Hemothorax , Pneumothorax and

patient Care of Chest Tubes

MEDICAL SURGICAL DEPARTMENT

OBJECTIVE
1- Define terms of the Hemothorax , Pneumothorax
2-List Indications for Chest Tube Insertion
3-discuss the chest tube complication
4- mention nursing preparation before the procedure
5-Discuss Nursing Responsibilities/Care of Patient with Chest Tube

MEDICAL SURGICAL DEPARTMENT

 INTRODUCTION
Chest drain insertion is a common procedure, which may be carried
out in clinical areas. Most are planned, but some may need to be
done as emergencies. When they are not inserted properly, they
may puncture major organs such as:

heart, lungs, liver and spleen. Whenever possible, written evidence

of consent should be obtained from the patient before the procedure,
the only exception being in unconscious patients and in an
emergency.
MEDICAL SURGICAL DEPARTMENT
INTRODUCTION CONT

The British Thoracic Society recommend that the

following complications should be listed and
discussed with the patient: Pain ,Intra-pleural
infection,Wound infection , Drain dislodgement ,
Drain blockage , Pneumothorax ,Bleeding ,
Drain-related visceral injury , Mortality of 1%
MEDICAL SURGICAL DEPARTMENT
MEDICAL SURGICAL DEPARTMENT
 Evidence of Harm:
contributing to 140000 deaths annually Thoracic injuries occur in
approximately (Gomez; L ,2023)

The National Patient Safety Agency (NPSA) has received reports of

12 deaths relating to chest drain insertion and 15 cases of serious
harm between Jan 2005 and March 2008. A substantial number of less
severe incidents have been reported highlighting poor management of
inserted chest drains. Many more are likely to be unreported.

MEDICAL SURGICAL DEPARTMENT

 DEFINITION
Chest tubes are long, clear plastic tubes that are placed in
the pleural or the mediastinal space to evacuate an
abnormal collection of air or fluid that collects as a result
of injury, disease, or surgical procedures.

If the lung has been decompressed because of this

collection, the lung can then re-expand.
MEDICAL SURGICAL DEPARTMENT
Indications for Chest Tube Insertion
 Pneumothorax: Presence of air in the
pleural space .
 Hemothorax: Presence of blood in the
pleural space.
 Hemopneumothorax: Presence of air and
blood in the pleural space

MEDICAL SURGICAL DEPARTMENT

Indications for Chest Tube Insertion
Pleural effusion
Empyema
Pleurodesis
Broncho-pleural fistula, post-op or due to
mechanical ventilation.
Following cardiothoracic surgery.

MEDICAL SURGICAL DEPARTMENT

INDICATIONS CONT,
First: Pneumothorax: a collection of air in
the pleural space occur after:
 After central line insertion
 After chest surgery,
 After trauma to the chest,
 After a traumatic airway intubations.

MEDICAL SURGICAL DEPARTMENT

INDICATIONS CONT,

If the air continues to collect in the chest, the

pressure in that collection can rise and push the
whole mediastinum

over to the other side – this is called a “tension

pneumothorax”, and is definitely life-
threatening.
MEDICAL SURGICAL DEPARTMENT
HEMOTHORAX
A collection of blood in the pleural space, may
be from surgery, may be from a traumatic injury
The source of blood may be the chest wall, lung
parenchyma, heart, or great vessels.
Hemothorax is usually a consequence of blunt or
penetrating trauma., it may be a complication of
the disease, may be iatrogenically induced
(Mancini & Milliken, 2022).
MEDICAL SURGICAL DEPARTMENT
 INDICATIONS CONT,
Third: Pus can collect in the pleural space “Empyema”.

Fourth: Fluid, usually serous, may be from CHF,

sometimes from a tumor process, will collect between the
pleura“ Pleural Effusion”.
To prevent collection of fluid/air. eg : after thoracotomy

.Post operative; eg cardiac surgery

MEDICAL SURGICAL DEPARTMENT

COMPLICATIONS

 Tension pneumothorax
 Malpositioned tube
 Penetration of peritoneal cavity.
 Penetration of heart/major vessels.
 Pleural sepsis.
 Failure of lung to re-expand.

