inspect. Has the chest tube been pulled out beyond the chest wall? If you cannot see or\u00a0hear any obvious leaks at the site, the leak is likely from the lung.<\/li>\r\n \t<li>Check patient history. Would you expect a patient air leak?<\/li>\r\n<\/ul>\r\nNotify the prescriber of any new, increased, or unexpected air leaks that are not corrected by the above actions.\r\n\r\nTo document the air leak, note the numbered column through which the bubbling occurs. If bubbling is present at the 3rd marker, document \"air leak level 3.\"\r\n\r\n[caption id=\"attachment_6264\" align=\"aligncenter\" width=\"186\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-679-001.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-679-001-300x186.jpg\" alt=\"Air leak meter\" class=\"wp-image-6264\" height=\"116\" width=\"186\" \/><\/a> Air leak meter on chest drainage system[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">\u00a011. Check that the\u00a0clamp is open.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">The chest tube should <em>not<\/em> be clamped unless for specific reasons. See special considerations below.\r\n\r\n[caption id=\"attachment_6263\" align=\"aligncenter\" width=\"178\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-687-002.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-687-002-300x171.jpg\" alt=\"Blue clamp is open\" class=\" wp-image-6263\" height=\"101\" width=\"178\" \/><\/a> Blue clamp is open[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">12. Measure date and time, and the amount of drainage, and mark on the outside of the chamber at the end of each shift and prn. Record amount and characteristics of the drainage on the fluid balance\u00a0sheet and patient chart.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Drainage that is red and free-flowing indicates a hemorrhage. A large amount of drainage, or drainage that\u00a0changes in colour, should be recorded and reported to the primary health care provider.\r\n\r\nDrainage that suddenly decreases may indicate a blood clot or obstruction in the chest tube drainage system.\r\n\r\n[caption id=\"attachment_6259\" align=\"aligncenter\" width=\"152\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-681.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-681-176x300.jpg\" alt=\"Drainage in collection chamber\" class=\" wp-image-6259\" height=\"259\" width=\"152\" \/><\/a> Drainage in collection chamber[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">13. Promote oxygenation by encouraging frequent position changes, mobilization, and deep-breathing and coughing exercises.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">All of these strategies promote lung expansion and promote fluid drainage.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">14. The following should be documented and assessed according to\u00a0agency policy:\r\n<ul>\r\n \t<li>Breath sounds<\/li>\r\n \t<li>Patient comfort level or pain level<\/li>\r\n \t<li>Appearance of insertion site and\/or dressing<\/li>\r\n \t<li>Presence of air leaks<\/li>\r\n \t<li>Fluctuation (tidalling) in water-seal chamber<\/li>\r\n \t<li>Amount of suction<\/li>\r\n \t<li>Amount of drainage and type<\/li>\r\n \t<li>Presence of subcutaneous emphysema<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Proper documentation is required to manage a chest tube drainage system to ensure it is functioning effectively. Sample documentation:\r\n\r\n<em>date \/ time: Chest tube rt. lateral lower chest in situ\u00a0\u2192 underwater seal chest tube drainage system. Resps easy. Chest auscultated\u00a0\u2193air entry RLL. No adventitious sounds. Denies sputum. Continues to DB&amp;C hourly. +2 air leak noted intermittently. No subcutaneous emphysema noted. Dressing dry and intact. --------BRth RN<\/em><\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 704.906px\" colspan=\"4\">Data sources: Bauman &amp; Handley, 2011; BCIT, 2015c; Durai, Hoque, &amp; Davies, 2010; Rajan, 2013; Teleflex Medical Incorporated, 2009<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<h5>Special considerations:<\/h5>\r\n<ul>\r\n \t<li>Do not strip or milk the chest tube: In practice, stripping\u00a0is used to describe compressing the chest tube with the thumb or forefinger and, with the other hand, using a pulling motion down the remainder of the tube away from the insertion site. <em>Milking<\/em> refers to techniques such as\u00a0squeezing, kneading, or twisting the tube to create bursts of suction to move clots. Any aggressive manipulation (compressing the tube to dislodge blood clots) can generate extreme pressures in the chest tube. There is no evidence showing the benefit of stripping or milking a chest tube (Bauman &amp; Handley, 2011; Durai et al., 2010; Halm, 2007).<\/li>\r\n \t<li>The <em>only<\/em> exceptions to clamping a chest tube are: 1) if the drainage system is being changed; 2) if assessing the system for an air leak; 3) if the chest tube becomes disconnected from the chest drainage system\u2014the chest tube should not be clamped for more than a few minutes (Salmon, Lynch, &amp; Muck, 2013); or 4) if the condition of the patient is resolved and the chest tube is ready for removal (as per prescriber's orders).<\/li>\r\n<\/ul>\r\n<div class=\"textbox shaded\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/Chest_tubes.html\"><em>Chest Tubes - Care and Maintenance<\/em><\/a> by Kirstin McLaughlin and Wendy McKenzie, Thompson Rivers University (2019)<\/div>\r\n&nbsp;\r\n<div>\r\n<div class=\"textbox shaded\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/dry_suction_chest_drainage.html\"><em>Dry Suction\u00a0<\/em><i>Chest drainage system <\/i><\/a>developed by\u00a0 Kirstin McLaughlin and Wendy McKenzie, TRU School of Nursing (2019).<\/div>\r\n<\/div>\r\n<h2>Heimlich Valve<\/h2>\r\nA Heimlich valve (see Figures 10.13 and 10.14) is a small, specially designed flutter valve that is portable and mobile, allowing the patient to ambulate with ease. It attaches to the chest tube at one end and a drainage bag at the other. The valve can be worn under clothing. The valve functions in any position, never needs to be clamped, and can be hooked up to suction if required (Gogakos et al., 2015). Figure 10.15 illustrates\u00a0 how air entering the valve from the patient\u00a0 opens the sleeve to allow air to escape the patient's pleural space. The sleeve collapses preventing the\u00a0 back flow of air back into the patient.\r\n<table style=\"border-collapse: collapse;width: 100%;border: 0px solid #000000\">\r\n<tbody>\r\n<tr style=\"border: 0px solid #000000\">\r\n<td style=\"width: 50%;border: 0px solid #000000\">\r\n\r\n[caption id=\"attachment_6256\" align=\"aligncenter\" width=\"300\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-688.jpg\" style=\"font-weight: bold;text-align: center;font-size: 14pt\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-688-300x86.jpg\" alt=\"Heimlich valve\" class=\"wp-image-6256 size-medium\" height=\"86\" width=\"300\" \/><\/a> Figure 10.13 Heimlich valve[\/caption]<\/td>\r\n<td style=\"width: 50%;border: 0px solid #000000\">\r\n\r\n[caption id=\"attachment_6261\" align=\"aligncenter\" width=\"300\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-6581.