Oral and Tracheostomy Suction/ Chest Tubes

Video

Tracheostomy

A tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube.

Description

General anesthesia is used, unless the situation is critical. If that happens, a numbing medicine is placed into the area to help you feel less pain during the procedure.

The neck is cleaned and draped. Surgical cuts are made to show the tough cartilage rings that form the outer wall of the trachea. The surgeon creates an opening into the trachea and inserts a tracheostomy tube.

Why the Procedure is Performed

A tracheostomy may be done if you have:

• A large object blocking the airway

• An inability to breathe on your own

• An inherited abnormality of the larynx or trachea

• Breathed in harmful material such as smoke, steam, or other toxic gases that swell and block the airway

• Cancer of the neck, which can affect breathing by pressing on the airway

• Paralysis of the muscles that affect swallowing

• Severe neck or mouth injuries

• Surgery around the voicebox (larynx) that prevents normal breathing and swallowing

Reasons for a tracheostomy

A tracheostomy is usually done for one of three reasons:

1.     to bypass an obstructed upper airway;

2.     to clean and remove secretions from the airway;

3.     to more easily, and usually more safely, deliver oxygen to the lungs.

All tracheostomies are performed due to a lack of air getting to the lungs. There are many reasons why sufficient air cannot get to the lungs.

Airway Problems That May Require a Tracheostomy

• Tumors, such as cystic hygroma

• Laryngectomy

• Infection, such as epiglottitis or croup

• Subglottic Stenosis

• Subglottic Web

• Tracheomalacia

• Vocal cord paralysis (VCP)

• Laryngeal injury or spasms

• Congenital abnormalities of the airway

• Large tongue or small jaw that blocks airway

• Treacher Collins and Pierre Robin Syndromes

• Severe neck or mouth injuries

• Airway burns from inhalation of corrosive material, smoke or steam

• Obstructive sleep apnea

• Foreign body obstruction

Lung Problems That May Require a Tracheostomy

• Need for prolonged respiratory support, such as Bronchopulmonary Dysplasia (BPD)

• Chronic pulmonary disease to reduce anatomic dead space

• Chest wall injury

• Diaphragm dysfunction

Other Reasons for a Tracheostomy

• Neuromuscular diseases paralyzing or weakening chest muscles and diaphragm

• Aspiration related to muscle or sensory problems in the throat

• Fracture of cervical vertebrae with spinal cord injury

• Long-term unconsciousness or coma

• Disorders of respiratory control such as congenital central hypoventilation or central apnea

• Facial surgery and facial burns

• Anaphylaxis (severe allergic reaction)

How a tracheostomy is performed

Surgical Anatomy

The superior thyroid notch, cricoid and suprasternal notch usually can be easily palpated through the skin. The cricothyroid space can be identified by palpating a slight indentation immediately below the inferior edge of the thyroid cartilage. Cricothyroid arteries traverse the superior aspect of this space on each side and anastomose near the midline.

The innominate artery crosses from left to right anterior to the trachea at the superior thoracic inlet. Its pulsations can be palpated and occasionally seen in the suprasternal notch especially in case of a high riding vessel, representing a contraindication for a bedside percutaneous or open tracheostomy.

The isthmus of the thyroid gland lies across the 2nd to 4th tracheal rings and must be dealt with in any procedure at or around the upper trachea. 

Indications for PDT

They are the same as a routine open operative tracheostomy with particular attention to contraindications.¹

Contraindications for PDT

Absolute:
Emergent tracheostomy ( i.e., securing emergent airway) in any patient population, infants and children (<15 years)

Relative Surgical Contraindications:
Poor neck landmarks, neck mass (e.g. goiter), high innominate or pulsating vessels, previous neck surgery, limited neck extension, severe coagulopathy (uncorrected)

Relative Anesthetic Contraindications:
High PEEP (>18 cm), high airway pressure (>45 cm),  high FiO2 (80%), retrognathic mandible with a limited view of the larynx on laryngoscopy

Preparation for Tracheostomy

Once the decision to perform a tracheostomy has been made, the surgeon must determine if the patient is a good candidate for the surgery and obtain written informed consent. In addition, the range of motion of the neck needs to be assessed. The tracheostomy team, including the surgeons and anesthesiologists need to discuss the entire sequence and alternatives to the procedure. All equipment must be available and functioning properly.

