Chest Tube Insertion
The pleural space normally contains a thin layer of lubricating fluid that allows the visceral and parietal pleura to move without friction during respiration. An excess of fluid (hemothorax or pleural effusion), air (pneumothorax), or both in this space alters intrapleural pressure and causes partial or complete lung collapse.
Chest tube insertion allows drainage of air or fluid from the pleural space. Usually performed by a doctor with a nurse assisting, this procedure requires sterile technique. The insertion site varies, depending on the patient’s condition. For pneumothorax, the second to third intercostal space is the usual site because air rises to the top of the intrapleural space. For hemothorax or pleural effusion, the fourth to sixth intercostal spaces are common sites because fluid settles to the lower levels of the intrapleural space. For removal of air and fluid, a chest tube is inserted into a high and a low site.
After insertion, one or more chest tubes are connected to a thoracic drainage system that removes air, fluid, or both from the pleural space and prevents backflow into that space, thus promoting lung reexpansion. (See “Chest tube drainage system monitoring and care,” page 165.)
Equipment
Lidocaine local anesthetic (0.5% or 1%) ▪ sterile gowns, gloves, and masks ▪ eye goggles or face mask with eye shield ▪ alcohol wipes ▪ rolled towels or a blanket ▪ sterile drapes ▪ chlorhexidine-based antiseptic swabs ▪ sterile syringes (assortment of sizes: 3 ml, 5 ml, and TB) ▪ 22G and 25G needles ▪ sterile chest tube tray, which includes hemostats, forceps, trocar, scalpel, Kelly clamps, scissors, skin expanders, and sponges ▪ sterile chest tube catheter (#16 to #20 French catheter for air or serous fluid; #28 to #40 French catheter for blood, pus, or thick fluid) ▪ suture material (usually 2–0 to 3–0 silk with cutting needle) ▪ sterile petrolatum gauze ▪ two sterile 4″ × 4″ drain dressings (gauze pads with slits) ▪ sterile 4″ × 4″ or 2″ × 2″ gauze pads ▪ 3″ to 4″ (7.6 to 10 cm) sturdy elastic tape ▪ 1″ (2.5 cm) adhesive tape for connections ▪ two rubber-tipped clamps for each chest tube inserted ▪ sterile chest tube drainage system with tubing and connector ▪ sterile marker ▪ sterile labels ▪ Optional: sterile nonadherent gauze and transparent dressing, sterile water, Y connector (for more than one chest tube).
Prepackaged sterile chest tube trays are commercially available and contain most of the equipment listed.
Preparation of Equipment
Check the expiration date on the sterile packages, and inspect for tears. Then gather all equipment in the patient’s room. Set up the drainage system according to the manufacturer’s instructions and your facility’s policy. (See “Chest tube drainage system setup,” page 170.) Place the system next to the patient’s bed below chest level to facilitate drainage. Label all medications, medication containers, and other solutions on and off the sterile field.1
Implementation
Verify the doctor’s order for chest tube insertion and the number and sizes of chest tubes needed.
Gather the necessary supplies.
Conduct a preprocedure verification process to make sure that all relevant documentation, related information, and equipment are available and correctly identified to the patient’s identifiers.5
Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.6
Explain the procedure to the patient and provide privacy.
Make sure the patient has a signed informed consent form in his chart, unless the procedure is being performed in an emergency.7
Verify that the doctor has marked the insertion site with his initials or with another unambiguous mark set by your facility’s policy before the procedure is performed.6
Assess the patient for signs and symptoms of respiratory distress, including tachypnea, decreased or absent breath sounds, dyspnea, cyanosis, asymmetrical chest expansion, anxiety, restlessness, shortness of breath, tachycardia, hypotension, arrhythmias, and sudden sharp chest pain.
Review the patient’s chart for abnormal chest X-ray or blood gas results.
Assess the patient for a history of previous chronic lung disease, spontaneous pneumothorax, and pulmonary disease or procedures that may have included the need for chest tube placement.
Obtain the patient’s baseline data, including vital signs, skin color, perfusion, level of consciousness, oxygen requirements, hemodynamic stability, and respiratory rate, pattern, and effort to help identify and document acute changes that may occur during and after the procedure.
Participate in a time-out immediately before starting the procedure to perform a final assessment that the correct patient, site, positioning, and procedure are identified and that, as applicable, all relevant information and necessary equipment are available during and after the procedure.8
Administer sedation and pain medication as ordered. The doctor may request sedation (benzodiazepines) and opioid analgesia to reduce pain and to help the patient remain calm.
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