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CTT Care
CTT Care
MARITES A. ROSAPAPAN, RN
Clinical Instructor License No. 0274161
Chest tubes and bottles are some of the simplest devices used in the practice of medicine. Yet they are often misunderstood, sometimes misused and are a mystery to medical students, nurses and some practicing doctors.
Tube thoracostomy is the insertion of a tube into the pleural cavity to drain air, blood, bile, pus, or other fluids Provides continuous, large volume drainage until dealing with the underlying pathology Numerous indications in which patients are at great risk for major morbidity or mortality
Pneumothorax
If > 20 % of the hemithorax In any ventilated patient Tension pneumothorax after initial needle relief Persistent or recurrent pneumothorax after simple aspiration Secondary spontaneous pneumothorax in patients over 50 years
Absolute:
The need for emergent thoracotomy
Fused pleural space
Chest tubes in post thoracic surgery: 1. For lung resections: 2 tubes must be inserted one for air and one for fluid 2. For pneumonectomy: only one basal tube for fluid 3. For intra-thoracic extra pulmonary operations: only one basal tube if pleura is opened
Chest tube drainage device with under water seal Sterile gloves Preparatory solution Sterile drapes Surgical marker Lidocaine 1% with epinephrine Syringes, 10-20 mL (2) Needle, 25 gauge (ga), 5/8 in Needle, 23 ga, 1.5 in; or 27 ga, 1.5 in; for instilling local anesthesia
Blade (No. 10 or 11) on a handle Large and medium Kelly clamps Scissors Silk or nylon suture, 0 or 1-0 Needle driver (holder) Vaseline gauze Sponge gauze squares, 4 x 4(10) Sterile adhesive tape, 4 wide Chest tube of appropriate size :
= Woman : 28F = Infant : 12-16F
Different configurations
Curved or straight
Types of plastic
PVC Silicone
Coated/Non-Coated
Heparin Decrease friction
Best is semi recumbent at a 30- 45 The arm on the affected side should be abducted and externally rotated A soft restraint or silk tape can be used to secure the arm in this location
Safe Triangle
Identify the 5th space and the mid axillary line (MAL) Clean the area (remove excess hair)
Mark the site of insertion (4th or 5th space between MAL and AAL)
Wear sterile gloves, gown, hair cover, and goggles or face shield Apply sterile drapes to the area.
Administer a systemic analgesic (unless contraindicated). Use the 25-ga needle to inject 5 mL of the local anesthetic solution into the skin overlying the initial skin incision Infiltrate the skin area of incision by 5 ml of the anesthetic then direct down to periosteum and infiltrate with 10 ml Advance the needle and aspirate to confirm entry to pleura
Palpate the tract with a finger as shown, and make sure that the tract ends at the upper border of the rib under the skin incision Adding more local anesthetic to the intercostal muscles and pleura at this time is recommended.
A closed and locked Kelly clamp is used to enter into the pleural cavity by controlled pressure and twist.
Make sure to guide the clamp over the upper margin of the rib.
Once inside the pleural cavity, open the clamp to enlarge the entry and withdraw it open
Use a sterile, gloved finger to appreciate the size of the tract and to feel for lung tissue and possible adhesions
Rotate the finger 360 to appreciate the presence of dense adhesions that cannot be broken and require placement of the chest tube at another site
The proximal end of the chest tube is held with a Kelly clamp that guides the chest tube through the tract. The distal end of the chest tube should always be clamped until it is connected to the drainage device.
Desired intra pleural length equals the distance between incision and lung apex Direct the tube upwards and posteriorly in pneumothorax and above the diaphragm in effusion Before securing the tube with stitches, look for a respiration-related swing in the fluid level of the water seal
Two separate through-and-through, simple, interrupted stitches on each side of the chest tube are recommended Each stitch should be tightly tied to the skin, then wrapped tightly around the chest tube several times to cause slight indentation, and then tied again
Sealing suture: A central vertical mattress stitch with ends left long and knotted together can be placed to allow for sealing of the tract once the chest tube is removed. Place petrolatum (eg, Vaseline) gauze over the skin incision as shown
Prepare a Y-shaped fenestrated Apply support gauze dressing drain gauze from regular gauze around the chest tube and (4 x 4 in). secure it to the chest wall with 4-in adhesive tape
THORACOSTOMY TUBE
Single-Bottle Water Seal System Two-Bottle Water Seal System Three-Bottle Water Seal System Pleur-evac Operating System - single unit with all three bottles identified as chambers. Commercially prepared
2.
