The College of Maasin

Nisi Dominus Frustra

College of Nursing and Allied Health Sciences

ASSISTING IN
THORACOSTOMY TUBE
INSERTION & REMOVAL

- also called an OPEN CHEST DRAINAGE, is a surgical

procedure where a tube (chest tube) is inserted into the Presented by :
pleural cavity to drain the collection of pleural fluid, air, blood, ALMA CECILIA R. MALAZARTE
bile or pus .
 THORACOTOMY VS. THORACOSTOMY
Thoracotomy is surgery that makes an incision to access
the chest. It's often done to remove part or all of a lung
in people with lung cancer.
Thoracostomy is a procedure that places a tube in the
space between your lungs and chest wall (pleural
space).
https://www.healthline.com › health › thoracotomy
EQUIPMENT
 CHEST TUBE
-also known as a thoracic
catheter, is a flexible ,
sterile tube with a number
of drainage holes that is
inserted into the pleural
space or mediastinum.
It is used to remove air in the case of
pneumothorax or fluid such as in the case of
pleural effusion, blood, chyle, or pus when
empyema occurs from the intrathoracic space.
 NONTRAUMATIC TUBE
SIZES OF CHEST TUBES THORACOSTOMY INDICATIONS :
- 28-32F for men, 28F for women, 12-
28F for children, 12-16F for infants, and
10-12F for neonates.

TRAUMATIC TUBE THORACOSTOMY

INDICATIONS:
- 36-40F
(This size will be necessary to
accommodate the drainage of blood).
https://reference.medscape.com/features/slideshow/tubethoracostomy#4
 WATER SEAL CHEST TUBE DRAINAGE SYSTEM

-a sterile, disposable system that consists of a compartment

system that has a one-way valve, with one or multiple
chambers, to remove air or fluid and prevent return of the
air or fluid back into the patient .
The traditional chest drainage system typically has three chambers (Bauman &
Handley, 2011; Rajan, 2013).
 INSERTION SITE

▪ TRIANGLE OF SAFETY –
safest site for insertion of
thoracostomy tube/ chest drain
▪ anterior to mid-axillary line
▪ above the level of nipple
▪ below and lateral to the
pectoralis major
SITES FOR CHEST TUBE PLACEMENT :
1. PNEUMOTHORAX (air)—
second or third interspace along
midclavicular or anterior
axillary line.
2. HEMOTHORAX (fluid)-fourth
or fifth interspace in the
midaxillary line
A chest tube may also be inserted to drain the
pericardial sac after open heart surgery, and may be
placed directly under the sternum (Perry et al., 2014).
INDICATION
INDICATION ACCUMULATING SUBSTANCE

Pneumothorax Air
Hemothorax Blood
Pleural effusion Fluid
Chylothorax Lymphatic fluid
Empyema Pus
PLEURAL EFFUSION: An excessive collection of the pleural fluid in
the pleural cavity.
PNEUMOTHORAX: A leakage of air in the pleural activity.
HEMOTHORAX: A collection of the blood in the pleural cavity.
HEMOPNEUMOTHORAX: A collection of the blood and air in the
pleural cavity.
HYDROTHORAX: A collection of the fluid in the pleural cavity due
to organ (the liver or heart) failure.
CHYLOTHORAX: A collection of chyle (lymphatic fluid) in the
pleural cavity.
EMPYEMA: A collection of pus in the pleural cavity.
 WATER SEAL CHEST TUBE DRAINAGE SYSTEM

ONE-BOTTLE SYSTEM TWO - BOTTLE SYSTEM

THREE-BOTTLE SYSTEM
 ONE-BOTTLE SYSTEM
- consists of a bottle which collects and contains
the fluid and at the same time seals air leak
(leakage barrier-water seal).
-a rigid straw is immersed into the bottle, so
that its tip is located 2 cm below the surface of
the saline solution, which is put into the bottle.
The other end of this rigid straw is connected to
the thoracic drainage tube placed in the
pleural cavity.
 TWO-BOTTLE SYSTEM
- first bottle (closer to the patient)
collects the drainage and the second
bottle is the water seal, which remains at
2 cm (water seal and air vent).
-preferred over one-bottle system when
large quantities of liquid are drained
from the pleural cavity.
 THREE-BOTTLE SYSTEM

- for patients with large air leak into the pleural space,
gravity drainage may not be sufficient to evacuate the
chest, and suction may be required.
-suction is always required to pull air and fluid out of the
pleural space and pull the lung up against the parietal
pleura. If suction is required, a third bottle is added—a
suction control bottle.
WATER SEAL CHEST TUBE DRAINAGE
SYSTEM
https://www.mskcc.org/cancer-care/patient-education/about-your-chest-tube-placement
THREE CHAMBERS:
:

1. Collection chamber: The chest tube

connects directly to the collection
chamber, which collects drainage from
the pleural cavity.
- chamber is calibrated to measure
the drainage.
- outer surface of the chamber has a
“write-on” surface to document the
date, time, and amount of fluid and is
typically on the far right side of the
system.
2.Water-seal 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.
- must be filled with sterile water and maintained at
the 2 cm mark to ensure proper operation, and
should be checked regularly.
- Fill with additional sterile water as required. The water
in the water-seal chamber should rise with inhalation
and fall with exhalation (this is called tidaling), which
demonstrates that the chest tube is patent.
- Continuous bubbling may indicate an air leak, and
newer systems have a measurement system for leaks
— the higher the number, the greater the air leak.
The water-seal chamber can also monitor
intrathoracic pressure.
3. Wet or dry suction control chamber: Not all patients require
suction. If a patient is ordered suction, a wet suction system is
typically controlled by the level of water in the suction control
chamber and is typically set at -20 cm on the suction control
chamber for adults. If there is less water, there is less suction.
- amount of suction may vary depending on the patient and is
controlled by the chest drainage system, not the suction
source.
- Monitor the fluid level to ensure there is gentle bubbling in
the chamber.
A dry suction system uses a self-controlled regulator that adjusts
the amount of suction and responds to air leaks to deliver
consistent suction for the patient. If suction is discontinued, the
suction port on the chest drainage system must remain
unobstructed and open to air to allow air to exit and minimize the
development of a tension pneumothorax.
 PROCEDURE … Nursing Responsibility/ Nursing Action
1. Check the doctor’s order.
2. Explain the procedure to the patient.
3. Obtain consent. (This is an invasive
procedure and requires a consent)
4. Position the patient comfortably
according to location of infiltration :
SUPINE , SEMI –FOWLER’S or sitting on a
chair and leaning forward
5a. Skin below the axilla is marked
with a pen by the physician .
5b. Prepare the insertion area by
cleansing it with an antiseptic
solution.
5c. Put on gloves . Drape
accordingly while observing
sterile technique.
5d. A local anesthesia is injected
around the area of incision.
6. A needle attached to a syringe
is inserted in the marked area to
aspirate the fluid and confirm the
location of tube insertion.

7. An incision is made (around 1.5-

2 cm ) in the marked area.
https://www.researchgate.net/figure/Lateral-decubitus-position-for-chest-tube-insertion_fig7_268987947
PROCEDURE … quick view
8a. A chest or drainage tube is
inserted , measuring between 6
and 14 mm through the incision.

8b. The chest tube may have

valves around its insertion, and it is
connected directly to the outside
collection chamber, which collects
drainage from the chest cavity.

https://link.springer.com/chapter/10.1007/978-3-319-91164-9_8
9. Cover the remaining part of the incision wound and chest
tube with bandages to secure the tube in place.
10. Connect it to the drainage system .
11. Document the patient’s respiratory rate, oxygen saturation,
lung sounds, total chest tube output, and status of insertion site
and dressing.
https://www.shutterstock.com/search/chest+tube
 COMPLICATIONS : Nursing Action
BLEEDING: Assess the source of bleeding
TUBE DISLODGEMENT: Reinforce incision site/ area with sterile
gauze and report to physician ASAP. Monitor pt’s vital signs.
HEMOTHORAX: Report to AP ASAP and monitor v/s
EMPYEMA: Report S/Sx to AP. Monitor v/s
PULMONARY EDEMA (FLUID COLLECTION IN THE LUNGS): A
rare and life-threatening condition that is more common in patients
with diabetes and those with large pleural effusion. Report to AP.
Monitor v/s
 NURSING CARE FOR PATIENTS WITH CHEST TUBES
1. Monitor respiratory and cardiovascular status of patient
regularly ( q4hrs, at least). Frequent assessment is important to
monitor the adequacy of respirations and lung expansion.
2. Place in Fowler’s or high-Fowler’s position. This position
facilitates lung expansion
3. Check the insertion site every morning and replace /
reinforce dressing PRN. Assess chest tube, system function, and
drainage at least every 2 hours. The system must remain patent
and intact to function effectively.
NURSING CARE FOR PATIENTS WITH CHEST TUBES

4. Secure a loop of drainage tubing to the sheet or gown.

Looping the drainage tubing prevents direct pressure on the
chest tube itself.
5. When turning to the affected side, ensure that neither
the chest tube nor drainage tubing is kinked or occluded
under the patient. This maintains patency of the system.
NURSING CARE FOR PATIENTS WITH CHEST TUBES