MEDICAL
MEDICALSURGICAL DEPARTMENT
SURGICAL DEPARTMENT
 COMPLICATION CONT,
The most serious complication result from the chest tube
placement is tension pneumothorax, which develop if there
is any obstruction in the chest tube drainge system
Clamping chest tubes as a routine practice predisposes
patients to this complication
Clamping is recommended:
To locate the source of an air leak if bubbling occurs in the
water seal champers ,To replace the chest tube drainage unit

MEDICAL SURGICAL DEPARTMENT

PLEURAL SEPSIS.

- signs : pt febrile, drain site inflamed, purulent drainage

Action remove drain & start antibiotics
- accumulation of pus
Action may need needle aspiration / further drainage thro’
separate site.

MEDICAL SURGICAL
MEDICAL SURGICAL DEPARTMENT
DEPARTMENT
EQUIPMENT FOR INSERTION:

1. Several pairs of sterile gloves.

2. Sterile drape, betadine solution.

3. Vial of 1% lidocaine.

4. Alcohol sponge.

5. 10cc syringe.

6. 22G 1 inch and 22G 5/8th inch needles.

MEDICAL SURGICAL DEPARTMENT

EQUIPMENT FOR INSERTION:
7-Sterile forceps and scalpel.

8-One rubber tipped clamp for each chest tube

inserted, sterile gauze pads; sterile 4x4s.

9-Sturdy elastic tape and scissors.

10-The chest tube, a trochar, suture kit.

11-The thoracic drainage system with its collection

tubes.
MEDICAL SURGICAL DEPARTMENT
SOME PICTURE OF
EQUIPMENT

1. Low pressure suction regulator (colour coded orange)

2 Suction collection unit
3. Chest drain

MEDICAL SURGICAL DEPARTMENT

 EQUIPMENT FOR INSERTION:

Consist of a trochar is cannula and a long plastic tube about

1.8 m.
Many sizes from 8F to 32FG:
Small (24FG): for air alone
Medium (28FG): for serous fluid
Large (32-36FG): for blood/pus

At least 28FG in traumatic pneumothorax to prevent

occlusion with blood clot. Smaller size for simple
pneumothorax.
Children: size depends on age & distance between the ribs.
MEDICAL SURGICAL DEPARTMENT
 Insertion site:

The chest tube insertion site depends upon the indication

for tube placement.
In case of evacuating pneumothorax, insert the tube at the
4th or 5th intercostal space in the anterior axillary or
midaxillary line.
patients with pneumothorax only a is the 2nd intercostal
space in the midclavicular line.

MEDICAL SURGICAL DEPARTMENT

Insertion site cont,:

For draining pleural effusions, the tube can be placed

lower in the chest.

in emergency clinical settings the chest tube can readily

be inserted under local anaesthesia e.g 1% lignocaine
with or without an intercostal nerve bloc.

In the elective setting, oral or iv sedation and analgesia

can be administered prior to the insertion.
MEDICAL SURGICAL DEPARTMENT
POSITION

MEDICAL SURGICAL DEPARTMENT

 Maintaining safety of the underwater seal drainage system

Once the chest tube is inserted, it is then attached to a drainage system which only allows one
direction of flow.

This is usually the closed underwater seal bottle in which a tube is placed under water at a depth of
approximately 3cm with a side vent which allows escape of air, or it may be connected to a vacuum
control.

The chest drain bottle must be positioned below the insertion site/level of the chest at all times to
prevent fluid re-entering into the pleural space.

MEDICAL SURGICAL DEPARTMENT

 Maintaining safety of the underwater seal drainage system

Chest drains must not be clamped. Never clamp a bubbling chest

drain as this may result in a tension pneumothorax or possibly
worsening subcutaneous emphysema.
Avoid kinking or obstructing the chest drain tubing.
Daily reassessment of the amount of drainage should be recorded on
the patient’s fluid balance. Bubbling and the presence of respiratory
swing should be documented on the patient’s observation chart.
Inform medical staff if drainage suddenly increases or there is more
than 100ml/hr of blood drainage.