Equipment

A regimented approach to preparation and performance of the procedure has been shown to significantly reduce the incidence of procedural complications⁴.

Our approach includes the following equipment and protocols:

• We routinely use Cook Blue Rhino single dilator kit and videobronchoscopy to perform the procedure.

• The following must be available:

• An attending anesthesiologist must be present for maintenance of airway, provision of intravenous sedation and performance of bronchoscopy.

• An intubation roll and a cricoid hook.

• Open tracheostomy set.

Technique

Watch a tracheostomy (24 MB Windows Media file)

The technique described here is based on Seldinger’s principle ². The technique we use was first described and later modified by Ciaglia ³.  The use of bronchoscopy was first introduced by Marelli et al and has subsequently been adopted by many centers ^{4, 5}.

Positioning

1.     The patient’s neck is extended over a shoulder roll (unless there is a contraindication).

2.     The anesthesiologist stands at the head end of the bed and under direct laryngoscopy positions the endotracheal tube (ETT) so that the cuff is midway at the vocal cord level.

Incision

1.     We routinely inject the skin with 1% lidocaine with 1:100,000 epinephrine solution.

2.     A horizontal or vertical incision centered on the inferior border of the cricoid cartilage may be used. We routinely use a 3-4 cm vertical incision.

Placement of Introducer Needle

1.     A minimal dissection is performed onto the pretracheal tissue in order to push the thyroid isthmus downward.

2.     The larynx is stabilized and pulled cephalad with the operator’s left hand.

3.     A bronchoscopy is then performed and the light reflex is used to select the best site for the introducer needle.

4.     Placing the needle at the inferior edge of the light reflex, the tip of the needle is directed caudad into the tracheal lumen avoiding the posterior tracheal wall at all cost.

Introduction of Guide Wire, Stylet and Initial Tract Dilatation
The needle is withdrawn while keeping the cannula in the tracheal lumen. A J-tipped guide wire is then place under vision. The stylet is then placed with the safety ridge directed towards the tip of the wire. The tract is then dilated with the 8 FR dilator.

Dilatation with the Blue Rhino Dilator
The Blue Rhino dilator is loaded on the stylet with the tip resting on the safety ridge. The dilator is moved in and out to optimally dilate the tissue between the skin and the tracheal lumen. The Blue Rhino dilator is never advanced beyond the point where 40 FR mark disappears below the skin level.

Placement of the Tracheostomy Tube

1.     A tracheostomy tube is loaded onto the dilator
– Females: a size 6 cuffed Shiley tracheostomy tube is loaded on to the 26 FR dilator
– Males: a size 8 cuffed Shiley tracheostomy tube is loaded on to the 28 FR dilator

2.     The dilator is then loaded on the safety ridge of the stylet and placed into the tracheal lumen under direct visualization.

Confirmation of Placement 
The bronchoscope is withdrawn from the ETT and introduced via the tracheostomy tube. The placement is confirmed by visualizing the carina.

Securing the Tube
We routinely secure the tube with 2 sutures of 2-0 nylon on each side of the flange. In addition, a tracheostomy tape is used to hold the tube in place. A flexible extension tube is used to connect the tube to the ventilator circuit to avoid undue movement of the tube in the immediate postoperative period.

Postoperative Consideration

A chest X-ray is not routinely required as long as the entire procedure was done under direct visualization and there were no adverse events intraoperatively⁶. The postoperative care is same as for the open procedure.

The tract between the skin and the tracheal lumen takes a little longer (10-14 days) to mature as there is no formal layer by layer dissection involved. We, therefore, perform the first tube change on Day 10-12 postoperatively.