6. Teach the patient how to ambulate with the drainage

system, keeping the system lower than the chest. In most
cases, suction can be discontinued during ambulation.
Ambulation facilitates lung ventilation and expansion. Drainage
systems are portable to allow ambulation while chest tubes are
in place. Keeping the drainage system lower than the chest
promotes drainage and prevents reflux
 NURSING CARE FOR PATIENTS WITH CHEST TUBES
7. Observe insertion site when changing chest tube dressings for
redness, swelling, pain, or drainage. Report any signs of infection,
including fever, to the healthcare provider. Interruption of skin
integrity by chest tube insertion increases the risk for infection.
8. Ensure all tubing connections are taped per hospital policy or
provider preference. If a connection does come loose, reconnect it
as soon as possible.
A closed, sealed system is vital to prevent air from entering the
pleural space and an open pneumothorax. Report to physician
immediately .
 NURSING CARE FOR PATIENTS WITH CHEST TUBES
9. Safety/emergency equipment must always be at the patient’s
bedside and with the patient at all times during transportation to
other departments.
Safety equipment includes: a. 2 clamps b. Sterile water c. 4 x 4 sterile
dressing d. Waterproof tape
10. Never clamp a chest tube without a doctor’s order or valid
reason. The tube must remain unobscured and unclamped to drain
air or fluid from the pleural space.
(There are a few exceptions where a chest tube may be clamped )
 THE ONLY EXCEPTIONS TO CLAMPING A CHEST TUBE :
1) if the drainage system is being changed,
2) if assessing the system for an air leak,
3) if the chest tube becomes disconnected from the chest
drainage system — the chest tube should not be
clamped for more than a few minutes (Salmon, Lynch, & Muck, 2013),
4) if the condition of the patient is resolved and the
chest tube is ready for removal (as per physician
orders).
 PATIENT TRANSPORT
1. If the patient needs to be transferred to another department or is
ambulant, the suction should be disconnected and left open to air.
DO NOT CLAMP THE TUBE
2. Clamps must not be used on the patient for transport because of
the risk of tension pneumothorax
3. Ensure the chamber is below the patient’s chest level during
transport
4. Flutter Valve systems (pneumostat, Heimlich) may be used for
patient interhospital transfers
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Chest_drain_management/
 REMOVAL OF CHEST TUBE
-after the lung is re-expanded and drainage is minimal.

- usually performed by the physician

- determined by evaluating the chest x-ray and
assessing the patient and the amount of drainage from
the tube.
 INDICATION
1. original indication for placement is no longer
present
2. chest tube becomes non-functional
3. the following criteria are met :
a. daily fluid output is < 100-200ml /day
b. lung has fully expanded
c. no air leak is present
EQUIPMENT

