Daily Management of Chest Tubes

Trauma patients with chest tubes need evaluation of their chest tubes every day. This blog post serves as a tutorial for how to evaluate a chest tube each morning for rounds.

Indications

A chest tube can be used to evacuate the pleural space of air or fluid. Some indications include:

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  pneumothorax
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  pleural effusion
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  hemothorax
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  empyema
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  chylothorax
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  any combination thereof (i.e. hemopneumothorax)

Daily Evaluation

The following items should be reviewed every morning in a patient with a chest tube:

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  Chest Xray: each patient should have a daily chest xray to evaluate:
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  The location of the chest tube: a radio-opaque line runs the length of the chest tube so that it can be evaluated radiographically; the resident should ensure that the patient's chest tube is within the thoracic cavity. A break in this radio-opaque line occurs at the location of the last hole on the tube; this hole (break in the line) should be completely within the chest cavity.
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  The lung markings: the lung should extend to the chest wall when a chest tube is in place. Xrays can also demonstrate persistent fluid/air collections that have not been drained in the thoracic cavity.
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  Suction or Water Seal: this is best evaluated if the red float is visible in the suction indicator window, not by if suction is hooked up to the Pleur-E-Vac system. If the float is not visible, this is referred to as “water seal.”
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  Suction actively evacuates pleural space of air. Water seal is an intermediate step to pulling out the chest tube that allows the team to see if the lung will remain inflated without active suction evacuating the pleural space.
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  Chest tube output: the resident should note the character and amount of the output. Each day, the Pleur-E-Vac should be marked with the date, time and initials of the resident to indicate the amount of output. These numbers are generally more reliable than those found in the electronic chart.
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  The leak status: this is evaluated by looking at bubbling in the air leak meter, usually found on the left lower aspect of the chest tube canister. The meter traditionally runs from 1-7, with a grade 7 leak representing the most severe leak. There are four types of air leaks:
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  Expiratory: this occurs during expiration
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  Forced expiratory: this type of leak only occurs with Valsalva maneuver or coughing
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  Inspiratory: this only occurs in patients undergoing positive pressure ventilation
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  Continuous: a combination of inspiratory and expiratory leak

The above serves as a basic guide of the minimal factors that should be evaluated daily in patients with chest tubes. For the CCH Trauma Management Algorithm, please see this link.

Thanks to Dr. Baddr Shaksheer for this post.