 

Risks

The risks for any anesthesia are:

• Problems breathing

• Reactions to medications, including heart attack and stroke

The risks for any surgery are:

• Bleeding

• Infection

• Nerve injury, including paralysis

• Scarring

Other risks include:

• Damage to the thyroid gland

• Erosion of the trachea (rare)

• Puncture of the lung and lung collapse

• Scar tissue in the trachea that causes pain or trouble breathing

Complications and Risks of Tracheostomy

As with any surgery, there are some risks associated with tracheotomies. However, serious infections are rare.

Early Complications that may arise during the tracheostomy procedure or soon thereafter include:

• Bleeding

• Air trapped around the lungs (pneumothorax)

• Air trapped in the deeper layers of the chest(pneumomediastinum)

• Air trapped underneath the skin around the tracheostomy (subcutaneous emphysema)

• Damage to the swallowing tube (esophagus)

• Injury to the nerve that moves the vocal cords (recurrent laryngeal nerve)

• Tracheostomy tube can be blocked by blood clots, mucus or pressure of the airway walls.  Blockages can be prevented by suctioning, humidifying the air, and selecting the appropriate tracheostomy tube.

Many of these early complications can be avoided or dealt with appropriately with our experienced surgeons in a hospital setting.

Over time, other complications may arise from the surgery.

Later Complications that may occur while the tracheostomy tube is in place include:

• Accidental removal of the tracheostomy tube (accidental decannulation)

• Infection in the trachea and around the tracheostomy tube

• Windpipe itself may become damaged for a number of reasons, including pressure from the tube; bacteria that cause infections and form scar tissue; or friction from a tube that moves too much

These complications can usually be prevented or quickly dealt with if the caregiver has proper knowledge of how to care for the tracheostomy site.

Delayed Complications that may result after longer-term presence of a tracheostomy include:

• Thinning (erosion) of the trachea from the tube rubbing against it (tracheomalacia)

• Development of a small connection from the trachea (windpipe) to the esophagus (swallowing tube) which is called a tracheo-esophageal fistula

• Development of bumps (granulation tissue) that may need to be surgically removed before decannulation (removal of trach tube) can occur

• Narrowing or collapse of the airway above the site of the tracheostomy, possibly requiring an additional surgical procedure to repair it

• Once the tracheostomy tube is removed, the opening may not close on its own.  Tubes remaining in place for 16 weeks or longer are more at risk for needing surgical closure

A clean tracheostomy site, good tracheostomy tube care and regular examination of the airway by an otolaryngologist should minimize the occurrence of any of these complications.

High-risk groups

The risks associated with tracheostomies are higher in the following groups of patients:

• children, especially newborns and infants

• smokers

• alcohol abusers

• diabetics

• immunocompromised patients

• persons with chronic diseases or respiratory infections

• persons taking steroids or cortisone

 

After the Procedure

If the tracheostomy is temporary, the tube will eventually be removed. Healing will occur quickly, leaving a minimal scar. Sometimes, a surgical procedure may be needed to close the site (stoma).

Occasionally a stricture, or tightening of the trachea may develop, which may affect breathing.

If the tracheostomy tube is permanent, the hole remains open.

Outlook (Prognosis)

Most patients need 1 to 3 days to adapt to breathing through a tracheostomy tube. It will take some time to learn how to communicate with others. At first, it may be impossible for the patient to talk or make sounds.

After training and practice, most patients can learn to talk with a tracheostomy tube. Patients or family members learn how to take care of the tracheostomy during the hospital stay. Home-care service may also be available.

You should be able to go back to your normal lifestyle. When you are outside, you can wear a loose covering (a scarf or other protection) over the tracheostomy stoma (hole). Use safety precautions when you are exposed to water, aerosols, powder, or food particles.

Types of Tracheostomy Tubes

A tracheostomy (trach) tube is a curved tube that is inserted into a tracheostomy stoma (the hole made in the neck and windpipe (Trachea)). There are different types of tracheostomy tubes that vary in certain features for different purposes.  These are manufactured by different companies.  However, a specific type of tracheostomy tube will be the same no matter which company manufactures them.

