International Journal of Academic Research and Development

International Journal of Academic Research and Development

ISSN: 2455-4197
Impact Factor: RJIF 5.22
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Volume 3; Issue 2; March 2018; Page No. 252-257

Nursing practices: Troubleshooting thoracostomy tube management

Abeer El-Said, Hassane El-sol
Lecturer of Medical-Surgical Nursing, Faculty of Nursing, Menoufia University, Egypt

Abstract
Thoracostomy tube is a sterile tube with a number of drainage holes that is inserted into the pleural space. The pleural space is the
space between the parietal and visceral pleura, and is also known as the pleural cavity. A patient may require a chest drainage
system any time the negative pressure in the pleural cavity is disrupted, resulting in respiratory distress. It 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. Specific
common indications for thoracostomy tubes placement; as Pneumothorax. While coagulopathy is contraindication for its
placement. When the nursing team provide their care to patients with thoracostomy tube; they had five priorities, they are closely
monitoring of respiratory status, checking underwater seal for bubbles, milking not strip every 2 hours, assess the output color and
maintain the chest site cover with sterile occlusive dressing. The management of patient with thoracostomy tube drainage systems
need to efficient nursing practice to fully understand what to do in case problems arise. Rapid management for any troubleshooting
or complication as potential pneumothorax/respiratory distress, air leak, accidental chest tube removal or chest tube falls out,
accidental disconnection of the drainage system, bleeding at the insertion site, drainage suddenly stops and respiratory distress
increases, sudden increase in bright red drainage and subcutaneous emphysema. Nurses are responsible for the safe delivery of
care so they should be skillful practices about signs and symptoms of troubleshooting thoracostomy tube and interventions for each
type.

Keywords: thoracostomy tube, troubleshooting thoracostomy tube, nursing management

1. Introduction lung parenchyma), which normally contains less than 25 mL

Thoracostomy Tube (TT) or chest drain, thoracic of pleural fluid. The presence of excess fluid, air, blood, chyle,
catheter, chest tube, and intercostal drain; is a flexible plastic or pus in this pleural space results in displacement of
tube that is inserted through the chest wall and into the pleural pulmonary volume, which disrupts gas exchange [4].
space or mediastinum. The pleural space is the space between There are numerous reasons for excess air and/or fluid in the
the parietal and visceral pleura, and is also known as the pleural space. Specific common indications for thoracostomy
pleural cavity. A patient may require a chest drainage system tubes placement include:
any time the negative pressure in the pleural cavity is disrupted,  Pneumothorax: accumulation of air or gas in the pleural
resulting in respiratory distress. Chest tubes are commonly space.
made from clear plastics like PVC and soft silicone [1].  Symptomatic Pleural effusion: accumulation of fluid in
Tube thoracostomy is the most commonly performed surgical the pleural space
procedure in thoracic surgery. Today, TT placement remains  Chylothorax: a collection of lymphatic fluid in the pleural
among the most commonly performed procedures, from space
bedside to operating room, from life-threatening emergencies  Empyema: a pyogenic infection of the pleural space
to postoperative chest drainage in elective surgery. It is widely  Hemothorax: accumulation of blood in the pleural space
used throughout the medical, surgical, and critical care  Hydrothorax: accumulation of serous fluid in the pleural
specialties [2]. space
TT may be lifesaving and facilitates evacuation (and  Penetrating chest trauma.
monitoring) of hemothorax, prevents the development of  Severe blunt chest trauma.
tension pneumothorax while promoting lung re-expansion,  Broncho-pleural fistula: an abnormal communication
tamponade low pressure pulmonary bleeding, and improves between a bronchus and the pleural cavity [5].
respiratory function in the injured patient. In the surgical
patient, chest tubes facilitate postoperative recovery. Patients Other indications include
with malignancies may benefit from symptomatic relief  Postoperative use in thoracic/cardiac surgery; and
brought about by drainage of persistent, large pleural effusions Complicated Para pneumonic effusion or empyema to
[3&4]
. drain blood associated with the surgery.
1.1 Thoracostomy tube: Indications.  Chemical pleurodesis for benign and malignant
Physiologically, a potential space exists between the parietal conditions: Pleurodesis is a procedure used to treat
pleura (abutting chest wall) and the visceral pleura (abutting patients with recurrent pleural effusions or recurrent

