 Hi, welcome to Nursing School Explained and this video on chest tubes and chest drainage systems which are indicated for the treatment of hemothorax and pneumothorax. Let's look at the anatomy here. So here we have our trachea with the right and main stem bronchi and then we have the lung in here that's been partially collapsed. As you can see, it does not reach all the way down to the diaphragm. And then we have the pleural space here, the pleural cavity between the visceral and the parietal pleura. So the chest tube gets inserted through the rib cage into that parietal pleura. Then it gets hooked up to this drainage collection system which basically has three major compartments which are the suction control chamber, the water seal chamber, and the drainage chamber. The suction control chamber, pretty self-explanatory, is hooked up to the wall suction. There are two different kinds of suction. First dry suction and then wet. So for dry suction there's no water that controls the amount of suction that is being provided and it's controlled only by the wall suction right here. When there's wet suction it usually means that it's set to a negative 20 centimeters of water pressure which is the standard that most drainage systems come with. Now the order might be different depending on what the patient needs and how significant that hemoanumothorax is. And the wet suction control controls the amount of suction no matter of the setting of the wall suction. So no matter what the dial is up here, there will never be the number above the negative 20 centimeters of water pressure unless the orders are otherwise stated. Next we have the water seal chamber which basically acts as a one-way valve. So I like to compare this as if you have a glass of water with a straw in it. And if you would blow into it the bubbles, the air would cause some bubbles in the water but the air would then escape into the water but air would not be able to come back up through the straw into your mouth. And that's basically what's happening here. So as the air escapes the patient's chest cavity it causes some bubbling in that water seal but then it seals it and prevents the air from flowing back into the patient. And that movement actually there's a movement called tidiling which basically is like a tide the rise and fall of the tide which means that the water level will increase with inspiration and then it will decrease with expiration and that is a normal finding so tidiling is okay and we'll talk about this when we talk about nursing measures. And then third we have the drainage chamber and that mostly applies so if there is a hemothorax. So now not only air can drain out here but also blood and fluid can drain out of here and this will be collected in the drainage chamber and then it will fill up in red here you can see the blood that's draining and then as it fills this first chamber it fills up and then it overflows into this next container and then it overflows here until this drainage system or the drainage chamber is completely full and then the entire system has to be changed if there is more blood to be drained but it all depends on the patient's condition and so forth. So we don't change this chamber at the end of every shift we just change it when it becomes full so that it's no longer draining whatever needs to be drained from the patient's chest cavity. Now the chest tube insertion is a painful procedure these tubes are sometimes very thick they can be like a 20 age or a 30 French so that's a pretty thick tube so that's very painful and it goes right through the rib cage so the provider will apply local anesthetic and then most likely you have to pre-medicate the patient if they are awake and alert if they're not intubated certainly other medications will be needed even for intubation and then you want to elevate the head of the bed if it's not contraindicated because it's going to help facilitate chest movement but always be careful because hemo and pneumothoracies happen in traumatic injuries so we want to make sure that there's no sea spine precautions we want to protect the patient's neck if we're unsure if a cervical spine injury has occurred and then after the insertion the the tube is sutured in place and then it is covered with an occlusive dressing and the reason is that now we have an opening here in that chest wall and air could theoretically escape around the edges of the tube and actually I could get back into the patient's chest wall because of the chest wall movement and that usually the occlusive dressing is petroleum gas which makes it airtight it's just a specialized tubing that's kind of like a waxy consistency that is very tightly wrapped around the tube and then taped in place with multiple special tapes to really keep it there after the chest tube is inserted we want to confirm placement with a chest x-ray and here is the pain management that's very important now regarding the nursing management of the tube and the drainage systems and how to problem solve if there are issues so the tubes need to be always loosely coiled and there can't be any compression so we don't want to occlude the tube and this tubing here is actually quite long then it has this kind of a stand down here that's a lot of times taped down because we don't want to just walk there and kick it over because that could cause some complications but the tubes want to be loosely coiled and then we want to make sure that all these connections are tight specifically around the patient's um about the around the insertion site um because or even here right if there's air now moving in it could theoretically get back into the patient and then it's counterintuitive to why the patient has the chest tube and then let's talk more about tidiling so tidiling again that's the tide rises and falls with the inspiration and the expiration and those fluctuations are normal now if there are no fluctuations at all that either means two things the drainage system is blocked so something has occluded the system or the lungs have now re-expanded so we have maximum expansion here which is not going to cause any more air to escape it to this drainage system and the patient is going to be almost healed getting ready for removal of the chest tube so the only way we're going to know is to assess the patient are they having symptoms what are the lung sounds what is the respiratory rate and so forth and then if there is continuous or increase in bubbling remember that um water glass we discussed when you blow into it there's bubbling um if there is continuous or increased bubbling so a little bit of bubbling is okay but if it's increased from your previous assessment that usually means that there's an air leak somewhere so the solve the the problem solving here requires again checking all the insertion site to make sure that this is airtight so to re-tape the connections and check that air occlusive dressing that we discussed over here that petroleum gauze now additionally the tubing that comes from the patient you can't milk it and milk in the tubing is basically just kind of stripping it and moving any clots along so that they would actually reach the drainage system and that is contraindicated because just by applying a little bit of pressure onto that tube it could change the pressure in that pleural cavity and could make the patient worse the drainage system is to be kept below the patient's chest pretty self-explanatory if there's blood coming out we want it to be draining with gravity otherwise we're going to reinstall that blood back into the patient's chest we're going to want to mark the output and this is what I talked about before so if this is for example 300 mils that the patient has had output initially we want to mark it here with the date and time and then the next nurse will start claiming their output at that 300 mark and then whatever is added from there will be the output that they will claim during their shift until it fills up and we need to switch it or the chest tube is disconnected now if for some reason the tube gets disconnected from the tube and the drainage system tubing right here that means that now we have it open to air and with the inspiration negative pressure would increase in the chest meaning that air could get back in there making this pneumothorax worse so the quick solution is to put the end of the tube in a container with sterile water at a 2 centimeter water level which will basically seal it just like I described you the straw with that glass of water it will basically seal it until you can gather another drainage collection chamber to permanently make the drainage system work thanks for watching this video actually we got one more thing and now how to assess the patient so besides looking at the chest tube and the drainage system we always want to assess the patient their lung sounds because are they improving are they diminished is there any subcutaneous emphysema we certainly want to manage for pain because with every inhalation and exhalation this large tube sits in the patient's cavity so that's going to be very painful and at the same time we want to encourage coughing and deep breathing so that they re-expand the lung and push that fluid or the air that's sitting in the pleuro cavity out into the drainage system and then we want to check for subcutaneous emphysema because if it wasn't there already if there was a problem now we might be able to detect it by palpating the chest for that subcutaneous emphysema so here's additional assessments for your patient thank you for watching this video on chest tubes and chest drainage systems I hope it has helped you gain a better understanding if you haven't already done so please also watch the video about pneumothorax and hemothorax and I'll see you next time here on nursing school explained