having reviewed over different disturbances over the past few lessons that we talked about for the plural space it's time to actually talk about the basics of our chest tube and its setup [Music] all right you guys welcome back to another video lesson from icu advantage my name is eddie watson and my goal is to give you guys the confidence to succeed in the icu by making these complex critical care subjects easy to understand i truly hope that i'm able to do just that and if i am i do invite you to subscribe to the channel down below when you do make sure you hit that bell icon and select all notifications so you never miss out when i release a new lesson as always the notes for this lesson as well as all the previous videos are available exclusively to the youtube and patreon members you can find links to join both of those down in the lesson description below also don't forget to head over to icuadvantage.com or follow that link down in the lesson description to take a quiz on this lesson test your knowledge while also being entered into a weekly gift card as well as don't forget that you can help support this channel through the purchase of an icu advantage sticker again those are found at the website icoadvantage.com forward slash support link down in the description now this lesson here is going to be primarily referring to the plural chest tubes mediastinal chest tubes will eventually be covered sometime in the future now while some of this information does apply to both there certainly are some important differences there as well so let's start out with a quick diagram and review of our entire setup from our patient to the wall so here we have our patient and then here we're going to have the chest tube that's inserted we're going to have tubing that comes from the end of our chest tube and goes down and then goes to our collection chamber or our chest drainage unit and again if you do want to understand more about the drainage unit i'm going to link to a lesson up above where i really went in depth about the physiology and how all that works then from the drainage unit we have the suction tubing that will come off and then go to our wall suction so having this whole set up here there's actually a few different things that we need to be assessing and monitoring for our patient as well as the system so i'm going to go through and talk about a lot of those things here so first when it comes to the patient some things that we're specifically looking for in our patients so obviously we're going to be you know listening to breath sounds we're going to be monitoring their oxygen saturation we're going to be looking for that symmetric lung expansion on both sides but we're also really going to be looking for signs of respiratory distress so here think are tachypnea a rapid shallow breathing if they're using accessory muscles these could be signs that either there's problems with our chest tube setup or that things aren't draining properly definitely things you want to be keeping an eye on another important thing to assess for our patient is actually going to be their pain level having a chest tube can actually often hurt the patient and the pain that they have from the chest tube is actually going to prevent them from taking good deep breaths which is going to be really important when they have this in and so here we do want to be using our analgesics to help relieve this pain for our patients both from a comfort standpoint but like i just mentioned also an ability to take those good deep breaths and then for our patient if they are awake and obviously not sedated in an event we do want to be encouraging things like taking good deep breaths coughing as well as ambulation as well now from there the next thing that we want to be talking about is going to be the drainage that's actually coming from our chest tube so we want to be keeping an eye on the color the consistency as well as the amount of drainage that we have some important things to keep in mind are is this changing at all now typically over time we do expect to see our drainage if it was initially sanguinous or bloody that over time we should eventually see this lighten up and transition more to a yellowish plural fluid or something with a slight pink tinge to it a cirrosanguinous drainage but if it's actually going the other way and let's say we have something like frank blood that's obviously going to be a big change that we're going to need to alert the provider for and then especially if we're having that new frank bloody drainage and it's greater than 100 ml an hour that this could definitely be something concerning also for the chest tube in general if we're having greater than 200 ml of drainage per hour this is again something that we're going to want to keep an eye on as well as potentially letting the provider know as well now when it comes to monitoring this drainage and this output initially we're probably going to be recording this at least hourly obviously for certain situations we may actually be doing this more frequently than that but typically initially every hour we're going to be doing this as time goes on and that drainage slows up we can move to more time in between each assessment so you know q4 hours or potentially even every shift if the drainage is pretty minimal now you can't actually make marks on the front of the drainage unit so on the side where the level is that shows you how much drainage you have typically we'll make a line across there and then put the date and time on there so that we know when we were at that point and then obviously document that in your charting system and then patient movement and positioning can really help to facilitate drainage from the chest tube so having your patient in like a semi or high fallers position is actually going to be the best as well as if they're in the bed the rotation from side to side is going to help to kind of move that fluid around and again help to facilitate drainage out via the chest tube now this movement particularly like if you get your patient up out of bed and into the chair that this can actually lead to an increased amount of