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-6581-300x234.jpg\" alt=\"End connection to chest tube; other end may be left open to air or attached to a small drainage bag\" class=\"size-medium wp-image-6261\" height=\"234\" width=\"300\" \/><\/a> Figure 10.14 Blue end connects to chest tube; other end may be left open to air or attach to a small drainage bag[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border: 0px solid #000000\">\r\n<td style=\"border: 0px solid #000000\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_2709\" align=\"aligncenter\" width=\"400\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Heimlich_valve.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Heimlich_valve-300x174.jpg\" alt=\"\" width=\"400\" height=\"232\" class=\"wp-image-2709\" \/><\/a> Figure 10.15 Heimlich valve. Demonstration of how they work.[\/caption]<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div class=\"bcc-box bcc-info\">\r\n<h3 style=\"text-align: center\">Critical Thinking Exercises<\/h3>\r\n<ol>\r\n \t<li>What should you do\u00a0if your patient's chest tube becomes disconnected from the chest tube drainage system?<\/li>\r\n \t<li>When a patient has a chest tube, what emergency supplies must be at the patient's bedside at all times?<\/li>\r\n<\/ol>\r\n<\/div>\r\n<h2>Attributions<\/h2>\r\n<p class=\"hanging-indent\">Figure 10.8.\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Chest_Tube_Drainage_Holes.jpg\"><span>Chest tube drainage holes in a variety of chest tubes<\/span><\/a>\u00a0by <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:Bentplate84&amp;action=edit&amp;redlink=1\">Bentplate84<\/a> is used under a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\"><span class=\"cc-license-identifier\">CC BY-SA 3.0<\/span><\/a>\u00a0license.<\/p>\r\nFigure 10.9.\u00a0<a href=\"https:\/\/cnx.org\/contents\/FPtK1zmh@6.27:udJfuR_E@5\/The-Lungs\">Parietal and Visceral Pleurae of the Lungs<\/a> from <a href=\"https:\/\/openstax.org\/\">OpenStax College<\/a>,\u00a0<a href=\"http:\/\/cnx.org\/content\/col11496\/1.6\/\">Anatomy &amp; Physiology<\/a>.\u00a0Used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by\/3.0\/\">CC BY 3.0<\/a> license.\u00a0Download for free at\u00a0<a href=\"http:\/\/cnx.org\/contents\/14fb4ad7-39a1-4eee-ab6e-3ef2482e3e22@6.27\">http:\/\/cnx.org\/contents\/14fb4ad7-39a1-4eee-ab6e-3ef2482e3e22@6.27<\/a>.\r\n<p class=\"hanging-indent\">Figure 10.10.\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Blausen_0742_Pneumothorax.png\">Pneumothorax<\/a> by <a href=\"https:\/\/en.wikiversity.org\/wiki\/WikiJournal_of_Medicine\/Medical_gallery_of_Blausen_Medical_2014\"><span>Blausen.com staff<\/span><\/a>\u00a0is used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by\/3.0\/\">CC BY 3.0<\/a>\u00a0license.<\/p>\r\nFigure 10.11.<a href=\"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/10-7-chest-drainage-systems\/\">Chest tube drainage system<\/a> from BCIT is used under\u00a0a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\">CC BY-SA 4.0<\/a>\u00a0international license.\r\n<p class=\"hanging-indent\">Figure 10.12. Adapted from GrepMed, n.d.; Chung, n.d.; Salmon, Lynch &amp; Muck, 2013, by author.<\/p>\r\nFigure 10.13 &amp;\u00a010.14 <a href=\"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/10-7-chest-drainage-systems\/\">Heimlich Valve<\/a> from BCIT is used\u00a0under a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\">CC BY-SA 4.0<\/a>\u00a0international license.\r\n<p class=\"hanging-indent\">Figure 10.15.\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Heimlich_valve.GIF\">Line diagram of Heimlich Valve (Flutter Valve) including mechanism for one-way airflow<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Orinoco-w\">Orinoco-w<\/a> is used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\"><span class=\"cc-license-identifier\">CC BY-SA 3.0<\/span><\/a>\u00a0license.<\/p>","rendered":"<p style=\"text-align: left\">A <strong>chest tube<\/strong>, also known as a thoracic catheter, is a sterile tube with a number of drainage holes inserted into the pleural space (see Figure 10.8). The pleural space is the space between the parietal and visceral pleura, and is\u00a0also known as the pleural cavity (see Figures 10.9). A patient may require a chest drainage system any time the negative pressure in the pleural cavity is disrupted and causes respiratory distress. Negative pressure is disrupted when air, or fluid and air, enters the pleural space and\u00a0separates the visceral pleura from the parietal pleura, preventing the lung from fully expanding and collapsing. Small amounts of fluid or air accumulating in the pleural space are often absorbed by the body without a chest tube.<\/p>\n<p>Figure 10.10 demonstrates a pneumothorax. A large amount of fluid or air cannot be absorbed by the body and will require a drainage system in order to optimize oxygenation (Bauman &amp; Handley, 2011; Perry et al., 2018). Another type of chest tube called a Heimlich valve is discussed later in this chapter.<\/p>\n<table class=\"aligncenter\" style=\"border: 0px solid #000000; width: 500px;\">\n<tbody>\n<tr style=\"border: 0px solid #000000\">\n<td style=\"width: 332.063px;border: 0px solid #000000\">\n<figure id=\"attachment_2696\" aria-describedby=\"caption-attachment-2696\" style=\"width: 243px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/chest-tube-drainage-holes.png\" style=\"font-style: normal;font-weight: bold;font-family: inherit;font-size: inherit;text-align: left\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/chest-tube-drainage-holes.png\" alt=\"\" width=\"243\" height=\"208\" class=\"wp-image-2696 size-full\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/chest-tube-drainage-holes.png 243w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/chest-tube-drainage-holes-65x56.png 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/chest-tube-drainage-holes-225x193.png 225w\" sizes=\"auto, (max-width: 243px) 100vw, 243px\" \/><\/a><figcaption id=\"caption-attachment-2696\" class=\"wp-caption-text\">Figure 10.8 Chest tube samples; note the various holes<\/figcaption><\/figure>\n<p>&nbsp;<\/td>\n<td style=\"width: 331.063px;border: 0px solid #000000\">\n<figure id=\"attachment_2697\" aria-describedby=\"caption-attachment-2697\" style=\"width: 300px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Lung_Pleurea.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Lung_Pleurea-300x226.jpg\" alt=\"\" width=\"300\" height=\"226\" class=\"wp-image-2697 size-medium\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Lung_Pleurea-300x226.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Lung_Pleurea-65x49.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Lung_Pleurea-225x170.