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pneumothorax. This procedure involves administering a Chest tubes, like most catheters, are measured in French
sclerosing agent into the pleural space which causes the catheter scale. Chest tubes are also provided in right angle,
visceral and parietal pleura to adhere to each other trocar, flared, and tapered configurations for different drainage
without the thin coating of fluid between them. need [8].
 Chemotherapy administration: May be administered As well, some chest tubes are coated with heparin to help
through a chest tube [5, & 6]. prevent thrombus formation, though the effect of this is
disputed. Chest tube has an end hole (proximal, toward the
1.2 Thoracostomy tube: Contraindications patient) and a series of side holes. The number of side holes is
The need for emergent thoracotomy is an absolute generally 6 on most chest tubes. The length of tube that has
contraindication to tube thoracostomy. side holes is the effective drainage length (EDL). In chest
Relative contraindications include the following: tubes designed for pediatric heart surgery, the EDL is shorter,
 Coagulopathy generally by only having 4 side holes [9].
 Pulmonary bullae Channel style chest drains, also called Blake drains, are so-
 Pulmonary, pleural, or thoracic adhesions called silastic drains made of silicone and feature open flutes
 Pulmonary abscess that reside inside the patient. Drainage is thought to be
 Skin infection at the chest tube insertion site [5&7]. achieved by capillary action, allowing the fluids to travel
through the open grooves into a closed cross section, which
1.3 Characteristics of tube thoracostomy contains the fluid and allows it to be suctioned through the
Thoracostomy tubes are commonly made from clear plastics tube. Though these chest tubes are more expensive than
like PVC and soft silicone. Chest tubes are made in a range of conventional ones, they are theoretically less painful [10].
sizes measured by their external diameter from 6 Fr to 40 Fr.

Fig 1: TT with labeled parts [11].

1.4 Thoracostomy tube drainage holes gentle bubbling in the chamber. A dry suction system uses a
A chest tube drainage system; is a sterile, disposable system self-controlled regulator that adjusts the amount of suction and
that consists of a compartment system that has a one-way responds to air leaks to deliver consistent suction for the
valve, with one or multiple chambers, to remove air or fluid patient. If suction is discontinued, the suction port on the chest
and prevent return of the air or fluid back into the patient. In drainage system must remain unobstructed and open to air to
general, a traditional chest tube drainage system will have allow air to exit and minimize the development of a tension
these three chambers: pneumothorax [13].
Collection or drainage chamber: The chest tube connects
directly to the collection chamber, which collects drainage
from the pleural cavity [12].
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 [13].
Wet or dry suction control chamber: Not all patients require Fig 2: Thoracostomy tube system [11].
suction. If a patient is ordered suction, a wet suction system is
typically controlled by the level of water in the suction control 1.5 Process of chest tube placement
chamber and is typically set at -20 cm on the suction control Selecting appropriate tube sizes [5].
chamber for adults. Monitor the fluid level to ensure there is It is significant for the clinician to select the best proper tube

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size according to patient’s age before tube insertion. As,

obvious in the following table:

Table 1: The best proper tube size according to the patient’s age.
Patient’s age. Thoracostomy tube size
Newborn 8 FR–12 FR
Child 18 Fr
Adult male 28–32 Fr
Adult female 28 Fr
Larger adult sizes 36 FR–40 FR

Table 2: Equipment for tube thoracostomy [14].

Fig (3&4): common sites of chest tube insertion [11].