drainage but this is something that's going to be expected and it's not going to be concerning if it just happens initially and is not a persistent high volume drainage after that now from there we do want to focus on the dressing for our chest tube so obviously is it clean dry and intact we're going to be doing at least daily dressing changes on that so you want to make sure that you have the date and time on there but if it is becoming saturated if your patient is having a lot of drainage around the outside of the chest tube then you may need to change this chest tube more often when it comes to doing that dressing change it's really important that we are cleaning and prepping the site with either chg or betadine epovidone iodine and so here we want to be cleaning the entire area around the chest tube as well as the chest tube itself at least up two centimeters from the insertion site once we've done this we want to put gauze in and around the site so this is either going to be 4x4 gauze pads or drain sponges drain sponges are certainly preferred if you have that and then you just want to put that around the chest tube and kind of alternate the angle of the opening but if you don't have those available you can just use the four by fours and then we want to put typically we'll do like folded four by fours up underneath the chest tube and then we'll lay the fully expanded gauze on top of it and then securing everything down with chest tube tape in addition to securing the gauze at the insertion side of the chest tube it's also important that we do an extra piece of tape further down on the chest tube securing it to the patient and the point of this is that if anything is pulled it's going to pull on where this chest tube is taped to the patient down below instead of pulling on the insertion site itself now one thing to also keep in mind too is that you may potentially use something like zero form around the insertion site now this is typically more common in traumas and the point of this is it really helps to create an airtight seal so moving on let's actually talk about the insertion site itself and so really the first thing we want to keep an eye on is whether there's been any kind of movement to that chest tube and really is that chest tube moving outward because obviously this can cause some problems if it becomes dislodged too much so it's going to be really important that we're getting daily chest x-rays for these patients and so we do want to be taking a look at this chest x-ray and making sure that that chest tube is still in place and the big thing that we're looking for is that the fenestrations or the holes that are at the end of the chest tube which help to facilitate that drainage that they're still in the pleural space within the chest wall and so here's an example of that on x-ray just to kind of show you it's pretty easy to see here along the chest tube there's actually a radio opaque line that shows up and then there's a gap that you'll see up here towards the end and that's to mark where the fenestration begins so as long as that part is still within the chest wall then we know that we're okay if it moves out from there then this is where we potentially create a path for air to communicate back into the pleural space potentially leading to a pneumothorax and obviously can cause problems now our chest tubes are also going to be secured with sutures so we do want to evaluate those sutures make sure that they're still intact and secure we also want to be keeping an eye out for signs of infection so things like redness and swelling if our patient has a fever if there's any discoloration of the skin around there these are things that we want to be keeping an eye on with that insertion site as well we also want to pay attention to and note whether there's any drainage coming from around the outside of the chest tube and here we want to be keeping an eye on the type and the amount of this drainage and then lastly we also want to assess the area around the chest tube insertion site for signs of subcutaneous emphysema or subcu air and this is essentially where air gets trapped underneath the skin in the tissue now when this happens this is something that we call crepitus and if you've never felt it before i promise the first time you feel it it's going to be very obvious it's a very unique feeling it's always been described as like rice crispy kind of popping and crackling feeling as you're pressing around the skin around the insertion site if you do notice that your patient has crepitus you want to mark the area where that crepitus is sometimes initially for new chest tube placements especially for our traumatic situations that it's not necessarily uncommon to have subcutaneous emphysema and to notice this crepitus in your patient but like i said it's really important that we mark around where the area is because we want to make sure that the area isn't expanding obviously if that sub-q air is expanding that crepitus is moving further along the patient's chest and up towards their shoulder their side and back things like that we know that we have a problem this is something the provider needs to be alerted to all right so now let's talk about some of the things with our actual drainage unit itself and the first thing is actually going to be the position of it it's really important that we have the drainage unit below the level of the insertion site and below our patient essentially the reason for this is if we're above this point then we're just not going to have drainage coming out from our patient and that's the whole point of having the chest tube now the next thing when it comes to the drainage unit is to keep an eye on something that we refer to as tidaling so essentially tidally is going to be the oscillation of the water level that's by our water seal so over to the side we've got the level here with the ball that's in there and as the patient breathes you're going to potentially see this moving up and down and this is actually going to be normal as a result of the changing intrapleural pressures throughout the respiratory cycle so for spontaneously breathing patients