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Managing complications

The primary goal of closed-chest drainage is to optimize ventilation and gas exchange by draining the air or fluid from the pleural cavity. When the closed-chest drainage system is not working properly, patients may show early signs of altered oxygenation, such as restlessness, hyperventilation, and tachycardia. They may also report increased pain on the affected side. At this point, it is essential to troubleshoot the equipment, quickly identify the problem, and provide effective interventions.

Start by checking the patency of the chest tube and looking for loose connections between the patient and drainage system. Determine if the chest tube is clamped, kinked, or occluded by following the length of the entire tubing. If the tubing has disconnected from the drainage unit, instruct the patient to exhale and cough. This rids the pleural space of as much air as possible. Submerge the end of the chest tube in 1 inch of sterile water until you can cleanse the tips of the tubing and reconnect them quickly. Tighten any loose connections and tape them securely or use a locking plastic tie.




Next, determine whether or not there is an air leak. If you see excessive and continuous bubbling in the water-seal chamber or the air-leak meter, especially if the system is connected to a suction source, look for a leak in the drainage system. Using rubber-tipped clamps, try to locate the leak by clamping the tube momentarily at various points along its length. Begin at the tube’s proximal end, near the dressing. Look at the water-seal/air-leak meter chamber. If the bubbling stops, the air leak is at the chest-tube insertion site or inside the chest. Examine the chest-tube insertion site quickly to see if the dressing is loose or the tube is dislodged. If the dressing is loose, air may be entering around the tube as the patient inhales. Palpate around the chest tube site and listen for a crackling sound indicating subcutaneous emphysema, which can result from a poor seal at the chest-tube insertion site. Ask the patient to cough to rid the pleural space of as much air as possible, apply an occlusive dressing or reinforce the dressing if it is intact, and monitor the patient to see if oxygenation improves. The sound of hissing air, a large amount of new drainage at the insertion site, or visibility of the drainage holes at the proximal end of the chest tube suggest that the tube has dislodged. Notify the physician immediately and prepare for another chest-tube insertion. Have emergency equipment (oxygen, resuscitation cart, chest- tube insertion kit) nearby including a flutter (Heimlich) valve or a large-gauge needle for an emergency thoracostomy.

If the bubbling continues after you clamp the tube momentarily near the insertion site, place another clamp a little further down the tube about 20 to 30 cm (8 to 12 inches) toward the drainage system and remove the first clamp. Each time you clamp at the more distal location, check the water-seal/air-leak meter chamber. When you place a clamp between the source of the air leak and the water-seal/air-leak meter, the bubbling will stop. That indicates a leak in the tubing distal to the clamp. Replace the tubing or secure the connection and release the clamp. If you clamp along the tube’s entire length and the bubbling doesn’t stop, the drainage unit might be cracked and you will have to replace it.

When a chest tube disconnects from a closed-chest drainage system, quickly clamp the tube as long as there is no bubbling in the water-seal/air-leak meter. Use a disinfectant to clean the end of the chest tube and the reattachment site and re-establish the connection. If there is bubbling in the water-seal/air-leak meter and your assessment has determined that there is an air leak from the chest, do not clamp the chest tube as this will cause air to accumulate in the pleural cavity with no means of escape. This can rapidly lead to a collapsed lung and tension pneumothorax, a potentially life-threatening event. Instead of clamping the tube, submerge the distal end of the tube in 1 inch of sterile water to create a temporary water seal while you prepare the system for reattachment or replacement.

If the drainage system has tipped over or is disrupted or damaged, or the drainage collection chamber is filled to its maximum capacity, replace it. Prepare a new closed-chest drainage system so that you can attach it as quickly as possible. Clamp the chest tube but only for the brief time it takes to re-establish drainage.

If a chest tube is completely dislodged, cover the site immediately with a sterile gauze dressing. If you can hear air leaking out of the site, make sure the dressing is not occlusive. If it is, it can cause a tension pneumothorax. Stay with the patient and monitor his vital signs while another staff member notifies the physician. Observe for signs of a tension pneumothorax, hypotension, distended jugular veins, absent or decreased breath sounds, tracheal shift, hypoxemia, weak and rapid pulse, dyspnea, tachypnea, diaphoresis, and chest pain. Make sure the equipment for chest-tube insertion and emergency equipment are nearby.

When a patient has a recurrent pneumothorax, the physician may perform pleurodesis, a procedure that involves instilling a chemical agent, such as talc, into the pleural space. The subsequent inflammatory response creates scar tissue and adhesion between the pleural layers and reduces the risk of recurrent pneumothorax. However, it may also make subsequent surgery more difficult. For this procedure, the physician will instill the chemical agent or talc slurry into the chest tube and allow it to flow into the pleural cavity. The chest tube must remain clamped for a period of time to allow the chemicals to work. Closely monitor the patient during this time to detect any changes that could indicate a tension pneumothorax. If you see them, notify the physician immediately and unclamp the tubing.



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