• Disposable gloves
• PPE, as indicated
• Suture removal kit (tweezers and scissors)
• Sterile Vaseline-impregnated gauze and 4x4
gauze
dressings
• Occlusive tape, such as foam tape
ASSESS :
1. respiratory status
2. lung sounds
3. pain
 IMPLEMENTATION
1. Bring necessary equipment to the bedside stand or overbed table.
(Bringing everything to the bedside conserves time and energy. Arranging items
nearby is convenient, saves time, and avoids unnecessary stretching and twisting
of muscles on the part of the nurse).
2. Perform hand hygiene and put on PPE, if indicated.
(Hand hygiene and PPE prevent the spread of microorganisms. PPE is required
based on transmission precautions ).
3. Identify the patient.
(Identifying the patient ensures the right patient receives the intervention and
helps prevent errors).
IMPLEMENTATION
4. Administer pain medication as prescribed. Premedicate the patient
before removing the chest tube, at a sufficient interval to allow for the
medication to take effect, based on the medication prescribed.
(Most patients report discomfort during chest tube removal).
5. Close curtains around bed and close the door to the room, if possible.
(This ensures the patient’s privacy )
6. Explain what you are going to do and the reason for doing it to the
patient. Explain any nonpharmacologic pain interventions the patient may use
to decrease discomfort during tube removal.
(Explanation relieves anxiety and facilitates cooperation.Nonpharmacologic
pain management interventions, such as relaxation exercises, have been shown
to help decrease pain during chest tube removal (Friesner, et al., 2006). )
IMPLEMENTATION
7. Put on clean gloves. (Gloves prevent contact with contaminants and body fluids).
8. Provide reassurance to the patient while the physician removes the dressing and
then the tube.
(Removal of the dressing and the tube can increase the patient’s anxiety level.
Offering reassurance will help the patient feel more secure and help decrease
anxiety).
9. After the physician has removed the chest tube and assist in securing the
insertion site with an occlusive dressing.
(In most institutions, physicians remove chest tubes, but some institutions train nurses to
remove them).
10. Assess the patient’s lung sounds, respiratory rate, oxygen saturation, and pain
level.
(Once the tube is removed, respiratory status will need to be assessed to ensure that
no distress is noted).
IMPLEMENTATION
11. Anticipate the physician ordering a chest x-ray.
(The physician may want a chest x-ray taken to evaluate the status of the lungs
after chest tube removal).
12. Dispose of equipment appropriately.
(This reduces the risk for transmission of microorganisms and contamination of
other items).
13. Remove gloves and additional PPE, if used. Perform hand hygiene
(Removing PPE properly reduces the risk for infection transmission and
contamination of other items. Hand hygiene prevents the spread of
microorganisms).
14. Document the patient’s respiratory rate, oxygen saturation, lung sounds,
total chest tube output, and status of insertion site and dressing.
 EVALUATION
• Patient exhibits no signs and symptoms of respiratory
distress after the chest tube is removed.
• Patient verbalizes adequate pain control.
• Patient’s lung sounds are clear and equal.
• Patient’s activity level gradually increases.
THE HEIMLICH ONE-WAY VALVE
-a rubber flutter one-way valve
within a rigid plastic tube which
connects to standard chest drain.
- does not need to be kept upright
like the underwater sealed drain - less than 13 cm (5 inches) long and
and therefore is suitable for facilitates patient ambulation.
outpatient use.
- efferent portal of the Heimlich
valve must be kept open to the
atmosphere making control of the
fluid effluent difficult.
THE HEIMLICH ONE-WAY VALVE
-device is bulky under clothing and
staining is a constant problem.
-To avoid this problem, the valve
should be attached to a
perforated plastic bag, or a
specifically designed one-way
valve including a small reservoir
can be used.
 Technological Advancement: DIGITAL SYSTEMS
CHARACTERISTICS:
-large friendly reservoir for fluid collection
and analysis;
-functional in different levels of suction;
-compact to permit early patient ambulation;
-latex-free, quiet, tip-over safe, reusable, and
inexpensive;
-digital continuous accurate measurement of
the amount of the chest tube drainage and the
size of air leaks;
Digital Thoracic Drainage (Thopaz-Medela)
-written record of events in the pleural space;
-easy for both staff and patients to use;
-allows for the patient to be sent home on the same
device;
-data available to the nurses’ station or physician’s
office for assessment
-scientific digital flow recordings
-with an in built alarm system. There are various
alarms which alert the nurses regarding blocks, high
volumes and battery status.
-flushes the collection tubing connected to the inter-
costal drain preventing blockage of drains.
 REMEMBER…..
1. Keep the system closed and below chest level. Make sure all
connections are taped and the chest tube is secured to the chest wall;
2. Ensure that the suction control chamber is filled with sterile water to
the 20 cm-level or as prescribed. If using suction, make sure the
suction unit’s pressure level causes slow but steady bubbling in the
suction control chamber;
3. Make sure the water-seal chamber is filled with sterile water to the
level specified by the manufacturer. You should see fluctuation
(tidaling) of the fluid level in the water-seal chamber; if you don’t, the
system may not be patent or working properly, or the patient’s lung
may have reexpanded;
 REMEMBER…..
4. Look for constant or intermittent bubbling in the water-
seal chamber, which indicates leaks in the drainage system.
Identify and correct external leaks. Notify the health care
provider immediately if you can’t identify an external leak
or correct it;
5. Assess the amount, color, and consistency of drainage in
the drainage tubing and in the collection chamber. Mark the
drainage level on the outside of the collection chamber (with
date, time, and initials) every 8 hours or more frequently if
indicated. Report drainage that’s excessive, cloudy, or
unexpectedly bloody;
 REMEMBER…..
6. Encourage the patient to perform deep breathing, coughing,
and incentive spirometry. Assist with repositioning or ambulation
as ordered. Provide adequate analgesia;
7. Assess vital signs, breath sounds, SpO2, and insertion site for
subcutaneous emphysema as ordered;
8. When the chest tube is removed, immediately apply sterile
occlusive petroleum gauze dressing over the site to prevent air
from entering the pleural space;
9. Don’t let the drainage tubing kink, loop, or interfere with the
patient’s movement;
 REMEMBER…..
10. Don’t clamp a chest tube, except momentarily when replacing the
chest drainage unit, assessing for an air leak, or assessing the patient’s
tolerance of chest tube removal, and during chest tube removal;
11. Don’t aggressively manipulate the chest tube; don’t strip or milk it;
12. A patient who is free from pain, to the degree that an effective
cough can be produced, will generate a much higher pressure than can
safely be produced with suction;
13. If a patient cannot re-inflate his own lung, high volume, low pressure
"thoracic" suction in the range of 15-25 cm of water can help;