A commonly used tracheostomy tube consists of three parts: outer cannula with flange (neck plate), inner cannula, and an obturator. The outer cannula is the outer tube that holds the tracheostomy open. A neck plate extends from the sides of the outer tube and has holes to attach cloth ties or velcro strap around the neck. The inner cannula fits inside the outer cannula. It has a lock to keep it from being coughed out, and it is removed for cleaning. The obturator is used to insert a tracheostomy tube.  It fits inside the tube to provide a smooth surface that guides the tracheostomy tube when it is being inserted.

There are different types of tracheostomy tubes available and the patient should be given the tube that best suits his/her needs. The frequency of these tube changes will depend on the type of tube and may possibly alter during the winter or summer months. Practitioners should refer to specialist practitioners and/or the manufacturers for advice. 

 

Suctioning

The upper airway warms, cleans and moistens the air we breathe. The trach tube bypasses these mechanisms, so that the air moving through the tube is cooler, dryer and not as clean.  In response to these changes, the body produces more mucus.  Suctioning clears mucus from the tracheostomy tube and is essential for proper breathing. Also, secretions left in the tube could become contaminated and a chest infection could develop.  Avoid suctioning too frequently as this could lead to more secretion buildup.

Removing mucus from trach tube without suctioning

1.     Bend forward and cough. Catch the mucus from the tube, not from the nose and mouth.

2.     Squirt sterile normal saline solutions (approximately 5cc) into the trach tube to help clear the mucus and cough again.

3.     Remove the inner tube (cannula).

4.     Suction.

5.     Call 911 if breathing is still not normal after doing all of the above steps.

6.     Remove the entire trach tube and try to place the spare tube.

7.     Continue trying to cough, instill saline, and suction until breathing is normal or help arrives.

When to suction

Suctioning is important to prevent a mucus plug from blocking the tube and stopping the patient’s breathing.  Suctioning should be considered

• Any time the patient feels or hears mucus rattling in the tube or airway

• In the morning when the patient first wakes up

• When there is an increased respiratory rate (working hard to breathe)

• Before meals

• Before going outdoors

• Before going to sleep

The secretions should be white or clear. If they start to change color, (e.g. yellow, brown or green) this may be a sign of infection. If the changed color persists for more than three days or if it is difficult to keep the tracheostomy tube intact, call your surgeon’s office. If there is blood in the secretions (it may look more pink than red), you should initially increase humidity and suction more gently. A Swedish or artificial nose (HME), which is a cap that can be attached to the tracheostomy tube, may help to maintain humidity. The cap contains a filter to prevent particles from entering the airway and maintains the patient’s own humidity. Putting the patient in the bathroom with the door closed and shower on will increase the humidity immediately. If the patient coughs up or has bright red blood mucus suctioned, or if the patient develops a fever, call your surgeon’s office immediately.

How to suction

Equipment
Clean suction catheter (Make sure you have the correct size)

Distilled or sterile water

Normal saline

Suction machine in working order

Suction connection tubing

Jar to soak inner cannula (if applicable)

Tracheostomy brushes (to clean tracheostomy tube)

Extra tracheostomy tube

1.     Wash your hands.

2.     Turn on the suction machine and connect the suction connection tubing to the machine.

3.     Use a clean suction catheter when suctioning the patient. Whenever the suction catheter is to be reused, place the catheter in a container of distilled/sterile water and apply suction for approximately 30 seconds to clear secretions from the inside. Next, rinse the catheter with running water for a few minutes then soak in a solution of one part vinegar and one part distilled/sterile water for 15 minutes. Stir the solution frequently. Rinse the catheters in cool water and air-dry. Allow the catheters to dry in a clear container. Do not reuse catheters if they become stiff or cracked.

4.     Connect the catheter to the suction connection tubing.

5.     Lay the patient flat on his/her back with a small towel/blanket rolled under the shoulders. Some patients may prefer a sitting position which can also be tried.

6.     Wet the catheter with sterile/distilled water for lubrication and to test the suction machine and circuit.

7.     Remove the inner cannula from the tracheostomy tube (if applicable). The patient may not have an inner cannula. If that is the case, skip this step and go to number 8.