on inspiration that this is going to create more negative pressure which is going to cause a rise in the water level then on expiration they have more positive pressure and so we're going to see that water level fall so as they breathe in it goes up and they breathe out it goes down and it tidals up and down and so we actually have the opposite of this occur for patients who are on the ventilator and so here the inspiration is going to be the result of positive pressure causing the level to drop and then on expiration that this is where the pressures are gonna drop and so here we're gonna see the water level rise and so we're gonna have titling still existing but just going the opposite direction we would see with a spontaneously breathing patient one thing to keep in mind is that titling is going to be more apparent in patients where we actually have suction off when we have the section currently on and hooked up to the drainage unit that this is going to decrease the amount of titling that we can potentially see and so what happens if we see that titling has stopped well this could mean that the patient's lung has actually fully expanded this could mean that we have an air leak which i'm going to talk about here in just a minute could also mean that we have a kink tube or some sort of obstruction so make sure that if the titling stops especially if you had had it that you want to make sure and assess your system make sure that everything is okay and so sometimes we'll actually end up with a very high level of water there for the titling chamber and this is really the result of persistent high negative pressure so if the patient is coughing a lot take a big deep breath sometimes that can lead to excessively high negative pressure if you do see this though you can actually on the back of the drainage unit there's a button that you can press that helps to release this pressure and bring the level back down but make sure that you're only doing this when you have suction on and then the next thing i want to talk about is another very important thing this is actually going to be a air leak and then an air leak is going to be shown as bubbling in the water sealed chamber and so we actually have marks down there that help to quantify how much air leak is taking place typically they're marked anywhere from one to five and then the higher the number the the more bubbling and the more of an air leak that you have and then when it comes to assessing an air leak we can either have intermittent bubbling continuous bubbling or it's just not present and do know though that especially for patients that have a pneumothorax and a new chest tube that this bubbling and air leak is actually going to be normal initially anytime we have air moving through the system from the patient outward this is going to cause bubbling on the water seal showing us an air leak so again as we're evacuating air from that pleural space we would expect to see an air leak now if our patient has a persistent or a continuous air leak this is definitely something that we want to keep an eye on and if it's new this is definitely something we need to alert the provider for but there can be several reasons on why we would have this persistent air leak so for the patient themselves if they have a alveolar plural fistula or a bronchoplural frustula something like that that is allowing air to continue to go from our respiratory system into the pleural space that this would then continue to have a persistent air leak and some risk factors for a patient here are for patients on steroids those who've had significant trauma if they've got non-compliant lungs emphysema if we have them on high peep or high pressures that this can lead to damage as well as if they have significant scar tissue that these are all risks for our patient now a persistent air leak can also be the result of the insertion site so if we have excessive space around the chest tube that this could potentially allow air to be getting in there again this is where one of the benefits of something like zero form would be helpful as well as like i just talked about earlier the chest tube dislodgement so if we have those fenestrated holes outside of the pleural space that that could also allow air into our system this air leak could also be the result of a problem with our tubing or the connections that we have on our tubing as well as although rare it could potentially be a result of a problem with our collection chamber now if we do have a persistent air leak especially a new persistent air leak that we want to identify where it is coming from so one of the first things we can do is actually pinch around the insertion site if this pinching and pushing the skin up around the chest tube stops the air leak we know that that's where the cause is potentially coming from and something like zeroform might be beneficial here now if that doesn't fix it then what we're gonna do is take a set of clamps and we're gonna briefly clamp the chest tube now it's really important that we don't clamp this for more than a few seconds at most 10 seconds because especially if our patient actually has a continuous persistent air leak uh something that's driven by a problem internally that this can actually lead to attention pneumothorax which as we've talked about previously can be a potentially life-threatening situation so we just want to do very short clamps so we want to start clamping the chest tube itself if we clamp the chest tube itself and the air leak goes away and we've already previously identified that pinching the skin around the insertion site did not make it go away that this means that the air leak is coming from the patient some of those potential causes that i just talked about now from there we want to clamp below our connection point where the tubing and the chest tube come together again if it stops here we know that the leak is coming from that connection and so we want to really ensure that we have a good tight connection there if it's still persistent we want to work our way clamping about every 12 inches down the tubing trying to identify where the problem in the