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Lung_Pleurea-350x264.jpg 350w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Lung_Pleurea.jpg 600w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-2697\" class=\"wp-caption-text\">Figure 10.9 Chest wall structure; note the lung&#8217;s pleura<\/figcaption><\/figure>\n<p>&nbsp;<\/td>\n<\/tr>\n<tr style=\"border: 0px solid #000000\">\n<td style=\"border: 0px solid #000000;width: 676.063px\" colspan=\"2\">\n<figure id=\"attachment_2698\" aria-describedby=\"caption-attachment-2698\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Pneumothorax.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Pneumothorax-300x300.jpg\" alt=\"\" width=\"300\" height=\"300\" class=\"wp-image-2698\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Pneumothorax-300x300.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Pneumothorax-150x150.jpg 150w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Pneumothorax-65x65.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Pneumothorax-225x225.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Pneumothorax-350x350.jpg 350w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Pneumothorax.jpg 450w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-2698\" class=\"wp-caption-text\">Figure 10.10 Pneumothorax<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>The location of the chest tube depends on what is being drained from the pleural cavity. If air is in the pleural space, the chest tube will be inserted above the second intercostal space at the mid-clavical line. If there is fluid in the pleural space, the chest tube is inserted at the fourth to fifth\u00a0intercostal space, at the mid-axillary line. A chest tube may also be inserted to drain the pericardial sac after open heart surgery. These tubes are placed directly under the sternum and are referred to as mediastinal chest tubes (Perry et al., 2018).<\/p>\n<p>Some conditions that may require a chest tube drainage system include (Bauman &amp; Handley, 2011; Perry et al., 2018):<\/p>\n<ul>\n<li>Pleural effusion<\/li>\n<li>Pneumothorax<\/li>\n<li>Hemothorax<\/li>\n<li>Spontaneous pneumothorax<\/li>\n<li>Tension pneumothorax<\/li>\n<li>Traumatic pneumothorax (stab or gunshot wound)<\/li>\n<li>Cardiac tamponade (accumulation of blood surrounding the heart after open heart surgery or chest surgery)<\/li>\n<\/ul>\n<h2>C<strong>hest Tube Drainage Systems<\/strong><\/h2>\n<p>A chest tube is connected to a closed chest drainage system, which allows for air or fluid to be drained and prevents air or fluid from entering the pleural space. Because the pleural cavity normally has negative pressure, which allows for lung inflation and deflation, any tube connected to it must be sealed so that air or liquid cannot enter the space where the tube is inserted (Bauman &amp; Handley, 2011; Rajan, 2013). In a chest drainage system, a water seal provides that protection. Chest tube drainage systems are sterile and disposable and consist of either two or three compartments (see Figure 10.11). The traditional chest drainage system typically has three chambers (Bauman &amp; Handley, 2011; Rajan, 2013). Figure 10.12 illustrates how a chest drainage system works. Note how the three chambers are connected and the path that air (pneumothorax) or blood (hemothorax) would take if the chest tube were attached to such a system.<\/p>\n<figure id=\"attachment_2735\" aria-describedby=\"caption-attachment-2735\" style=\"width: 472px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/09\/472px-Labelled_chest_tube_drainage_system.png\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/09\/472px-Labelled_chest_tube_drainage_system.png\" alt=\"\" width=\"472\" height=\"599\" class=\"wp-image-2735 size-full\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/09\/472px-Labelled_chest_tube_drainage_system.png 472w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/09\/472px-Labelled_chest_tube_drainage_system-236x300.png 236w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/09\/472px-Labelled_chest_tube_drainage_system-65x82.png 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/09\/472px-Labelled_chest_tube_drainage_system-225x286.png 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/09\/472px-Labelled_chest_tube_drainage_system-350x444.png 350w\" sizes=\"auto, (max-width: 472px) 100vw, 472px\" \/><\/a><figcaption id=\"caption-attachment-2735\" class=\"wp-caption-text\">Figure 10.11 Chest tube drainage system with labels<\/figcaption><\/figure>\n<figure id=\"attachment_2701\" aria-describedby=\"caption-attachment-2701\" style=\"width: 450px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/wet-suction-water-seal-chest-drainage-system-001.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/wet-suction-water-seal-chest-drainage-system-001-300x243.jpg\" alt=\"\" width=\"450\" height=\"364\" class=\"wp-image-2701\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/wet-suction-water-seal-chest-drainage-system-001-300x243.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/wet-suction-water-seal-chest-drainage-system-001-65x53.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/wet-suction-water-seal-chest-drainage-system-001-225x182.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/wet-suction-water-seal-chest-drainage-system-001-350x283.jpg 350w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/wet-suction-water-seal-chest-drainage-system-001.jpg 550w\" sizes=\"auto, (max-width: 450px) 100vw, 450px\" \/><\/a><figcaption id=\"caption-attachment-2701\" class=\"wp-caption-text\">Figure 10.12 Under water seal drainage system<\/figcaption><\/figure>\n<p>Always review what type of system is used in your agency, and follow the agency&#8217;s and the manufacturer&#8217;s directions for setup, monitoring, and use. An explanation of the different chambers in is order:<\/p>\n<ol>\n<li>Collection chamber: The chest tube connects directly to the collection chamber, which collects drainage from the pleural cavity. The chamber is calibrated to measure the drainage. The outer surface of the chamber has a &#8220;write-on&#8221; surface to document the date, time, and amount of fluid. This chamber is typically on the far right side of the system\u00a0(Teleflex Medical Incorporated, 2009).<\/li>\n<li>Water-seal chamber: This chamber has a one-way valve that allows air to exit the pleural cavity during exhalation but does not allow it to re-enter during inhalation due to the pressure in the chamber. The water-seal chamber must be filled with sterile water and maintained at the 2 cm mark to ensure proper operation, and should be checked regularly. Fill with additional sterile water as required. The water in the water-seal chamber may rise with inhalation and fall with exhalation (this is called <strong><em>tidaling<\/em><\/strong>), which\u00a0demonstrates that the chest tube is patent. Tidaling can also be seen in the drainage tube that connects the patient to the chest drainage unit. Note the differences between dry suction systems and wet suction systems in terms of what bubbling means (se<span style=\"color: #000000\">e Table 10.4<\/span>). Some chest drainage systems have a feature that allows for measurement of air leaks\u2014the higher the number, the greater the air leak. The water-seal chamber can also monitor intrathoracic pressure (Teleflex Medical Incorporated, 2009). Some systems have dry seal technology that serves the same purpose (Teleflex, 2018).