8.     a. There are different types of inner cannulas, so caregivers will need to learn the specific manner to remove their patient’s. Usually rotating the inner cannula in a specific direction will remove it.

b. Be careful not to accidentally remove the entire tracheostomy tube while removing the inner cannula. Often by securing one hand on the tracheostomy tube?s flange (neck plate) one can/ will prevent?accidental removal.

c. Place the inner cannula in a jar for soaking (if it is disposable, then throw it out).

9.     Carefully insert the catheter into the tracheostomy tube. Allow the catheter to follow the natural curvature of the tracheostomy tube. The distance to the location of catheter becomes easier to determine with experience. The least traumatic technique is to pre-measure the length of the tracheostomy tube then introduce the catheter only to that length. For example if the patient?s tracheostomy tube is 4 cm long, place the catheter 4 cm into the tracheostomy tube. Often, there will be instances when this technique of suctioning (called tip suctioning) will not clear the patient?s secretions. For those situations, the catheter may need to be inserted several mm beyond the end of the tracheostomy tube (called deep suctioning). With experience, caregivers will be able to judge the distance to insert the tracheostomy tube without measuring.

10. Place your thumb over the suction vent (side of the catheter) intermittently while you remove the catheter. Do not leave the catheter in the tracheostomy tube for more than 5-10 seconds since the patient will not be able to breathe well with the catheter in place.

11. Allow the patient to recover from the suctioning and to catch his/her breath. Wait for at least 10 seconds.

12. Suction a small amount of distilled/sterile water with the suction catheter to clear any residual debris/secretions.

13. Insert the inner cannula from extra tracheostomy tube (if applicable).

14. Turn off suction machine and discard catheter (clean according to step 3 if to be reused).

15. Clean inner cannula (if applicable).

The chest drainage system is a closed system designed to drain air or fluid from the pleural cavity while restoring or maintaining the negative intrapleural pressure

needed to keep the lung properly expanded. The space between the lungs and chest wall is called the pleural cavity and it normally contains only a small amount of

fluid for lubrication between the lungs and the chest wall. Negative intrapleural pressure between the lungs, chest wall, and diaphragm allows the movement of the

chest and diaphragm to expand and contract the lungs. Large amounts of fluid or air in the pleural cavity impede the expansion of the lungs, causing respiratory distress or “collapse” of the lung. Excess fluid or air can enter the pleural cavity by several means. Thoracic surgery breaks the vacuum seal in the pleural cavity,

allowing fluid and air to enter. Trauma to the chest wall can lead to bleeding into the pleural cavity (hemothorax) or air entering the pleural cavity (pneumothorax).

Occasionally, spontaneous pneumothorax occurs, without apparent cause. The chest drainage system is designed to help restore the vacuum seal in the pleural cavity by draining excess fluid or air while keeping the pleural cavity sealed. Occlusive dressings, water seals, gravity, and additional suction, if necessary, work together to

create a sealed system with slight negative pressure to draw fluids away from the chest. The drainage system uses a water seal to prevent air return into the pleural cavity. Once pleural air passes through the water seal, it cannot return to the chest and is vented to the atmosphere. Occlusive dressings at the puncture site prevent air from entering the pleural space. All connections between the tubing are airtight. The chest drainage system can be attached to suction to increase the negative pressure between the pleural space and the drainage system, which improves drainage. The amount of suction is controlled by a dial in some chest drainage setups and by the amount of saline added to the suction control container in other setups. When setting up a chest drainage system, it is important to understand why the system works. Read the manufacturer’s instructions for commercial chest drainage setups.

 ASSESSMENT

1. Assess the physician’s or qualified practitioner’s orders to determine what kind of chest drainage system is required.

2. Assess the available equipment to determine what kind of drainage system setups are available.

3. Assess the client’s environment to determine what kind of equipment will be required and what drainage system would be optimal for the client.

 DIAGNOSIS

1.2.1.1 Risk for Infection

 PLANNING

Expected Outcomes:

1. The chest drainage system will be appropriate for the client as well as consistent with the system ordered by the physician or qualified practitioner.

