Chest tubes are great. They can overcome all kinds of obstructions in the chest - air (pneumothorax), blood (hemothorax), air and blood (hemo-pneumothroax), and even pus (empyema). We will be focusing on the anatomy and management of these systems in this blog (by request of a reader). This will be a no nonsense approach to managing the chest tube. Let's start with a few DO NOT items.
DO NOT
1. Do not trust that the stitches will hold the chest tube in. There should never be any extra pressure on the on chest drainage tube besides the weight of the tube itself and whatever sediment is inside. This means keeping a close eye on the tube during transfer of the patient. When evaluating to see if the chest tube has been partially dislodged, look and make sure that none of the side holes of the chest tube are showing outside of the skin. See the image below.
2. Do not clamp the chest tube unless you believe there is backflow into the chest for some reason. There should always be a pathway for the obstruction (air, blood, pus) to escape. Chest tubes should generally always be connected to suction, if not, they can drain to gravity as well. Clamping can also occur inadvertently. Check your tubes to make sure you have an unobstructed path from chest to atrium.
3. Do not raise the drainage unit above the patient. There should always be a high-to-low pressure gradient from chest to collection atrium. Raising the atrium above the patient encourages backflow into the chest, which is the opposite of what we are trying to accomplish with our chest tube.
DO
1. Do make sure you have adequate suction. See the image below where it indicates "suction monitor bellows." When adequate suction is applied, it will pull the balloon to the point of an arrow that indicated adequate suction. -80mmhg is usually used on the wall suction to ensure adequate suction (you have to read the user manual for each device to make sure this is correct for what you are using). I've provided the links to some common units at the end of the blog. That have very detailed instructions for safe use.
2. Do monitor collection. Whatever you are suctioning out of the chest should be measured at given intervals. Usually, providers will mark on the chest tube chamber where the fill line is at the end of each hour. Monitoring blood collection from the hemothorax can indicate if transfusion may also be needed. The air leak monitor will also let you know if a lot of air is going through the system. The leak may indicate a leak in the device setup, or in the patient's chest. Bubbles from right to left indicate leak.
3. Do watch the patient's respiratory status closely. If your patient is spontaneously breathing, you will be able to much better assess how well the chest tube is working to clear the obstruction. However, if the patient is being provided positive pressure ventilation, this generally complicates things (especially if there is a pneumo or hemopneumo at play). The higher the pressure of PPV, the more volume of air it can move into the tensioning area. Watch out for increasing pressure readings and alarms on your ventilator, or more difficulty with bagging the patient. The lowest pressures and volumes needed to adequately oxygenate and ventilate that patient should be used.
Ambulance Specific Items
Most ambulances only have one suction unit inside (besides the portable suction). So, what happens if you have a patient that has bilateral chest tubes? If your suction unit has a strong battery, or can be charged during use on transport, you could use the portable on one chest tube and your ambulance wall suction on the other. Alternatively, there are Y-port splitters that can be used to attach two chest tubes to the same suction unit. These are cheap and might be a good investment for the chance that you could need to section both sides of a chest. This would be even more important if you work in an air ambulance. Due to the expansion of the pneumothorax that happens upon ascent, chest tubes absolutely cannot be clamped.
Further information
Looking at the atrium above, all of the different components may seem a little confusing. There is a system called the '3 bottle system.' Understanding this system makes the entire chest tube setup very simple. I found an article that Life In The Fast Lane that has several videos about insertion, the three bottle system, maintenance, flutter valves, etc. They did a really nice job getting all the information onto one page that they entitled "Own The Chest Tube" that covered a lot of the points I was thinking of covering in this blog. No need to reinvent the wheel, here is the link:
https://lifeinthefastlane.com/own-the-chest-tube/
Phemcast also put out two amazing episodes about pneumothorax that I absolutely love. Check them out here:
https://phemcast.co.uk/2017/12/01/episode-24-tension-pneumothorax-1/
https://phemcast.co.uk/2017/12/01/episode-25-tension-pneumothorax-2/
Here is the link to the chest tube user manual type documents:
http://www.atriummed.com/en/chest_drainage/Documents/OasisWallChart-010395-Letter-Size.pdf
http://www.atriummed.com/EN/Chest_Drainage/Documents/Ocean-BlueHandbook-010140.pdf
https://www.teleflex.com/emea/documentLibrary/documents/940579-000001_UnderstandingChestDrainage_1009.pdf