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The amount of suction is regulated by the wall gauge in two-bottle. The amount of suction is regulated by the depth of the tip of venting glass submerged in the water not by the suction machine (continuous negative pressure) in three-bottle. Water seal bottle fluctuates during: inhalation = up exhalation = down (tidaling is a normal sign) bubbling means persistent leak of air from the lungs or leak in the system When applying clamp always near to the patient (1st clamp ) and 6 inches away for the 2nd clamp (rubberized tip only) only for a few seconds and as necessary
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Emergency equipment must be available always in the bedside extra bottles petrolatum gauze adhesive tape clamp with rubberized tip Milk the tube in the direction of the bottle. Fluctuation/tidaling will stop when: lung has re expanded dependent loop develops and suction is not working
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4.
Always put the drainage system below chest. Never clamp the chest tube during transport or prolonged period of time. Location of the tip of chest tube will be confirmed by an X-ray and full expansion of the affected lung. Chest tube is removed when the lungs have re-expanded in 24 hours to several days.
During tube removal avoid a sudden large inspiration this may produce pneumothorax.
When tube is accidentally disconnected. What to do? Place the distal-end tube in a container with sterile water When tube is accidentally pulled-out from the chest Ask client to do valsalvas maneuver then apply an occlusive dressing
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Complications are reduced when done by experienced operators Good experience is gained after doing at least 10 SUPERVISED procedures (ATS) Experience maintained by doing 5 procedures / year (ATS) Complications may be dangerous and fatal so good tube care and follow up is essential
1. Improper placement
Horizontal (over the diaphragm)
(Acceptable for hemothorax)
Subcutaneous - Must be repositioned Placed too far into the chest (against
the apical pleura) - Should be retracted In inter lobar fissure: Correct
2. Bleeding
Local - Usually responds to direct
pressure
4. Dislodgement:
Due to accidental pull re-introduce a sterile tube
When intrapleural pressure rises above 3 cm water contents of pleura are expelled but hydrostatic pressure of water prevent water from gaining into the pleura
Excess fluid accumulated in the bottle must be removed regularly otherwise back pressure occurs
The bottle must be kept below the bed level (100cm below insertion)
CONCEPT
Straw concept
Trap
Seal
Manometer
Inspiration
Proper connection to the seal Connections must be sealed with adhesive tape No prophylactic antibiotics needed No dependent loops to be present 1or 2 loops near the patient facilitate movements and minimize pain While in bed fix the tube to the bed with a pin Dressing must be changed if soaked
Dependent loop Wrong connection
The following can significantly restrict tube function and could be dangerous:
A full bottle with glass straw tip deep under the fluid surface.
Too narrow or too soft tubing may spontaneously kink or collapse or the patient may lie on it An obstructed or small size air vent permits pressure to build up in the chest bottle. Any fluid in a dependent loop of tubing will obstruct flow and create back pressure, especially to an air leak
Date
Air
Fluid
Others
Air
Fluid
Others
WALL
2. Effusion:
When thick and not easily drained
3. Hemothorax:
Unless active bleeding is present
The fixing stitches are cut, patient takes deep inspiration, tube withdrawn, the track sealed rapidly with a gauze, the sealing stitch is tightened
st 1 check
the patient:
st 1 check
the patient:
Ventilator management:
Minimize airway pressure:
1. Decrease Vt
Ventilator management:
DIFFERENTIAL VENTILATION Ventilate only the healthy side Ventilate both sides differently using Carlens tube Tube pressurization in expiration and occlusion during inspiration Make leak site more dependent High frequency ventilation