2. The chest drainage system will be set up in accordance with institutional policy.

3. The chest drainage system will not pose a hazard for infection or loss of air seal to the client.

Equipment Needed:

Disposable Chest Tube Drainage System

• Sterile water or saline

• Disposable chest tube drainage system

• Suction tubing if the drainage system will be connected to suction

• Tape

Reusable Bottle Chest Drainage System

• Sterile glass bottles—1 to 3 depending on the physician’s or qualified practitioner’s order

• Sterile water or saline

• Glass tubes—2 to 7 depending on the physician’s or qualified practitioner’s order

• Rubber tubing

• Suction tubing if the drainage system will be connected to suction

• Rubber stoppers with holes the size of the glass tubes to be used on the glass bottles—2 with 2 holes and 1 with 3 holes

• Tape

• Sterile gloves

 CLIENT EDUCATION NEEDED:

1. Teach the client that some bubbling in the water seal container and the suction container is normal.

2. Instruct the client regarding the need to keep the drainage system below the level of the chest tube insertion site.

 

 

 

 

 

 EVALUATION

• The chest drainage system is appropriate for the client and consistent with the system ordered by the physician or qualified practitioner.

• The chest drainage system was set up in accordance with institutional policy.

• The chest drainage system did not pose a hazard for infection or loss of air seal to the client.

 DOCUMENTATION

Nurses’Notes

• Indicate the type of chest drainage system used.

• If suction control was ordered, indicate the centimeter level of fluid in the suction control bottle.

 

Maintaining the Chest Tube and Chest Drainage System

 

This nursing skill involves the care of a client with a chest tube in place. Skills to be assessed include monitoring and maintaining the chest tube and the disposable drainage system; there are also specific safety issues to be aware of when caring for a client withchest tube in place.

 ASSESSMENT

1. Assess that the chest tube is set to the appropriate amount of suction as ordered by the physician or qualified practitioner. Suction is what draws the air or fluid from the pleural space, and it is essential that the appropriate amount is applied.

2. Assess that the water level in the water seal chamber is maintained at the marked line. If the level drops below the marked level, there is a chance that air could be drawn into the pleural cavity and cause or increase a pneumothorax.

3. Assess for an air leak in the water seal chamber. An air leak indicates a persistent or new pneumothorax.

4. Assess that all connections are taped. The presence of a loose connection could allow air to be drawn into the pleural cavity and cause a pneumothorax.

5. Assess the chest tube dressing and change every 24–48 hours. The dressing provides an occlusive covering to prevent any air from entering the pleural cavity and also prevent infection at the insertion site.

6. Assess the drainage system and note the amount and color of the drainage. The output is closely monitored to note bleeding and also to know when output has decreased enough for the tube to be removed.

7. Assess that the tubing is free of kinks and dependent loops and is not pinned to the bed. The presence of kinks or loops prevents adequate drainage of the chest tube, and pinning the chest tube to the bed increases the risk that the tube could become accidentally dislodged.

8. Ensure that the drainage system has not been tipped over, dropped, or crushed. Any trauma to  the collection system could cause damage and increase the risk of air being drawn into the pleural cavity.

9. Identify risk factors for a tension pneumothorax in the client with a chest tube. A tension pneumothorax is a life-threatening condition and prevention is important.

 DIAGNOSIS

1.5.1.1 Impaired Gas Exchange

1.2.1.1 Risk for Infection

 PLANNING

Expected Outcomes:

1. Client will have chest tube and drainage system maintained without increase of the pneumothorax.

2. Client will be free of infection related to the chest tube.

3. Chest tube and drainage system will be maintained in a safe manner.

Equipment Needed

• Orders from physician or qualified practitioner

• Sterile water or normal saline

• Silk tape, 1-inch roll

• 3 Packages of 4 3 4 pads

• Vaseline, gauze, 1 package for each chest tube to be dressed

• Foam tape, 2-inch roll

 

 

 CLIENT EDUCATION NEEDED:

1. Explain the rationale for the dressing change or drainage system change.

2. Explain the rationale for the assessment of an air leak.

3. Teach the client to be aware of the drainage system and to avoid tipping or kicking it over.

 

 

 

 EVALUATION

• Client has a chest tube and drainage system maintained without increase of the pneumothorax.