Doctor will then gently open a space into the chest cavity and
guide the tube into a chest. Chest tubes come in various sizes
for different conditions. The doctor will stitch the chest tube in
place to prevent it from moving. After chest-tube insertion,
connect the tube’s distal end to the chest drainage system.
Secure the tube at the insertion site with sutures. The nurse
apply an occlusive sterile petroleum gauze dressing around the
tube; then apply a dry, sterile split 4x 4 dressing over
everything. Secure all tube connections from the chest tube to
Preparation: The nurse obtaining informed consent, shaving the drainage container, using either tape or zip ties [12&15].
any hair from the insertion site, if necessary, disinfection e a
large area on the affected chest side, from the armpit down to Drainage: The tube is then attached to a special one-way
the abdomen and across to nipple. Preparation involves drainage system that allows air or fluid to flow out only. This
sterilizing the area and. Use an ultrasound to identify a good prevents the fluid or air from flowing back into the chest
location for inserting the tube [15]. cavity. While the chest tube is in, patient will probably need to
Anesthesia: The doctor may inject an anesthetic into patient stay in the hospital. Once the drain is in place, a chest
skin. The medication will help make more comfortable during radiograph will be taken to check the location of the drain. A
the chest tube insertion, which can be painful [16]. nurse will monitor patient breathing and check for possible air
Incision: By a scalpel, doctor will make a small (¼- to 1 ½- leaks [15&17].
inch) incision between ribs, near the upper part of the patient
chest. The incision site depends on the reason for the chest Stayment Length: the chest tube is left in depends on the
tube [17]. condition that caused the buildup of air or fluid. Some lung
Patient position and insertion: Patient positioning depends cancers can cause fluid to re-accumulate. Doctors may leave
on the insertion site, and the patient’s clinical status. Usually, the tubes in for a longer period of time in these cases [17].
the patient is flat, with a small sterile folded towels or a
blanket placed under the patient shoulder. Commonly, a chest
tube is inserted at the mid-axillary line between the fourth and
fifth ribs on a line lateral to the nipple [5]. If the chest drainage
tube is to be used to drain air, the tube is placed at second
intercostal space. If the tube is to drain fluid, the tube is placed
posteriorly near at fifth or sixth intercostal space Figure
(3&4). In the hemothorax; it may be placed at the base of the
lung as well as at the apex [18].

Fig 5: Steps of thoracostomy tube insertion [11].

1.6 Safety considerations

 Nurses often assist physicians in the insertion and
removal of a closed chest tube drainage system.
 After initial insertion of a chest tube drainage system,
assess the patient every 15 minutes to 1 hour. If the
patient is stable (vital signs within normal limits; drainage
amount, color, or consistency is within normal limits; the

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patient is not experiencing any respiratory distress or bursts of suction to move clots. Any aggressive
pain), assessment may be completed every 4 hours [12&13]. manipulation (compressing the tube to dislodge blood
 Prior to managing a patient with a chest tube, review clots) can generate extreme pressures in the chest tube.
reason for the chest tube, the location of the chest tube, There is no evidence showing the benefit of stripping or
normal volume of drainage, characteristics of the milking a chest tube [12, 13&19].
drainage, date of last dressing change, and any previously  The only exceptions to clamping a chest tube are 1) if the
recorded air leaks measurements [18]. drainage system is being changed, 2) if assessing the
 Safety/emergency equipment must always be at the system for an air leak, 3) if the chest tube becomes
patient’s bedside. Safety equipment includes: disconnected from the chest drainage system — the chest
 Two guarded clamps tube should not be clamped for more than a few minutes,
 Sterile water or 4) if the condition of the patient is resolved and the
 Vaseline gauze (Jelonet) chest tube is ready for removal (as per physician orders)
[20]
 4 x 4 sterile dressing .
 Waterproof tape
 Never clamp a chest tube without a doctor’s order or valid
reason.
 Chest tube drainage systems are replaced only when the
collection chamber is full or the system is contaminated
[19]
.

1.7 Nursing considerations

 Do not strip or milk the chest tube: In practice,
stripping is 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. Milking refers to techniques
such as squeezing, kneading, or twisting the tube to create Fig 6: Thoracostomy or chest tube: Nursing priorities [11].

Table 3: Nursing care for thoracostomy tube patients [12 & 18].
1-Review the patient chart for the reason for the chest tube and location and insertion date.
2-Explain assessment process to patient. Create privacy to assess the patient and drainage system.
3. Complete respiratory assessment, ensure patient has minimal pain, and measure vital signs. Place patient in semi-Fowler’s position for
easier breathing.

