ASSISTING IN THE INSERTION AND

REMOVAL OF CHEST TUBE

THORACOSTOMY
 CHEST TUBE INSERTION

Chest tube insertion (tube thoracotomy) is the

insertion of one or more flexible tubes into the
pleural space to remove air, blood, or fluid. This
procedure is done by the physician.
 WATER SEAL CHEST DRAINAGE

Water-seal chest drainage is a closed (airtight) system for

drainage of air and fluid from the chest cavity.
(1)The underwater-seal system is established by connecting
a catheter (chest tube) that has been placed in the
patient's pleural cavity to drainage tubing that leads
to a sealed drainage bottle.

(2) Air and fluid drain into the bottle, but water acts as a seal
to keep the air from being drawn back into the pleural space.

(3) By keeping the drainage bottle at floor level, fluid will be

prevented from being siphoned back.

(4) As air and fluid are drained, pressure on the lungs is

relieved and re-expansion of the lung is facilitated.
 SELECTION OF THE SYSTEM

The physician will specify the drainage setup he prefers to

use. It is a nursing responsibility to be familiar with the various
systems and their operation.

The Single-Bottle Water-Seal System.

▪ Connecting or drainage tubing joins the patient's chest tube
with a drainage tube (glass rod) that enters the drainage
bottle.
▪ The end of the glass rod is submerged in water, extending
about 2.5 cm (1 inch) below the water level.
 SELECTION OF THE SYSTEM
The Single-Bottle Water-Seal System.
▪ The water seal permits drainage of air and fluid from the
pleural space but does not allow air to reenter the chest.
▪ Drainage depends upon gravity, the mechanics of
respiration, and, if ordered, the addition of controlled
suction.
▪ The second tube in the drainage bottle is a vent for the
escape of any air drained from the lung. If suction is
ordered, it is attached here.
▪ Bubbling at the end of the drainage tube may or may not
be visible. Bubbling may mean persistent air leaking
from the lung or a leak in the system.
 SELECTION OF THE SYSTEM

The Single-Bottle Water-Seal System.

▪ The water level in the bottle fluctuates as the patient
breathes. It rises when the patient inhales and lowers
when the patient exhales.
▪ Since fluid drains into this bottle, be certain to mark the
water level prior to opening the system to the patient.
This will allow correct measurement of patient drainage.
 SELECTION OF THE SYSTEM

The Two-Bottle Water-Seal System.

▪ The two-bottle system consists of the same water-seal
bottle plus a fluid collection bottle.
▪ Pleural fluid accumulates in the collection bottle, and
not in the water-seal bottle (as in the single-bottle
system)
▪ Drainage depends upon gravity or the amount of
suction added to the system.
▪ When suction is added, it is connected at the vent
tube in the water-seal bottle.
 SELECTION OF THE SYSTEM

The Three-Bottle Water-Seal System.

▪ This system consists of the water-seal bottle, the fluid
collection bottle, and a third bottle which controls the amount
of suction applied.
▪ The third bottle, called the manometer bottle, has three tubes.
▪ One short tube above the water level comes from the
water-seal bottle. A second short tube leads to the
suction.
▪ The third tube extends below the water level and opens to
the atmosphere outside the bottle.
▪ It is this tube that regulates the suction, depending upon
the depth the tube is submerged. It is normally
submerged 20 cm (7.6 inches).
 SELECTION OF THE SYSTEM

The Commercial System

▪ There are several disposable commercial drainage
systems available. They are plastic devices,
divided into chambers for fluid collection, water-
seal, and suction control. Follow the
manufacturer's instructions for commercial
drainage systems used at your facility.
SELECTION OF THE SYSTEM
SELECTION OF THE SYSTEM
 SELECTION OF THE SYSTEM

ASSESSMENT:
▪ Post operatively e.g. cardiac surgery, thoracotomy
▪ Pneumothorax
▪ Hemothorax
▪ Chylothorax
▪ Pleural effusions
 PLANNING

Assemble the following:

▪ Thoracotomy tray
▪ Sterile gloves
▪ Padded hemostats
▪ Suture material
▪ Local anesthetic
▪ Chest tube and connector
▪ Chest drainage system: connecting tubing and collection bottles,
or commercial system.
▪ Suction apparatus (if ordered)
▪ Mobile table or stand.
 IMPLEMENTATION

Knowing the reason for the chest tube

1. Review the patient chart for the reason
and location informs the health care
for the chest tube and location nd
provider on the type of expected
insertion date.
drainage.