• Client is free of infection related to the chest tube.

• Chest tube and drainage system are maintained in a safe manner.

 DOCUMENTATION

Nurses’Notes

• Document chest tube to suction at ordered amount.

• Note presence or absence of air leak.

• Note state of the dressing and when it was changed.

• If there was a disconnection or dislodgment of the tube, note client condition, physician or qualified practitioner notified, and actions taken.

• Record chest tube drainage amount and color.

 

Measuring the Output from a Chest Drainage System

 

The chest drainage system is a closed system designed to drain air or fluid from the pleural cavity while restoring or maintaining intrapleural pressure by creating

a vacuum seal. The goal of the chest drainage system is to allow the lung to reexpand after surgery or trauma. One or more chest tubes are inserted and covered

with airtight dressings. These tubes are attached to approximately 6 feet of rubber tubing, which terminates in a water seal drainage collection system attached

to wall suction. The system draws fluid and air away from the intrapleural space.While the escaping air is not measured, the fluid drained through the chest tube is considered to be output and must be measured at regular intervals. The amount is then added to the intake and output totals. Because the chest drainage system is a closed system, the drainage is not emptied from the system when the output measurement is taken. The drainage level is marked on the outside of the drainage container at each measurement, and the amount of fluid between the previous mark and the current mark is calculated for the output measurement. Disposable

plastic chest drainage systems may have three columns for drainage. If the drainage container has been tipped or moved, the drainage may have run into the other columns, requiring marking and calculating the drainage in all of the columns.

 ASSESSMENT

1. Assess the chest drainage system to determine how the drainage will be measured.

2. Assess the drainage to determine its color, consistency, and amount.

 DIAGNOSIS

1.4.1.2.2.2 Risk for Fluid Volume Deficit

 PLANNING

Expected Outcomes:

The amount of drainage from the chest drainage system will be accurately determined and recorded.

Equipment Needed:

• Intake and output record

• Marker or pen

  CLIENT EDUCATION NEEDED:

1. Explain to the client the need for accurate intake and output measurements.

2. Explain to the client the importance of leaving the drainage system below the level of the chest.

3. Tell the client to be careful not to tip over the drainage system or set it on the bedside table.

4. Explain to the client that movement of the drainage in the tube is normal.

5. Explain to the client that, unlike urine and other drains, it is normal not to empty and discard the drainage container regularly.

 

 

 

 

 EVALUATION

• The amount of drainage from the chest drainage system was accurately determined and recorded.

 DOCUMENTATION

Input and Output Record

• Note the amount of drainage in the intake and output record. If the amount is significantly different from previous readings, indicate this.

 

Obtaining a Specimen from a Chest Drainage System

 

The chest drainage system is a closed system designed to drain air or fluid from the pleural cavity and help restore its vacuum seal. Occasionally the drainage will

need to be sampled. If the client has signs of infection or if the drainage is copious or an unusual colour, a specimen can be obtained for analysis. Because the

chest drainage system is closed, the specimen must be  obtained using a closed technique.

 ASSESSMENT

1. Assess the physician’s or qualified practitioner’s orders to determine what kind of specimen is required.

2. Assess the available equipment to determine what kind of equipment will be needed for the specimen retrieval.

 DIAGNOSIS

1.2.1.1 Risk for Infection

 PLANNING

Expected Outcomes:

The chest drainage specimen will be obtained without increasing the client’s risk of infection or loss of air seal.

Equipment Needed

• Alcohol swabs

• Betadine swabs

• Syringe with needle (syringe size determined by the amount of drainage needed for the specimen)

• Specimen container

• Label for specimen container

• Lab slip

 

 

 

 

 EVALUATION

• The chest drainage specimen was obtained without increasing the client’s risk of infection or loss of air seal.

 DOCUMENTATION

Nurses’Notes

• Indicate the date and time the specimen was collected. Keep a copy of the lab slip in the chart if the lab slip has a chart copy.