<\/li>\n<li>Suction control chamber: Chest drainage systems can function either via wet or dry suction. Not all patients require suction. If suction is ordered, knowing the type of drainage system you have and how it works will allow you to ensure it is working correctly (Teleflex Medical Incorporated, 2009).<\/li>\n<\/ol>\n<p>In addition to the three chambers,\u00a0the drainage system has\u00a0many safety features to ensure that high negative pressures can be monitored and relieved quickly. To review these safety features and additional information regarding the chambers of a closed chest tube drainage system, visit the <a href=\"http:\/\/www.teleflex.com\/en\/usa\/ucd\/chest_drainage_systems.php\" target=\"_blank\" rel=\"noopener\">Teleflex Medical Incorporated website<\/a>.<\/p>\n<p>Sometimes the prescriber will order a chest tube attached to suction to facilitate rapid drainage. In this case, the amount of suction should be prescribed. Chest drainage systems designs include dry suction systems and wet suction systems. Table 10.4 outlines the key differences between dry and wet suction units.<\/p>\n<table style=\"border-collapse: collapse;width: 100%\">\n<tbody>\n<tr>\n<td style=\"width: 100%\" colspan=\"2\">\n<h3 style=\"text-align: center\">Table 10.4 The Differences Between a Dry Suction Chest Drainage System and a Wet Suction Chest Drainage System<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%\">\n<h4 style=\"text-align: center\">Dry Suction Chest Drainage System<\/h4>\n<\/td>\n<td style=\"width: 50%\">\n<h4 style=\"text-align: center\">Wet Suction Chest Drainage System<\/h4>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%\">\n<ul>\n<li>Newer technology.<\/li>\n<li>Negative pressures are controlled by the unit&#8217;s design (a system that includes a float ball, vents and controlled release system.<\/li>\n<li>One way valves reduce risk of\u00a0 fluid migration\u00a0 from one chamber to the next if the unit is tipped over.<\/li>\n<li>Water is only used to fill the water seal chamber therefore set up is quick.<\/li>\n<li>A silent system (bubbling isn&#8217;t the norm like the wet suction system). In this type of system, bubbling indicates a leak.<\/li>\n<li>Light weight allows for easier transport than a heavy unit.<\/li>\n<li>The control dial on the chest drainage unit controls the amount of suction.<\/li>\n<li>Capable of higher levels of suction as compared to the wet suction system.<\/li>\n<li>Some dry suction units have an air-leak monitor feature.<\/li>\n<li>Suction is regulated by the suction dial on the unit and not the suction source (ie. wall or portable suction machine).<\/li>\n<li>Equipped with a negative pressure release valve to release\u00a0 pressure caused by vigorous coughing, chest tube stripping\u00a0 (not recommended), decreasing or disconnecting suction.<\/li>\n<li>If suction is discontinued, the suction port on the chest drainage system must remain unobstructed and open to air to allow air to exit and minimize the risk of development of a tension pneumothorax<\/li>\n<\/ul>\n<\/td>\n<td style=\"width: 50%\">\n<ul>\n<li>Older technology.<\/li>\n<li>Water level controls the negative pressure transmitted to the chest. As the water level evaporates, the negative pressure lowers. As such water levels must be checked and topped up frequently.<\/li>\n<li>The weight of the fluid makes transport more challenging.<\/li>\n<li>Takes time to set up. Also has a water seal chamber.<\/li>\n<li>These units are noisy because of the bubbling in the water seal chamber. Bubbling is expected<\/li>\n<li>If using suction, increasing the suction at the regulator increases air flow through the system but has minimal effect on the amount of suction imposed on the chest cavity. Excessive suction at the regulator causes the system to be noisier (more bubbling) and quickens evaporation of the water in the water seal chamber.<\/li>\n<li>Some wet suction systems have an air leak monitoring feature.<\/li>\n<li>equipped with a negative pressure release valve to release\u00a0 pressure caused by vigorous coughing, chest tube stripping\u00a0 (not recommended), decreasing or disconnecting suction.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 100%\" colspan=\"2\">Sources: Atrium, 2009; Teleflex, 2018; Zisis et al., 2015<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Table 10.5 provides a list of potential complications and interventions related to chest tube drainage systems.<\/p>\n<table>\n<tbody>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\" colspan=\"4\">\n<h3 style=\"text-align: center\">Table 10.5 Complications and Interventions Related to Chest Tube Drainage Systems<\/h3>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000;width: 30%\" colspan=\"2\">\n<h4 style=\"text-align: center\">Complications<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 70%\" colspan=\"2\">\n<h4 style=\"text-align: center\">Interventions<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Potential pneumothorax\/respiratory distress<\/td>\n<td style=\"border: 1px solid #000000\" colspan=\"2\">This is the primary concern for a patient with a chest tube drainage system.<\/p>\n<ul>\n<li>Signs and symptoms include decreased SpO<sub>2<\/sub>, increased work of breathing (WOB), diminished breath sounds, decreased chest movement, complaints of chest pain, tachycardia or bradycardia, hypotension.<\/li>\n<li>Notify health care provider.<\/li>\n<li>Request urgent chest x-ray.<\/li>\n<li>Ensure drain system is intact with no leaks or blockages such as kinks or clamps.<\/li>\n<li>Apply oxygen and take a set of vital signs.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Air leak<\/td>\n<td style=\"border: 1px solid #000000\" colspan=\"2\">An air leak may occur from the chest tube insertion site or the drainage system. Immediately:<\/p>\n<ul>\n<li>check connections and ensure they are secure.<\/li>\n<li>assess insertion site. This may include removing the dressing to observe the insertion site.<\/li>\n<\/ul>\n<p>You can test the drainage system itself for a leak by<\/p>\n<ul>\n<li>Using a booted (or padded) clamp, begin at the dressing and clamp the drainage tubing momentarily.<\/li>\n<li>Look at the water-seal\/air leak meter chamber. Keep moving the clamp down the drainage tubing toward the chest drainage system, placing it at 20 to 30 cm intervals. Each time you clamp, check the water-seal\/air leak meter chamber.<\/li>\n<li>When you place the clamp between the source of the air leak and the water-seal\/air leak meter chamber, the bubbling will stop. If bubbling stops the first time you clamp, the air leak must be at the chest tube insertion site or the lung.