MEDICAL SURGICAL DEPARTMENT

N.B
 Chest tube dislodgement can cause life-
threatening complications such as
tension pneumothorax.

MEDICAL SURGICAL DEPARTMENT

- Underwater Seal
 Allows air to ESCAPE but NOT
RE-ENTER chest cavity
 Negative pressure dependent upon
level of water
 Pleurovac must always be below level of
patient
 Persistent bubbling = air leak from
lung
MEDICAL SURGICAL DEPARTMENT
MEDICAL SURGICAL DEPARTMENT
Fluctuation of the water level in the tube
between the pleural space and the drainage bottle, provides a
the patency of the drainage system and intrapleural pressure.

 In non-ventilated patients, the water in the water-seal

chamber will fluctuate approximately

5-10cm as the patient breathes in and out. During inspiration,

the water level in the column
increases and decreases with expiration.
 In ventilated patients, the water column actions will be
reversed – it decreases with inspiration

and increases with expiration. If not visible, check the

drainage tubing for kinks and notify medical staff.

MEDICAL SURGICAL DEPARTMENT

Preparing the patient for chest drain insertion
•Explain the procedure to the patient and provide reassurance.
•Position the patient – check with medical staff how the patient
should be positioned.
• Consent should be obtained unless the patient is unconscious
•The patient will require O2 to be administered during the
procedure.
• A large bore cannula should be inserted.
•Premedication will be required as the procedure is often painful.
Additional opioid analgesia may be required during the procedure.

MEDICAL SURGICAL DEPARTMENT

Preparing the patient for chest drain insertion

•Cardiac monitoring is required: obtain baseline

observations prior to chest drain insertion.
• Monitoring of vital signs is necessary during the
procedure:
•A chest X-ray will be required once the chest
drain is inserted.

MEDICAL SURGICAL DEPARTMENT

 Assess for the following subjective and objective data

Hemothorax •Pneumothorax
• Shortness of breath • Shortness of breath
• Difficulty breathing • Decreased or absent breath
• Sharp or stabbing chest pain, or chest sounds on auscultation
heaviness • Hyperresonant on
• Decreased breath sounds on the affected percussion (presence of air)
side
• Asymmetrical chest
• Dullness to percussion both anteriorly movement
and posteriorly on the left (presence of
fluid) • Cyanosis, abnormal ABGs
• Decreased oxygen saturation levels • Jugular vein distention
• Signs of shoke hypotension, tachycardia, (tension pneumothorax
rapid weak pulse, and pale, clammy skin

MEDICAL SURGICAL DEPARTMENT

Example Nursing diagnosis

Impaired gas exchange related to air and fluid collection

in lungs and pleural space as manifested by: chest tube,
decreased breath sounds, abnormal pulse oximetry
Expected patient outcomes
Full expansion of lungs
Normal breath sounds bilaterally
Normal puls oximetry

MEDICAL SURGICAL DEPARTMENT

THE NURSING PRIORITIES FOR PATIENTS WITH
HEMOTHORAX AND PNEUMOTHORAX

•Maintaining airway patency and adequate ventilation

•Assess and manage pain effectively
•Provide wound care and monitor for signs of infection
•Preventing and monitoring for potential complications
•Provide information about the disease
process/prognosis and treatment regimen.

MEDICAL SURGICAL DEPARTMENT

Nursing Goals
Goals and expected outcomes may include:
•The client will establish a normal/effective respiratory pattern
with ABGs within the client’s normal range.
•The client will be free of cyanosis and other signs/symptoms
of hypoxia.
•The client’s lung expansion will be noted on the chest Xray.
•The client will exhibit adequate gas exchange and ventilatory
function as evidenced by a normal respiratory rate, absence of
significant mental status changes, and orientation to person,
place, and time.