tubing might be coming from and then finally if we've done all of that we still have a persistent leak despite clamping all the way down at the bottom then we know that this is the rare case where we actually have a problem with our collection unit and then we would need to change it out at this point again most important thing to stress here is that we absolutely do not want to be clamping that chest tube or the tubing any longer than just a couple seconds all right so next we want to be assessing the suction that we have and we want to make sure that we have our suction set to the order level that the provider has ordered so we want to ensure that we have first off sufficient suction coming from our wall suction and so on something like the atrium unit we're going to actually have these orange bellows that pop out to let us know that we actually have enough suction in place and they recommend at least negative 80 centimeters of water for the suction level coming from the wall unit obviously the amount that's going to the patient is going to be determined by the drainage unit itself but we want to make sure we have enough suction going to the drainage unit to achieve the appropriate amount of suction that's ordered and then if our patient is actually off of suction in order to water seal then we actually want to disconnect the tubing from the unit itself and this will allow the free flowing of air out of the top of the drainage unit in the cases of the atrium unit when we have the patient to water seal we're not going to see those orange bellows expanded because we don't have the suction in place and then lastly the the last thing that we want to be assessing for is going to be the tubing itself so it's really important that we're avoiding any kinks or any occlusions in the tubing because this would essentially be the same thing as clamping the tubing which could potentially be a problem for our patient another thing to be on the lookout for is to ensure that we don't actually have any dependent loops in the tubing so this would be where the tubing comes down and then goes back up before coming into the drainage unit having these dependent loops will actually increase intrapleural pressure and prevent the lung expansion we also want to be ensuring the integrity of all of our connections in our system and so here we're going to be using tape to ensure that that connection is secure and won't come undone and really the best way to do this is to do a spiraling connector of tape and this way you can always rotate the tubing around and see every part of that connection as opposed to if we just ran tape straight around the tube that connection from the chest tube to the tubing is a spot that is high risk for clot development as well as entrapment of clots so it's really important that we have a good visual of that location all right so those were the main things that we want to be assessing for when it comes to our patient and their chest tube there are a couple things i do want to hit on and cover with the remainder of this lesson that certainly are going to be important for you as well the first of these is going to be sampling this doesn't happen very often but there's a couple different ways that we can actually get a sample of the drainage of our patient the first is there's often going to be a sample collection port down at the bottom of the tubing where it connects to the drainage unit and here this is usually like a lower lock connection for a syringe so you just want to get the fluid down there towards the bottom dependently collecting the fluid down there and then hold the tubing just right so that fluid is hanging out near the bottom where that connection is and then draw up our sample from there now in a lot of these systems we can also sample with a needle directly from the tubing itself and so here we want to make sure and clean the site with alcohol and then we want to use a 20 gauge or smaller needle but we can just insert it directly into the tubing make sure we have that dependent collection of fluid draw out our sample and then that tubing is actually going to be self-sealing so we're not going to have to do anything after that now the next thing i want to talk about is really important thing for you to know and that's going to be how to deal with a dislodged chest tube so it's really important that if you have anybody that has a chest tube there are certain things that we're going to want to make sure that we have at the bedside so you always want to have petroleum gauze 4x4 gauze a transparent dressing as well as a chest tube clamp available and so the first thing that i want to talk about is actually going to be if we have a disconnection of the tubing to the chest tube itself so if this happens in front of you the very first thing you want to do is grab and cover the end of the tubing with your hand and then if you can get the clamp and clamp that chest tube again it's going to be really important at this point that whether we're covering it with our hand or we have it clamped that time is going to be of the essence here now from there we want to actually take the end of the chest tube and insert it into sterile water and then unclamp that chest tube doing this is going to reestablish that water seal and will buy us a little bit more time to get a new drainage unit set up from there we want to prepare that new sterile drainage unit and then get that reattached to the chest tube and then make sure that you let the provider know immediately and here you're probably going to be expecting a chest x-ray to be done now in a more severe case where the chest tube itself has been dislodged or completely pulled out of a patient first off immediately you want to cover the insertion site with your hand and then call for help now if your patient is able to assist you you want to have them cough and exhale as long as they possibly can and this is going to keep air from re-entering that pleural space but make sure that you're uncovering with your hand while they do this and then recover when they're taking a breath from here we need to prepare the sterile occlusive dressing and so