Basics of Chest Tube Setup and Assessment

Introduction

• Lecturer: Eddie Watson from ICU Advantage
• Aim: Simplify critical care subjects for ICU success
• Channels: Notes via YouTube and Patreon members
• Quiz available at: icuadvantage.com
• Focus: Plural chest tubes (mediastinal chest tubes to be discussed in future)

Overview of Chest Tube Setup

1. **Components: From Patient to Wall: **
   • Chest tube insertion
   • Tubing to chest drainage unit
   • Suction tubing to wall suction
2. Monitoring:
   • Patient's breath sounds, O2 saturation, symmetric lung expansion, respiratory distress signs
   • Assess pain levels to ensure patients take deep breaths (use analgesics)
   • Encourage breathing exercises, coughing, and ambulation

Drainage Monitoring

• Parameters:
  • Color, consistency, amount
  • Expected transition from sanguineous to yellowish pleural fluid
  • Concerns:
    • Frank blood
    • Drainage > 100 ml/hr or > 200 ml/hr
• Frequency:
  • Initially hourly; later every 4 hours or every shift
• Documentation:
  • Mark and date/timestamp levels on drainage unit
• Positioning and Movement:
  • Semi or high Fowler's position
  • Side-to-side rotation and ambulation

Dressing and Insertion Site Care

• **Dressing: **
  • Ensure clean, dry, intact
  • Daily dressing changes, date/time documentation
  • Prep with CHG or Betadine
  • Use 4x4 gauze pads/drain sponges, chest tube tape
• **Securing Chest Tube: **
  • Apply additional tape further down to prevent insertion site pulling
• Insertion Site Assessment:
  • Check sutures, signs of infection (redness, swelling, fever, discoloration)
  • Drainage type and amount
  • Signs of subcutaneous emphysema (crepitus)
  • Daily chest x-rays to ensure tube placement

Drainage Unit and Suction Monitoring

• Position:
  • Unit below insertion site
• Tidaling:
  • Normal up/down water seal oscillation
  • Differences for spontaneously breathing vs. ventilated patients
  • Reduced with suction on
  • Absence could indicate lung expansion, air leak, kinked tube, or obstruction
• Air Leaks:
  • Shown as bubbling in water seal chamber
  • Intermittent, continuous, or absent
  • Diagnostic steps: pinch skin, clamp chest tube/tubing
• **Suction: **
  • Ensure appropriate wall suction (negative 80 cm water)
  • Disconnect tubing for water seal when suction is off
• Check tubing integrity:
  • Avoid kinks, occlusions, dependent loops
  • Securing connections with spiral method

Sampling, Dislodgement, and Maintenance

• Fluid Sample Collection:
  • Use sample port or needle on tubing
• Handling Dislodged Tubes:
  • Cover tubing/insertion site immediately
  • Insert end into sterile water if disconnected
  • Apply occlusive dressing with 3-border seal if fully dislodged
• Replacing Full Drainage Unit:
  • Clamp and replace unit
• Additional Points:
  • Check water seal level
  • Avoid tubing loops
  • Best practice: Avoid aggressive striping/milking of tube (use pinching method)
  • Ensure drainage unit stays upright

Conclusion

• Importance of proper chest tube care and monitoring
• Encouragement to subscribe to ICU Advantage and test knowledge