2. Perform hand hygiene. identify patient

Hand hygiene reduces the transmission
using two identifiers and explain
of microorganisms.
assessment process to patient. Create
Proper identification provides patient
privacy to assess the patient and
safety measures for safe care.
drainage system.
 IMPLEMENTATION
Patient should be in a semi-Fowler’s
position, have minimal pain,
Patient should behave
in a semi-Fowler’s
no respiratory distress, and
position, have minimal pain,
have no evidence of an air leak around the
have no respiratory distress, and
have no evidenceinsertion
of an air leaksite, and no drainage from the
around
the insertion site,insertion site or
and no drainage chest tube equipment.
from
the insertion site or chest tube
Frequent assessment of the respiratory
equipment.
3. Complete respiratory assessment, status
Frequent assessment is important
of the respiratory if the patient’s
3. Complete respiratory assessment,
ensure patient has minimal pain,status
ensure patient has minimal pain, and
and is importantcondition is stable, resolving, or
if the patient’s
measure
measure vitalvital
signs.signs. Placeinpatientcondition
Place patient in semi-is stable, resolving, orand ensures that the chest tube
worsening,
worsening, and ensures that the chest
Fowler’s position
semi-Fowler’s foreasier
position for easier breathing. is functioning correctly.
tube is functioning correctly.
breathing. Assessment should be every 15 minutes to
Assessment should be every 15 minutes
1 hour
to 1 hour until patient until Increase
is stable. patient is stable. Increase
monitoring if patient’s condition
monitoring if patient’s condition worsens.
worsens.
Chest as
Chest tubes are painful, tubes are painful, as the parietal
the parietal
pleura are
pleura are very sensitive. very
Ensure sensitive. Ensure patient
patient
has adequate pain has relief, especiallypain
adequate prior relief, especially prior to
to repositioning, sitting, or ambulation.
repositioning, sitting, or ambulation.
 IMPLEMENTATION

▪ Set up the thoracotomy tray on the instrument table,

using sterile technique.
▪ Using sterile technique, place other supplies on the
sterile field.
▪ Assist the physician with the skin prep and administration
of local anesthetic as for thoracentesis.
 IMPLEMENTATION

▪ Assist the physician with tube insertion, as directed.

There are varying methods of introducing a tube into the
pleural space. The method used depends upon the size
of the tube to be inserted, the equipment available, and
the physician's preference.
IMPLEMENTATION
IMPLEMENTATION
IMPLEMENTATION
 IMPLEMENTATION

▪ Assist the physician with tube insertion, as directed.

There are varying methods of introducing a tube into the
pleural space. The method used depends upon the size
of the tube to be inserted, the equipment available, and
the physician's preference.
 IMPLEMENTATION

▪ The physician connects the patient's chest tube and the

drainage tubing, checks the entire system to verify all
connections, and tapes the connections to ensure an
airtight system. He will then unclamp the chest tube. The
clamps are never removed until the drainage system is
airtight and ready to function.
 IMPLEMENTATION

▪ The chest tube is normally sutured in place and covered

with a sterile dressing.
▪ Arrange for a follow-up chest X-ray, if ordered.
▪ Tape the padded hemostats and a package of sterile
vaseline gauze to the head of the patient's bed. This
equipment must be available for emergency use should
the chest tube become dislodged or the drainage system
opened.
 EVALUATION

▪ Observe patient for respiratory difficulty.

▪ Continue to observe the drainage system for proper
function.
▪ Record the procedure in the Nursing Notes.
▪ Note the patient's tolerance to the procedure.
▪ Observe amount, color, and consistency of chest
drainage at ordered time intervals and record results in
patient's clinical record
 REMOVAL OF THE CHEST TUBE

▪ Perform hand hygiene and don non-sterile gloves, put on face

shield.
▪ Position client on Semi-fowler’s
▪ Remove dressing and cleanse site with chlorhexidine alcohol
solution.
▪ Physician will pre-medicate with analgesic if necessary
▪ Discontinue suction
▪ Clamp chest tube (the one being removed and any other
tubes that share the same chest drainage unit)
▪ Remove suture(s) holding chest tube in place
▪ Instruct patient to take a deep breath & hold it
 REMOVAL OF THE CHEST TUBE

▪ In one smooth and rapid manner, remove chest tube, applying

direct and immediate pressure.
▪ Have a second person apply Hypafix tape while maintaining
occlusive pressure.
▪ Instruct patient to breathe normally.
▪ Unclamp remaining chest tubes and resume previous suction.
Keep tubing of removed chest tube clamped if a double
chamber drainage collection system is in use.
▪ If a chest tube is remaining on a double chamber drainage
collection system, tie tubing in a knot and keep discontinued
tubing clamped until remaining chest tube is removed
 REMOVAL OF THE CHEST TUBE

▪ Remove non-sterile gloves and perform hand hygiene, then

removal facemask with shield and perform hand hygiene.
▪ Dispose of drainage collection system in biohazard bin in dirty
utility room.
▪ Obtain CXR within 4 hours of removal, or STAT, if you observe
signs of respiratory distress, subcutaneous emphysema or
bleeding from site.
▪ Ensure physician reviews CXR
▪ Document in patient chart, note final amount of chest
drainage to calculate total drainage.
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