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Accidental chest tube removal or chest tube falls out<\/td>\n<td style=\"border: 1px solid #000000\" colspan=\"2\">A\u00a0chest tube falling\u00a0out\u00a0is an emergency. Immediately apply pressure to chest tube insertion site and apply sterile gauze or place a sterile petroleum gauze and dry dressing over insertion site and ensure tight seal. Apply dressing when patient exhales. If patient goes into respiratory distress, call a code. Notify primary health care provider to reinsert new chest tube drainage system.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Accidental disconnection of the drainage system<\/td>\n<td style=\"border: 1px solid #000000\" colspan=\"2\">A\u00a0chest tube drainage system disconnecting from the chest tube inside the patient\u00a0is an emergency. Momentarily but immediately clamp the tube and place the end of chest tube in sterile water or NS. The two ends will need to be swabbed with alcohol and reconnected.<\/p>\n<p>Have an emergency &#8220;accidental chest tube removal kit&#8221; at the bedside which includes: clamp, petroleum impregnated dressing, two sterile 4 \u00d7 4&#8217;s; container of sterile normal saline or sterile water, occlusion dressing, alcohol swabs.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Bleeding at the insertion site<\/td>\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Bleeding may occur after insertion of the chest tube. Apply pressure to site and monitor.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Subcutaneous emphysema<\/td>\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Subcutaneous emphysema is painless tracking of air underneath the subcutaneous tissue. It may be seen in the chest wall, down limbs, around drain sites, or around the head or neck. When the skin is palpated, it feels similar to having tissue paper trapped beneath the skin. Subcutaneous emphysema is not life threatening but requires monitoring in the event it worsens. In the event of worsening symptoms suggesting subcutaneous emphysema, report to primary health care provider.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Drainage suddenly stops and respiratory distress increases<\/td>\n<td style=\"border: 1px solid #000000\" colspan=\"2\">The chest tube may be clogged by a blood clot or by fluid in a dependent loop.<\/p>\n<p>Assess the drainage system and the patient, and notify primary health care provider if required.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Sudden increase in bright red drainage<\/td>\n<td style=\"border: 1px solid #000000\" colspan=\"2\">This may indicate an active bleed. Monitor amount of drainage and vital signs, and notify the primary health care provider.<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000\" colspan=\"2\">The drainage unit has tipped over<\/td>\n<td style=\"border: 1px solid #000000\" colspan=\"2\">Situate the unit upright. Immediately check the fluid level in the water seal for correct volume. Replace lost fluid and likewise withdraw any excess fluid. If all of the chambers are contaminated with blood, consider replacing the entire unit. Use the swing out floor stand that is a part of the drainage unit. Consider securing the unit to an IV pole.<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000\" colspan=\"4\">Data source: BCIT, 2015c; Perry et al., 2018; Teleflex Medical Incorporated, 2009<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Checklist 88 reviews the care and management of a person with a closed chest tube drainage system<\/p>\n<table style=\"border-color: #000000\">\n<tbody>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;text-align: center\" colspan=\"4\">\n<h3 style=\"text-align: center\"><span style=\"color: #333333\"><a id=\"checklist88\"><\/a>Checklist 88: Care and Management of a Closed Chest Tube Drainage System<\/span><\/h3>\n<h5 style=\"text-align: center\"><em><span style=\"color: #333333\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;text-align: center\" colspan=\"4\">\n<h5 style=\"text-align: left\"><span style=\"color: #333333\">Safety considerations:<\/span><\/h5>\n<ul>\n<li style=\"text-align: left\">A chest tube may be inserted at the bedside, in procedure room, or in the surgical suite. Health care providers often assist physicians in the insertion and removal of a closed chest tube drainage system.<\/li>\n<li style=\"text-align: left\">After initial insertion of a chest tube drainage system, assess the patient at minimum every 15for at least an hour.\u00a0Once the patient is stable, and depending on the condition of the patient and the amount of drainage, monitoring may be less frequent. Always follow hospital policy for frequency of monitoring a patient with a chest tube.<\/li>\n<li style=\"text-align: left\">Prior to managing a patient with a chest tube, review reason for the chest tube, the location of the chest tube, normal volume of drainage, characteristics of the drainage, date of last dressing change, and any previously recorded air leaks measurements.<\/li>\n<li style=\"text-align: left\">Safety\/emergency equipment must always be at the patient&#8217;s bedside and with the patient at all times during transportation to other departments. Safety equipment should include:\n<ul>\n<li style=\"text-align: left\">Two guarded clamps<\/li>\n<li style=\"text-align: left\">Sterile water<\/li>\n<li style=\"text-align: left\">Vaseline gauze (Jelonet)<\/li>\n<li style=\"text-align: left\">4 \u00d7 4 sterile dressing<\/li>\n<li>occlusive dressing or\u00a0Waterproof tape<\/li>\n<li>small container of sterile water or saline<\/li>\n<li>alcohol swabs<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: left\"><em>Never<\/em> clamp a chest tube without a prescriber&#8217;s order or valid reason.\u00a0The tube must remain unobscured and unclamped to drain air or fluid from the pleural space. There are a few exceptions where a chest tube may be clamped; see special considerations below.<\/li>\n<li style=\"text-align: left\">Chest tube drainage systems are replaced only when the collection chamber is full or the system is contaminated.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center\" colspan=\"2\">\n<h4 style=\"text-align: center\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center\" colspan=\"2\">\n<h4 style=\"text-align: center\">\u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">1. Perform hand hygiene. Identify patient using two identifiers and explain assessment process to patient. Create privacy to assess the patient and drainage system.<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.<\/p>\n<p>Proper identification provides patient safety measures for safe care.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">2.\u00a0Complete respiratory assessment, ensure patient has minimal pain, and measure vital signs. Place patient in semi-Fowler&#8217;s position for easier breathing.<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Patient should be in a semi-Fowler&#8217;s position, have minimal pain, have <em>no <\/em>respiratory distress, and have <em>no <\/em>evidence of an air leak around the insertion site, and <em>no<\/em> drainage from the insertion site or chest tube equipment.