Intake and Output Record

• If the client’s chest tube drainage is being monitored closely, indicate the amount of drainage removed.

 

Removing a Chest Tube

 

Chest tubes are removed by the physician or qualified practitioner, with the assistance of the nurse. Generally, a chest tube has been placed during thoracic surgery to remove a collection of fluid or air (a hemothorax or pneumothorax) between the parietal pleura and the visceral pleura, or after cardiac surgery to prevent a collection of fluid or blood in the mediastinum, which could lead to cardiac tamponade. Chest tubes are also placed in the case of spontaneous pneumothorax. The chest

tube is removed once the lung has reexpanded and there is minimal drainage, or the risk of fluid collection in the mediastinum is diminished postcardiac surgery.

 ASSESSMENT

1. Assess whether the client has a new or larger air leak present prior to chest tube removal and notify the physician or qualified practitioner. A new air leak or a larger air leak may indicate a new or enlarging pneumothorax, and removal may need to be postponed.

2. Ensure that the client has had a chest x-ray prior to the removal of the chest tube. This assesses whether the lung is expanded prior to chest tube removal.

3. Check that your client has received pain medication prior to chest tube removal. Although it is a brief procedure, it can be uncomfortable.

4. Assess the anxiety level of the client regarding the chest tube removal procedure to determine what education, support, and/or medication might be needed.

5. Assess that the client has tolerated the absence of chest tube suction for 1–2 days prior to chest tube removal to confirm the appropriate time to remove the tube.

6. Check when the physician or qualified practitioner is planning to remove the tube to allow time to gather supplies and prepare the client.

7. Assess that the client can assist with the chest tube removal by performing the Valsalva’s maneuver at the appropriate time to prevent air from being pulled back into the pleural space at the moment of chest tube removal.

 

 DIAGNOSIS

9.1.1 Pain, related to chest tube removal

1.5.1.3 Ineffective Breathing Pattern

 PLANNING

Expected Outcomes:

1. Client will have the chest tube removed without complication.

2. The nurse will assist with the procedure while avoiding exposure to bodily fluids.

3. Client will not experience undue pain or anxiety during the chest tube removal.

Equipment Needed

• Sterile gloves (gowns and goggles if needed)

• Vaseline gauze (1 package for each chest tube to be removed)

• Sterile 4 3 4 pads (2 packages for each chest tube to be removed)

• Foam tape, preferably a 2-inch roll

• Disposable waterproof absorbing pads

• Sutures, if requested by physician or qualified practitioner

• Suture removal kit or sterile scissors, if requested by physician or qualified practitioner

• Chest tube clamps

• Pain medication to premedicate the client 15–30 minutes prior to chest tube removal, if possible

• Requisition for chest x-ray post-chest tube removal

 CLIENT EDUCATION NEEDED:

1. Explain the rationale for the removal of the chest tube.

2. Explain the rationale for taking the pain medication.

3. Explain to clients that they will be asked to help during the removal of the chest tube by taking a deep breath and holding it while bearing down slightly (as if to have a bowel movement). Explain to clients that this exercise will help to prevent them from recollecting air in their lung space.

4. Explain to clients that the dressing over the site of the chest tube will need to remain in place for 24 hours.

5. Teach clients the signs and symptoms of pneumothorax (shortness of breath, chest pain, or pain with inspiration) and instruct clients to notify the nurse if they have any of the symptoms.

 

 

 

 

 

 

 

 

EVALUATION

• Client had the chest tube removed without complication.

• The nurse assisted with the procedure while avoiding exposure to bodily fluids.

• Client did not experience undue pain or anxiety during the chest tube removal.

 DOCUMENTATION

Nurses’Notes

• Document chest tube removal procedure.

• Note the physician or qualified practitioner performing the procedure.

• Indicate client was premedicated.

• Note client’s response to the medication.

• Document outcome of the procedure.

• Note the status of the dressing.

• Document completion of the chest x-ray.

• Document assessment of the client post-chest tube removal.

• Record time procedure was completed.

Medication Administration Record

• Indicate client was premedicated.

• Document client’s response to the medication