Med-Surg Respiratory System, part 11: Pleural Disorders, Chest Tubes, Tension Pneumothorax

August 27, 2021 Updated: January 17, 2022 10 min read

In this article, we are going to talk about pleural disorders and chest tubes, and we’ll learn what a tension pneumothorax is.

The Med-Surg Nursing video series follows along with our Medical-Surgical Nursing Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.

Cool Chicken When you see this Cool Chicken, that indicates one of Cathy's silly mnemonics to help you remember. The Cool Chicken hints in these articles are just a taste of what's available across our Level Up RN Flashcards for nursing students!

Pathophysiology of pleural disorders

We began this respiratory system video playlist with an anatomy and physiology review. You'll recall that there are pleura that surround and protect each of the lungs. There are two layers to the pleura, and the space between those two layers is called the pleural cavity. If for some reason there were an accumulation of air, blood, or fluid in the pleural cavity — between the two layers of the pleura — that would increase tension in the pleural cavity, putting pressure on the lungs. That could lead to a lung collapse.

Pneumothorax

A pneumothorax is when there is an accumulation of air in the pleural cavity.

Pleural effusion

A pleural effusion is when there is an accumulation of fluid in that pleural cavity.

Hemothorax

A hemothorax is when there is an accumulation of blood in the pleural cavity.

Signs and symptoms of pleural disorders

The signs and symptoms of a pleural disorder may include respiratory distress and/or reduced or absent breath sounds on the affected side. Additionally, if hyperresonance can be heard when performing percussion (an assessment of the patient’s lungs performed by tapping on the patient’s chest wall to produce sounds), that is indicative of a pneumothorax. If the percussion sounds dull, that would indicate either a hemothorax or a pleural effusion.

Diagnosing pleural disorders

Pleural disorders are diagnosed with a chest X-ray.

Treatment for pleural disorders

Treatment for a pleural disorder involves the placement of a chest tube to eliminate the accumulation of air, blood, or fluid. Administering oxygen is another option.

Among the medications available to treat pleural disorders are benzodiazepines (which relieve anxiety in the patient) and opioid analgesics to help with the pain.

These medications and more may be found in our Nursing Pharmacology video series, which follows along with our Pharmacology Flashcards.

Chest tubes

A chest tube is a surgical drain that is inserted through the chest wall and into the pleural cavity. It helps to drain the blood, the air, or the fluid out of the pleural cavity.

The three chambers of the chest tube

A chest tube has three chambers. Looking from right to left these are: the drainage collection chamber, the water seal chamber, and the suction control chamber.

Drainage collection

The drainage collection chamber, as its name suggests, collects drainage from the pleural cavity. This chamber is calibrated, in order to measure the amount of drainage.

It is important to chart the amount and color of the drainage on a regular basis. Excess drainage (more than 100 ml/hr) should be reported to the provider.

And as a side note, it is important to notify the provider any time there is excess drainage in any type of device. For example, with a wound VAC (vacuum-assisted closure), if there is excess drainage, that would be cause for concern, and the provider would need to be notified. Similarly for a patient's JP drain (Jackson-Pratt drain — a closed-suction medical device), or Hemovac drain (a device placed under the skin during surgery to remove any blood or other fluids), if it fills with a lot of fluid very quickly, notify the provider.

Water seal

The middle chamber of the chest tube is the water seal chamber, which allows air to exit the pleural cavity when the patient exhales and prevents air from seeping back into the pleural cavity on inhalation.

Prep the water seal chamber by adding sterile fluid to the two-centimeter line. Make sure that the chamber is kept upright and situated below the chest insertion site.

Tidaling will be present in this chamber, and that is to be expected. Tidaling is the up and down movement of water that occurs with inspiration and expiration. A lack of tidaling can indicate that the lungs have re-expanded, which is desirable. However, lack of tidaling could also mean that there's an obstruction in the system, which is certainly not desirable.

Cool Chicken Seals swim in the tides! Tidaling expected in water seal!

Continuous bubbling is not expected in this chamber and is indicative of an air leak.

Suction control

The last chamber (the one on the left) is the suction control chamber, which is an atmospherically vented section containing water (like the water seal chamber). A suction pressure of −20 cm H2O is commonly recommended.

Unlike the water seal chamber, continuous bubbling is expected in the suction control chamber.