<\/p>\n<p>Frequent assessment of the respiratory status is important if the patient&#8217;s condition is stable, resolving, or worsening,\u00a0and ensures that\u00a0the chest tube is functioning correctly.<\/p>\n<p>Assessment should be at minimum every 15 minutes for the first hour immediately following chest tube insertion\/ Continue until patient is stable. Increase monitoring if patient&#8217;s condition worsens.<\/p>\n<p>Chest tubes are painful, as the parietal pleura is very sensitive. Ensure patient has adequate pain relief, especially prior to re-positioning, sitting, or ambulation.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">3. Ensure the chest drainage unit is below the level of the insertion site, upright, and secured to prevent it from being accidentally knocked over.<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">\n<figure id=\"attachment_62652\" aria-describedby=\"caption-attachment-62652\" style=\"width: 146px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-6871.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-6871-300x215.jpg\" alt=\"Chest tube lower than insertion site\" class=\"wp-image-6267 aligncenter\" height=\"105\" width=\"146\" \/><\/a><figcaption id=\"caption-attachment-62652\" class=\"wp-caption-text\">Chest tube lower than insertion site<\/figcaption><\/figure>\n<p>The drainage system must remain upright for the water-seal chamber to function correctly.<\/p>\n<p>The chest drainage system must be lower than the chest to facilitate drainage and prevent back flow.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">4. Assess chest tube insertion site to ensure sterile dressing is dry and intact and that the chest tube is secured to reduce risk of it being pulled out.<\/p>\n<p>Check insertion site for subcutaneous emphysema.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Dressing should remain dry and intact; no drainage holes should be visible in the chest tube.<\/p>\n<p>Dressing is generally changed 24 hours post-insertion, then every\u00a048 hours. Chest tubes are generally sutured in place.<\/p>\n<p>There should be no fluid leaking from around the site or sounds of air leaks from insertion site.<\/p>\n<figure id=\"attachment_6265\" aria-describedby=\"caption-attachment-6265\" style=\"width: 154px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-677.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-677-291x300.jpg\" alt=\"Chest tube Insertion site\" class=\"wp-image-6265\" height=\"159\" width=\"154\" \/><\/a><figcaption id=\"caption-attachment-6265\" class=\"wp-caption-text\">Chest tube insertion site<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">5.\u00a0Assess the drainage system\u00a0to ensure the system is intact and to prevent accidental tube removal or disruption of the drainage system.<\/p>\n<p>Ensure tubing is not kinked or bent under the patient or in the bed rails, or compressed by the bed.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Know what kind of chest drainage system this is. If suction is ordered, ensure the unit is functioning (wet suction units bubble; dry suction units only bubble if there is an air leak).<\/p>\n<p>If there is no suction, note any evidence of air leak. Note: when suction is on, air leaks are not demonstrated on the suction unit.<\/p>\n<p>Assess amount and character of the drainage and note if there is any significant changes.<\/p>\n<p>Kinked or bent tubing could interfere with the drainage of the pleural fluid.<\/p>\n<p>Dependent loops may collect fluid and impede drainage.<\/p>\n<p>The long tube may be coiled and secured to a draw sheet with a safety pin (allowing enough tubing so that the patient can move in bed comfortably) to prevent dependent loops.<\/p>\n<figure id=\"attachment_6266\" aria-describedby=\"caption-attachment-6266\" style=\"width: 136px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-687-003.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-687-003-277x300.jpg\" alt=\"Tubing free from kinks or dependent loops\" class=\"wp-image-6266\" height=\"147\" width=\"136\" \/><\/a><figcaption id=\"caption-attachment-6266\" class=\"wp-caption-text\">Tubing free from kinks and dependent loops<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">6.\u00a0Ensure prescribed suction is set at the correct level.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Dry suction systems: the amount of suction is determined by the suction control dial. Check that the &#8220;float&#8221; or &#8216;bellow&#8217; appears completely in the viewing window.<\/p>\n<p>Wet suction systems: the amount of suction is controlled by the water level. Ensure that the water level is correct and bubbling is evident.<\/p>\n<figure id=\"attachment_6257\" aria-describedby=\"caption-attachment-6257\" style=\"width: 194px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-6781.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-6781-300x184.jpg\" alt=\"Suction set at -20cm\" class=\"wp-image-6257\" height=\"119\" width=\"194\" \/><\/a><figcaption id=\"caption-attachment-6257\" class=\"wp-caption-text\">Suction pressure set at &#8211; 20 cm. Note the float does not appear in the window. As such suction is not working.<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">7.\u00a0If suction is <em>not<\/em> ordered, ensure the suction port is left open to air.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">\n<figure id=\"attachment_1102\" aria-describedby=\"caption-attachment-1102\" style=\"width: 194px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-115.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-115-300x199.jpg\" alt=\"Suction port on the top of a chest tube drainage system\" class=\"wp-image-1102\" height=\"129\" width=\"194\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-115-300x199.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-115-768x509.jpg 768w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-115-1024x678.jpg 1024w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-115-65x43.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-115-225x149.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-115-350x232.jpg 350w\" sizes=\"auto, (max-width: 194px) 100vw, 194px\" \/><\/a><figcaption id=\"caption-attachment-1102\" class=\"wp-caption-text\">Suction port on the top of a chest tube drainage system must remain open when suction is not in use. At this point this port functions as a vent<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">8.\u00a0Check the water-seal chamber to ensure water level is to the dotted line (2 cm) at least once every shift. Add water as necessary.<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Adequate water in the water-seal chamber prevents excess suction being placed on the delicate tissue.<\/p>\n<p>Water levels should be checked each shift as the water may evaporate.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">9. Assess the water-seal chamber and\/or the drainage tubing for tidaling (water moving up and down) with respirations.<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Gentle bubbling is normal as the lungs expand in wet suction systems.