4. Assess chest tube insertion site to ensure sterile dressing is dry and intact.
Check insertion site for subcutaneous emphysema

5. Maintain a closed system. Ensure all connections are taped and secured according to agency policy.

6. Ensure tubing is not kinked or bent under the patient or in the bed rails, or compressed by the bed.

7. Collection chamber (drainage system) is below the level of the chest and secured to prevent it from being
accidentally knocked over.

8. Periodically check water-seal chamber to ensure water level is to the dotted line (2 cm) — at least once every shift. Add water as
necessary.

9. Check water-seal chamber for tidaling (water moving up and down) with respirations. Gentle bubbling is
normal as the lungs expand.

10. Ensure suction control dial is set to ordered level (usually 20 cm).

11. If suction is ordered, a “float” (or equivalent) must be visible clearly in the window.

12. If suction is not ordered, ensure the suction port is left open to air. Suction window will appear blank if suction is not in use or not
working.

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13. In wet suction systems, expect gentle bubbling in the chamber.

14. Assess air leak meter to determine progress of patient’s internal air level, measured as level 1 to 7. On every
shift, document the level of air leak, and if the air leak occurs at rest or with coughing.

15. Check that the clamp is open.

16. Measure date and time, and the amount of drainage, and mark on the outside of the chamber. Record
amount and characteristics of the drainage on the fluid balance sheet and patient chart.

17. Encourage frequent position changes as well as deep-breathing and coughing exercises
18. The following should be documented and assessed according to agency policy:
 Presence of air leaks
 Fluctuation of water in water-seal chamber
 Amount of suction
 Amount of drainage and type
 Presence of crepitus (subcutaneous emphysema)
 Breath sounds
 Patient comfort level or pain level
 Appearance of insertion site and/or dressing

Table 4: Potential Troubleshooting and nursing management related to thoracostomy tube drainage systems [21, 22, 23 &24].
Troubleshooting Nursing management
 This is the primary concern for a patient with a chest tube drainage system. Signs and symptoms include
decreased SaO2, increased work of breathing (WOB), diminished breath sounds, and decreased chest
movement, complaints of chest pain, tachycardia or bradycardia, hypotension.
1-Potential pneumothorax
 Notify the doctor.
/respiratory distress
 Request urgent chest X-ray.
 Ensure drain system is intact with no leaks or blockages such as kinks or clamps.
 Apply oxygen and take vital signs.
 An air leak may occur from the chest tube insertion site or the drainage system. Do the following to test the
system for the site of an air leak:
 Using a booted (or padded) clamp, begin at the dressing and clamp the drainage tubing momentarily.
 Look at the water-seal/air leak meter chamber. Keep moving the clamp down the drainage tubing toward
2- Air leak the chest drainage system, placing it at 20 to 30 cm intervals. Each time you clamp, check the water-
seal/air leak meter chamber.
 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.
 A chest tube falling out is an emergency.
 Immediately apply pressure to chest tube insertion site and apply sterile gauze or place sterile gauze and
3- Accidental chest tube removal dry dressing over insertion site and ensure tight seal.
or chest tube falls out  Apply dressing when patient exhales.
 If patient goes into respiratory distress, call a code blue.
 Notify the doctor and reinsert new chest tube drainage system.
 A chest tube drainage system disconnecting from the chest tube inside the patient is an emergency.
4- Accidental disconnection of
 Immediately clamp the tube and place the end of chest tube in sterile water or normal saline.
the drainage system
 The two ends will need to be swabbed with alcohol and reconnected.
 Bleeding may occur after insertion of the chest tube.
5- Bleeding at the insertion site
 Apply pressure to site and monitor.
6- Subcutaneous emphysema  Subcutaneous emphysema is painless tracking of air underneath the subcutaneous tissue.

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 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.
 Monitor and report to physician.
7- Drainage suddenly stops and  The chest tube may be clogged by a blood clot or by fluid in a dependent loop.
respiratory distress increases  Assess the drainage system and the patient and notify primary health care provider if required.
8- Sudden increase in bright red  This may indicate an active bleed.
drainage  Monitor amount of drainage and vital signs, and notify the physician.

2. Conclusion prospective randomized study. Eur J Cardiothoracic Surg.

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