Chest tube nursing care best practices

For a patient who has a chest tube, follow these nursing care best practices:

  • Obtain a chest X-ray after the patient has had a chest tube inserted to confirm the tube position.
  • Keep an occlusive dressing on the chest tube insertion site.
  • Assess the insertion site on a regular basis for subcutaneous emphysema, which is when air gets trapped under the skin. If pushing on the skin feels “crunchy,” like Rice Krispies for example, that is indicative of subcutaneous emphysema. It is also important to monitor the site for signs of infection.
  • Clamp a chest tube only if it is ordered by the provider. Never “strip” the tubing. (Stripping usually refers to compressing the chest tube with the thumb or forefinger of one hand, while, with the other hand, using a pulling motion down the remainder of the tubing, away from the chest wall.)
  • Encourage the patient to cough, to breathe deeply, and to use an incentive spirometer to help with lung expansion and re-inflating the lungs.
  • Keep padded clamps, sterile water, and sterile gauze at the bedside, in the event they are needed.
  • If a chest tube becomes disconnected from the drainage system, place the end of the tube in sterile water in order to maintain the water seal.
  • If a chest tube becomes accidentally removed from the patient's chest, place a dry, sterile gauze over the insertion site and notify the provider. Note that specific instructions for disconnected or removed chest tubes may vary, depending on facility policy.
  • Finally, monitor the patient for complications, such as a tension pneumothorax.

Tension Pneumothorax

When a patient has a tension pneumothorax, air becomes trapped in their pleural cavity under positive pressure, meaning that air enters the pleural space upon inspiration but can't escape upon expiration. This accumulating pressure can lead to lung collapse.

Risk factors for a tension pneumothorax

Risk factors for a tension pneumothorax include occlusion of the chest tube, mechanical ventilation, and fractured ribs.

Signs and symptoms of a tension pneumothorax

The signs and symptoms of a tension pneumothorax include tracheal deviation toward the unaffected side (when the trachea is pushed to one side of the neck by abnormal pressure in the chest cavity or neck), as well as absent breath sounds on the affected side. The patient will likely exhibit respiratory distress, tachycardia, tachypnea (abnormally rapid breathing), neck vein distention, pallor, and anxiety.

It may also be possible to see an asymmetry of the thorax.

Labs and diagnostics for a tension pneumothorax

A tension pneumothorax is diagnosed with a chest X-ray and with ABGs. Check out our Arterial Blood Gas Interpretation Flashcards for Nursing Students to learn more about ABGs for your med-surg classes.

Treatment of a tension pneumothorax

Treatment for a tension pneumothorax includes the immediate insertion of a large bore needle into the pleural space to remove air and allow the lung to re-expand. The insertion of a chest tube would follow that procedure.


Full Transcript

Hi, I'm Cathy, with Level Up RN. In this video, we are going to talk about pleural disorders, as well as chest tubes and a tension pneumothorax. And at the end of the video, I will give you guys a little quiz to test your understanding of some of the information I'll be covering in this video. So definitely stay tuned for that. So if you recall, and if you watched the beginning of this video playlist, we did a little anatomy and physiology review for the respiratory system. So there are pleura that surround and protect each of the lungs. In this pleura, it has two layers. In the space between those two layers is the pleural cavity. And we would not expect the accumulation of air, blood, or fluid in that pleural cavity. Because if we do get one of those things in between those two layers, that puts pressure on the lungs and can lead to a lung collapse. So if we have the accumulation of air in that pleural cavity, that is called a pneumothorax. If we have the accumulation of blood in that space, that is a hemothorax. And then if we have the accumulation of fluid in that pleural cavity, that is a pleural effusion.

So in terms of the signs and symptoms of a pleural disorder, the patient may exhibit respiratory distress. They may have reduced or absent breath sounds on the affected side. And then when you perform percussion, if you hear hyperresonance, then that is indicative of a pneumothorax. And if you hear dull percussion, then that would be more indicative of a hemothorax or a pleural effusion. So in terms of diagnosis, we would diagnose a pleural disorder using a chest X-ray. And then treatment involves the placement of a chest tube to get rid of that accumulation of air, blood, or fluid. And we're going to talk a lot more about chest tubes here in a minute. And then medications that can be provided to the patient include benzodiazepines for anxiety, as well as opioid analgesics for pain.