<\/p>\n<p>Any bubbles in a dry suction system suggest an air leak.<\/p>\n<p>Tidaling is not evident when the chest drainage unit is attached to suction.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">10.\u00a0Assess air leak meter according to the chest drainage unit&#8217;s feature. On every shift, document the level of air leak and if the air leak occurs at rest or with coughing.<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Bubbling in the air leak meter indicates an air leak (or suction is on in a wet suction unit).<\/p>\n<p>If bubbling is NOT expected, measure and monitor.<\/p>\n<p>&nbsp;<\/p>\n<p>If an air leak is suspected, look for the source of the leak:<\/p>\n<ul>\n<li>Checking and tightening all connections.<\/li>\n<li>Testing the tube for leaks (see special considerations below).\u00a0If leak is in the tubing, replace the unit.<\/li>\n<li>If the leak may be at the insertion site, remove the chest tube dressing and inspect. Has the chest tube been pulled out beyond the chest wall? If you cannot see or\u00a0hear any obvious leaks at the site, the leak is likely from the lung.<\/li>\n<li>Check patient history. Would you expect a patient air leak?<\/li>\n<\/ul>\n<p>Notify the prescriber of any new, increased, or unexpected air leaks that are not corrected by the above actions.<\/p>\n<p>To document the air leak, note the numbered column through which the bubbling occurs. If bubbling is present at the 3rd marker, document &#8220;air leak level 3.&#8221;<\/p>\n<figure id=\"attachment_6264\" aria-describedby=\"caption-attachment-6264\" style=\"width: 186px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-679-001.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-679-001-300x186.jpg\" alt=\"Air leak meter\" class=\"wp-image-6264\" height=\"116\" width=\"186\" \/><\/a><figcaption id=\"caption-attachment-6264\" class=\"wp-caption-text\">Air leak meter on chest drainage system<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">\u00a011. Check that the\u00a0clamp is open.<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">The chest tube should <em>not<\/em> be clamped unless for specific reasons. See special considerations below.<\/p>\n<figure id=\"attachment_6263\" aria-describedby=\"caption-attachment-6263\" style=\"width: 178px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-687-002.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-687-002-300x171.jpg\" alt=\"Blue clamp is open\" class=\"wp-image-6263\" height=\"101\" width=\"178\" \/><\/a><figcaption id=\"caption-attachment-6263\" class=\"wp-caption-text\">Blue clamp is open<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">12. Measure date and time, and the amount of drainage, and mark on the outside of the chamber at the end of each shift and prn. Record amount and characteristics of the drainage on the fluid balance\u00a0sheet and patient chart.<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Drainage that is red and free-flowing indicates a hemorrhage. A large amount of drainage, or drainage that\u00a0changes in colour, should be recorded and reported to the primary health care provider.<\/p>\n<p>Drainage that suddenly decreases may indicate a blood clot or obstruction in the chest tube drainage system.<\/p>\n<figure id=\"attachment_6259\" aria-describedby=\"caption-attachment-6259\" style=\"width: 152px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-681.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-681-176x300.jpg\" alt=\"Drainage in collection chamber\" class=\"wp-image-6259\" height=\"259\" width=\"152\" \/><\/a><figcaption id=\"caption-attachment-6259\" class=\"wp-caption-text\">Drainage in collection chamber<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">13. Promote oxygenation by encouraging frequent position changes, mobilization, and deep-breathing and coughing exercises.<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">All of these strategies promote lung expansion and promote fluid drainage.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 338.906px\" colspan=\"2\">14. The following should be documented and assessed according to\u00a0agency policy:<\/p>\n<ul>\n<li>Breath sounds<\/li>\n<li>Patient comfort level or pain level<\/li>\n<li>Appearance of insertion site and\/or dressing<\/li>\n<li>Presence of air leaks<\/li>\n<li>Fluctuation (tidalling) in water-seal chamber<\/li>\n<li>Amount of suction<\/li>\n<li>Amount of drainage and type<\/li>\n<li>Presence of subcutaneous emphysema<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 349.906px\" colspan=\"2\">Proper documentation is required to manage a chest tube drainage system to ensure it is functioning effectively. Sample documentation:<\/p>\n<p><em>date \/ time: Chest tube rt. lateral lower chest in situ\u00a0\u2192 underwater seal chest tube drainage system. Resps easy. Chest auscultated\u00a0\u2193air entry RLL. No adventitious sounds. Denies sputum. Continues to DB&amp;C hourly. +2 air leak noted intermittently. No subcutaneous emphysema noted. Dressing dry and intact. &#8212;&#8212;&#8211;BRth RN<\/em><\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 704.906px\" colspan=\"4\">Data sources: Bauman &amp; Handley, 2011; BCIT, 2015c; Durai, Hoque, &amp; Davies, 2010; Rajan, 2013; Teleflex Medical Incorporated, 2009<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h5>Special considerations:<\/h5>\n<ul>\n<li>Do not strip or milk the chest tube: In practice, stripping\u00a0is used to describe compressing the chest tube with the thumb or forefinger and, with the other hand, using a pulling motion down the remainder of the tube away from the insertion site. <em>Milking<\/em> refers to techniques such as\u00a0squeezing, kneading, or twisting the tube to create bursts of suction to move clots. Any aggressive manipulation (compressing the tube to dislodge blood clots) can generate extreme pressures in the chest tube. There is no evidence showing the benefit of stripping or milking a chest tube (Bauman &amp; Handley, 2011; Durai et al., 2010; Halm, 2007).<\/li>\n<li>The <em>only<\/em> exceptions to clamping a chest tube are: 1) if the drainage system is being changed; 2) if assessing the system for an air leak; 3) if the chest tube becomes disconnected from the chest drainage system\u2014the chest tube should not be clamped for more than a few minutes (Salmon, Lynch, &amp; Muck, 2013); or 4) if the condition of the patient is resolved and the chest tube is ready for removal (as per prescriber&#8217;s orders).<\/li>\n<\/ul>\n<div class=\"textbox shaded\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/Chest_tubes.html\"><em>Chest Tubes &#8211; Care and Maintenance<\/em><\/a> by Kirstin McLaughlin and Wendy McKenzie, Thompson Rivers University (2019)<\/div>\n<p>&nbsp;<\/p>\n<div>\n<div class=\"textbox shaded\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/dry_suction_chest_drainage.html\"><em>Dry Suction\u00a0<\/em><i>Chest drainage system <\/i><\/a>developed by\u00a0 Kirstin McLaughlin and Wendy McKenzie, TRU School of Nursing (2019).