from here we're going to take the petroleum gauze we're going to open it up put it underneath probably three or four pieces of the sterile gauze lay that over the insertion site and then from here we're going to take the transparent dressing put that over the gauze which has the vaseline gauze underneath it and we want to create a three border seal so essentially all sides of it are sealed except for one side here typically going to be the bottom and so this is going to allow for the air to escape but then keeping that seal not allowing the air to come back into the chest and then obviously let the provider know immediately after this has happened because the attention pneumo is something that can potentially develop for this patient and then here we're going to be expecting that chest x-ray to be done as well as potentially reinserting a new chest tube for this patient so i would have everything that you need in preparation for that to take place potentially as quickly as possible and then lastly i did just want to cover a couple points of maintenance when it comes to the patient on the test tube and the drainage unit so the first is going to be if our drainage unit is actually full and so when this happens we're going to have to replace that drainage unit now if you're using the atrium setup which again is usually the most popular one that i've seen here we're going to want to actually clamp the tubing with the big blue clamp that's on there once that's done it may also be helpful to clamp the chest tube with a chest tube clamp just to ensure that we have a good clamp there and then at the top of the accordion tubing just coming off of the drainage unit you can actually disconnect the accordion tubing from the standard tubing and then reconnect that to your new drainage unit make sure that when you do reconnect it that you feel and hear that click as the tubing is reconnected then from there unclamp the tubing as well as the chest tube if you have that clamped as well you also want to make sure and keep an eye on the level for your water seal so you want to make sure that it's maintaining at the zero level there's going to be a line marked on there and that's going to give us that two centimeters of water sale also make sure that we are avoiding those dependent loops in the tubing so it's pretty easy for those to come up especially with movement so just always be keeping an eye on that and readjusting your tubing and then there's always the debate about to milk or not to milk our chest tubes and this is essentially when we are working to get the fluid uh typically this is gonna be with uh bloody sanguinous drainage as well as any potential clots moving and continuing down the chest tube to our drainage unit and so milking and stripping especially when this is done aggressively that this can actually lead to high negative pressure in that intrapleural space so really the best practice is not to do this unfortunately though i've seen this firsthand in a lot of different facilities there's going to be particular providers who still want this to be done so that said if you are doing it you really want to make sure that you're avoiding that aggressive strong repetitive stripping when you do make sure that you're clamping the chest tube tightly with your fingers closest to the patient and then carefully pull down to move the fluid and clots along the area that you're doing this sometimes taking something like a lotion can help to really create a good surface for a nice slow smooth stripping action that said the best practice is like i said to avoid the stripping and to do something like pinching and so here you actually want to pinch around the chest tube so pinch and release and then kind of work your way down the chest tube as you're doing this pinching and moving you can turn and rotate the tubing along with doing these pinches and this is really going to help to move the fluid and the clots along and then finally the last thing kind of a pretty simple thing here and this is going to be just making sure that that drainage unit stays upright oftentimes we'll have a stand so you want to swing the legs out to keep a good stable base on it be cognizant of it in the room be cognizant of the suction tubing we don't want to be tripping over that or kicking the drainage unit and knocking it over that said if it does get knocked over it's not necessarily the end of the world make sure you sit it up right away and at this point we want to be checking the integrity of the system so make sure that you have enough water and at the appropriate level on your water seal you also want to keep an eye on your drainage levels now a lot of the units will actually allow you to tip the unit to the side this is going to facilitate the drainage going back to the right into the appropriate chambers to fill up first that they're supposed to be filled in and these systems will allow you to do that while still preserving the integrity of the water seal on the other side so once you've done this you've gotten the drainage collected appropriately where it should be put it back flat like it's supposed to be and then again check that water seal level and make sure that's at the appropriate spot and we do have hangers on there as well so that may also be a secondary check to having the stand out as well as maybe having the hangers in place as well as when you are transporting a patient that we want to use those hangers to ensure that the drainage unit stays upright all right and that finishes this lesson talking about the basics of our chest tube and the system and our assessments that we want to do for our patients that have this covered a lot of good information in here hopefully you guys got some good nuggets of wisdom and knowledge from this lesson and that you can take this information and apply it to your patients moving forward that have a chest tube so i hope that you guys found this information useful if you did please leave me a like on the video down below it really helps youtube know to show this video to other people out there as well as leave me a 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