MEDICAL SURGICAL DEPARTMENT

NURSING INTERVENTIONS
Monitor chest drainage system to ensure a adequate
ventilation and to detect hemorrhage
Monitor respiratory rate and pattern and manifestations
of hypoxia to allow early recognition of significant
changes in respiratory function
Administer low flow oxygen via nasal cannula to treat
hypoxemia
Assist with position changes to increase patient comfort
and facilitate aeration of the lungs

MEDICAL SURGICAL
MEDICAL DEPARTMENT
SURGICAL DEPARTMENT
Nursing Responsibilities/Care of Patient with Chest Tube

 Keep drainage system 2-3 feet below patient’s chest

 Keep tubing patent; make sure no kinks or clots
present

 Observe and record amount of drainage. >100cc/hr

is heavy…notify physician.
 Encourage TCDB, ambulation as ordered.

MEDICAL SURGICAL DEPARTMENT

a patient has a chest tube to
gravity drainage:
 A. Position the patient on his back
 B. Restrict the patient of bedrest
 C. Provide long tubing to reach the
suction source
 D. Keep the drainage chamber below
chest level

MEDICAL SURGICAL DEPARTMENT

Nurse knows to clamp the chest tube:
 A. The drainage unit is disrupted or
broken.
 B. The patient develops a tension
pneumothorax.
 C. Locating a source of an air leak.
 D. The patient must be transported.

MEDICAL SURGICAL DEPARTMENT

INDICATIONS FOR CHEST TUBE
REMOVAL
 One day after cessation of air leak
 Drainge of less than 50 ml of fluid per day
 1-3 days post cardiac surgery
 2-6 days post thoracic surgery
 Obliteration of emphysema cavity
 Serosanguineous drainge from around the
chest tube insertion site

MEDICAL
MEDICALSURGICAL DEPARTMENT
SURGICAL DEPARTMENT
QUESTIONS
1-Nurse is providing care to a patient with a chest tube. On
assessment of the drainage system, you note continuous bubbling
in the water seal chamber and oscillation. Which of the following
is the CORRECT nursing intervention for this type of finding?
A. Reposition the patient because the tubing is kinked.
B. Continue to monitor the drainage system.
C. Increase the suction to the drainage system until the bubbling
stops.
D. Check the drainage system for an air leak.

MEDICAL SURGICAL DEPARTMENT

QUESTIONS
2-A patient is receiving positive pressure mechanical ventilation
and has a chest tube. When assessing the water seal chamber
what do you expect to find?
A. The water in the chamber will increase during inspiration and
decrease during expiration.
B. There will be continuous bubbling noted in the chamber.
C. The water in the chamber will decrease during inspiration
and increase during expiration.
D. The water in the chamber will not move.

MEDICAL SURGICAL DEPARTMENT

QUESTIONS
3-While helping a patient with a chest tube reposition in the bed,
the chest tube becomes dislodged. What is your immediate
nursing intervention?
A. Stay with the patient and monitor their vital signs while another
nurse notifies the physician.
B. Place a sterile dressing over the site and tape it on three sides
and notify the physician.
C. Attempt to re-insert the tube.
D. Keep the site open to air and notify the physician.

MEDICAL SURGICAL DEPARTMENT

QUESTIONS
4-A patient is recovering from a pneumothorax and has a chest
tube present. Which of the following is an appropriate finding
when assessing the chest tube drainage system?

A. Intermittent bubbling may be noted in the water seal

chamber.
B. 200 cc of drainage per hour is expected during recovery of a
pneumothorax.
C. The chest tube is positioned at the patient’s chest level to
facilitate drainage.
D. All of these options are appropriate findings.
MEDICAL SURGICAL DEPARTMENT
5-A patient is about to have their chest tube removed by the
physician. As the nurse assisting with the removal, which of the
following actions will you perform? Except:
A. Educate the patient how to take a deep breath out and inhale
rapidly while the tube in being removed.
B. Gather supplies needed which will include petroleum gauze
dressing per physician preference.
C. Place the patient in Semi-Fowler’s position.
D. Have the patient take a deep breath, exhale, and bear down
during removal of the tube.
E. Pre-medicate prior to removal as ordered by the physician.
MEDICAL SURGICAL DEPARTMENT