<\/div>\n<\/div>\n<h2>Heimlich Valve<\/h2>\n<p>A Heimlich valve (see Figures 10.13 and 10.14) is a small, specially designed flutter valve that is portable and mobile, allowing the patient to ambulate with ease. It attaches to the chest tube at one end and a drainage bag at the other. The valve can be worn under clothing. The valve functions in any position, never needs to be clamped, and can be hooked up to suction if required (Gogakos et al., 2015). Figure 10.15 illustrates\u00a0 how air entering the valve from the patient\u00a0 opens the sleeve to allow air to escape the patient&#8217;s pleural space. The sleeve collapses preventing the\u00a0 back flow of air back into the patient.<\/p>\n<table style=\"border-collapse: collapse;width: 100%;border: 0px solid #000000\">\n<tbody>\n<tr style=\"border: 0px solid #000000\">\n<td style=\"width: 50%;border: 0px solid #000000\">\n<figure id=\"attachment_6256\" aria-describedby=\"caption-attachment-6256\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-688.jpg\" style=\"font-weight: bold;text-align: center;font-size: 14pt\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-688-300x86.jpg\" alt=\"Heimlich valve\" class=\"wp-image-6256 size-medium\" height=\"86\" width=\"300\" \/><\/a><figcaption id=\"caption-attachment-6256\" class=\"wp-caption-text\">Figure 10.13 Heimlich valve<\/figcaption><\/figure>\n<\/td>\n<td style=\"width: 50%;border: 0px solid #000000\">\n<figure id=\"attachment_6261\" aria-describedby=\"caption-attachment-6261\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-6581.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Book-pictures-2015-6581-300x234.jpg\" alt=\"End connection to chest tube; other end may be left open to air or attached to a small drainage bag\" class=\"size-medium wp-image-6261\" height=\"234\" width=\"300\" \/><\/a><figcaption id=\"caption-attachment-6261\" class=\"wp-caption-text\">Figure 10.14 Blue end connects to chest tube; other end may be left open to air or attach to a small drainage bag<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border: 0px solid #000000\">\n<td style=\"border: 0px solid #000000\" colspan=\"2\">\n<figure id=\"attachment_2709\" aria-describedby=\"caption-attachment-2709\" style=\"width: 400px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Heimlich_valve.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Heimlich_valve-300x174.jpg\" alt=\"\" width=\"400\" height=\"232\" class=\"wp-image-2709\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Heimlich_valve-300x174.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Heimlich_valve-65x38.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Heimlich_valve-225x131.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Heimlich_valve-350x203.jpg 350w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Heimlich_valve.jpg 600w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><\/a><figcaption id=\"caption-attachment-2709\" class=\"wp-caption-text\">Figure 10.15 Heimlich valve. Demonstration of how they work.<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div class=\"bcc-box bcc-info\">\n<h3 style=\"text-align: center\">Critical Thinking Exercises<\/h3>\n<ol>\n<li>What should you do\u00a0if your patient&#8217;s chest tube becomes disconnected from the chest tube drainage system?<\/li>\n<li>When a patient has a chest tube, what emergency supplies must be at the patient&#8217;s bedside at all times?<\/li>\n<\/ol>\n<\/div>\n<h2>Attributions<\/h2>\n<p class=\"hanging-indent\">Figure 10.8.\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Chest_Tube_Drainage_Holes.jpg\"><span>Chest tube drainage holes in a variety of chest tubes<\/span><\/a>\u00a0by <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:Bentplate84&amp;action=edit&amp;redlink=1\">Bentplate84<\/a> is used under a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\"><span class=\"cc-license-identifier\">CC BY-SA 3.0<\/span><\/a>\u00a0license.<\/p>\n<p>Figure 10.9.\u00a0<a href=\"https:\/\/cnx.org\/contents\/FPtK1zmh@6.27:udJfuR_E@5\/The-Lungs\">Parietal and Visceral Pleurae of the Lungs<\/a> from <a href=\"https:\/\/openstax.org\/\">OpenStax College<\/a>,\u00a0<a href=\"http:\/\/cnx.org\/content\/col11496\/1.6\/\">Anatomy &amp; Physiology<\/a>.\u00a0Used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by\/3.0\/\">CC BY 3.0<\/a> license.\u00a0Download for free at\u00a0<a href=\"http:\/\/cnx.org\/contents\/14fb4ad7-39a1-4eee-ab6e-3ef2482e3e22@6.27\">http:\/\/cnx.org\/contents\/14fb4ad7-39a1-4eee-ab6e-3ef2482e3e22@6.27<\/a>.<\/p>\n<p class=\"hanging-indent\">Figure 10.10.\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Blausen_0742_Pneumothorax.png\">Pneumothorax<\/a> by <a href=\"https:\/\/en.wikiversity.org\/wiki\/WikiJournal_of_Medicine\/Medical_gallery_of_Blausen_Medical_2014\"><span>Blausen.com staff<\/span><\/a>\u00a0is used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by\/3.0\/\">CC BY 3.0<\/a>\u00a0license.<\/p>\n<p>Figure 10.11.<a href=\"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/10-7-chest-drainage-systems\/\">Chest tube drainage system<\/a> from BCIT is used under\u00a0a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\">CC BY-SA 4.0<\/a>\u00a0international license.<\/p>\n<p class=\"hanging-indent\">Figure 10.12. Adapted from GrepMed, n.d.; Chung, n.d.; Salmon, Lynch &amp; Muck, 2013, by author.<\/p>\n<p>Figure 10.13 &amp;\u00a010.14 <a href=\"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/10-7-chest-drainage-systems\/\">Heimlich Valve<\/a> from BCIT is used\u00a0under a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\">CC BY-SA 4.0<\/a>\u00a0international license.<\/p>\n<p class=\"hanging-indent\">Figure 10.15.\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Heimlich_valve.GIF\">Line diagram of Heimlich Valve (Flutter Valve) including mechanism for one-way airflow<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Orinoco-w\">Orinoco-w<\/a> is used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\"><span class=\"cc-license-identifier\">CC BY-SA 3.0<\/span><\/a>\u00a0license.<\/p>\n","protected":false},"author":397,"menu_order":6,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":"cc-by"},"chapter-type":[],"contributor":[],"license":[50],"class_list":["post-1109","chapter","type-chapter","status-publish","hentry","license-cc-by"],"part":1017,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/1109","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/users\/397"}],"version-history":[{"count":27,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/1109\/revisions"}],"predecessor-version":[{"id":5093,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/1109\/revisions\/5093"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/parts\/1017"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/1109\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/media?parent=1109"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapter-type?post=1109"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/contributor?post=1109"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/license?post=1109"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}