All right. Let's now talk more about chest tubes. So as I mentioned, the chest tube is going to help drain the blood, the air, or the fluid out of that pleural space. Let's first talk about the three chambers of the chest tube. And I'm going to describe them from right to left. So the first chamber is the drainage collection chamber. And as the nurse, you are going to need to chart the amount of drainage and the color of drainage on a regular basis. And you're going to want to report excess drainage to the provider. So if the patient is having over 100 milliliters an hour of drainage, that would be considered excessive, and you would definitely want to notify the provider. And as a side note, you want to notify the provider any time you see excess drainage in any type of device. So with a wound VAC, if you see excess drainage, that would be cause for concern, and you would need to notify the provider. It goes for drains, too, their JP drain or Hemovac drain. If you see it fill up with a lot of fluid very quickly, you would want to notify the provider.

Okay. So after the drainage collection chamber, we have the water seal chamber. And in this chamber, you want to add sterile fluid to keep it at the two-centimeter line. You want to make sure the chamber is kept upright and below the chest insertion site. There will be tidaling present in this chamber. So that's the up and down movement of water that occurs with inspiration and expiration. Lack of tidaling can indicate that the lungs have reexpanded, which is great. However, it could also mean that there's an obstruction in the system, which is not so great. So you're definitely going to need to do some troubleshooting if you notice that there is lack of tidaling in this chamber. Continuous bubbling is not expected in this chamber and is indicative of an air leak. So our little cool chicken here on this card for remembering that tidaling is expected in the water sealed chamber is that seals swim in the tides. So tidaling is expected in the water seal chamber. And then the last chamber we have is the suction control chamber. Continuous bubbling is expected in this chamber.

All right. Let's now talk about nursing care of a patient who has a chest tube and some best practices. So after the patient gets their chest tube inserted, they need to have a chest X-ray to confirm the tube position. You want to have an occlusive dressing over the insertion site, and you want to check the insertion site on a regular basis to check for subcutaneous emphysema, which is where air becomes trapped under the skin. And then we also want to monitor the site for signs of infection. And that subcutaneous emphysema, it kind of feels like Rice Krispies, for lack of a better description. It's kind of crunchy. If you push on there and you feel that kind of crunchiness, then that would be indicative of subcutaneous emphysema. You only want to clamp the chest tube if it is ordered by the provider. You never want to strip the tubing. And then you want to encourage the patient to deep breathe, to cough and use their incentive spirometer to help with that lung expansion, reinflating the lungs. And then you want to keep padded clamps, sterile water, and sterile gauze at the bedside. If the chest tube becomes disconnected from the drainage system, you want to place the end of the tube in sterile water in order to maintain that water seal. And then if the chest tube becomes accidentally removed from the patient's chest, you want to place dry, sterile gauze over the insertion site and notify the provider. And these instructions may vary depending on facility policy. So definitely check on your particular facility. And then lastly, you want to monitor for complications such as a tension pneumothorax, which we're going to talk about next.

With a tension pneumothorax, air becomes trapped in that pleural cavity under positive pressure, meaning that air enters that pleural space upon inspiration but can't escape upon expiration. And this can lead to lung collapse. So occlusion of the chest tube is definitely a key risk factor with a tension pneumothorax. Other risk factors can include mechanical ventilation, as well as fractured ribs. Signs and symptoms of a tension pneumothorax include tracheal deviation towards the unaffected side, as well as absent breath sounds on the affected side. You may see asymmetry of the thorax. The patient will likely be exhibiting respiratory distress, tachycardia, tachypnea, neck vein distention, pallor, and anxiety. So diagnosis of this can be done with a chest X-ray and with ABGs. And then treatment includes immediate insertion of a large bore needle into that pleural space to remove that air to allow for lung expansion. And then we would place a chest tube as well.

All right. It's time for a quiz. There's actually a lot of questions I could ask you. There's just a lot of important information to know about the conditions we just went over and chest tubes. So if you have our flashcards, definitely review the bold red items to make sure you have those facts and concepts down. All right. Question number one, if a patient has a pneumothorax, what type of sound will you hear upon percussion of the chest? If you answered hyperresonance, you are correct. Question number two, in which chest tube chamber is continuous bubbling expected? If you said the suction control chamber, you are correct. Question number three, tracheal deviation is indicative of what disorder? The answer is a tension pneumothorax. I hope you did well with that quiz. And if you didn't, just go back and watch the video again and review the flashcards. You got this. I know you can do it. Take care. Good luck studying.


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