Word: Thoracic: Assisting With Chest Tube Insertion

THORACIC: ASSISTING WITH CHEST TUBE INSERTION

DOCUMENT TYPE: PROCEDURE

Site Applicability

This procedure is applicable in Neonatal Intensive Care

Practice Level/Competencies

A pleural chest tube is required any time the negative pressure in the pleural cavity is disrupted by the presence of air or fluid resulting in pulmonary compromise. In an urgent situation, needle aspiration of the fluid/air collection may be required. See Thoracic: Needle Aspiration Procedure.A chest tube is inserted by a Physician or Nurse Practitioner.Nipple and breast bud should be avoided when placing a chest tube.Analgesia either intravenously or locally is required for chest tube placement unless an emergency condition exists.

Equipment & Supplies

Local AnaestheticAnalgesia BolusChest drainage unit (Atrium Oasis)Chest tube drain Pigtail (#6 or #8.5 F) or Trochar (#8 or #10 F)Argyle 5-in-1 barbed connector if inserting a TrocharChest tube insertion trayDexidin 2 solution (2% chlorhexidine gluconate with 4% isopropyl alcohol)Disposable hat and masksNeedle, 25/28 gauge and 1 cc syringeEmergency Clamps (non-toothed), 2 Pink waterproof tapeRequisition, Chest x-raySterile drapes, 1 2Sterile gloves and gown 3-0 Curved suture setTegaderm, 2-3Suction Regulator & Suction tubingSteristrip or Episeal strip

Procedure

STEPS

RATIONALE

1. Bring Pod supply cart to bedside.

2. Request assistance.

Notify CNL/CSN when procedure occurring to ensure help is available

3. Administer analgesia as ordered.

Use intravenous analgesia

4. Don mask and cap, wear eye protection, wash hands.

5. Prepare sterile tray, add:

Chest tube

Skin cleaning solution.

Suture material (if needed)

Smaller 5 in 1 adaptor if trocar chest tube being inserted

6. Set-up chest drainage unit. Secure end of tubing in sterile towel. Bring unit to bedside.

Refer to Document: Thoracic Chest Tube Drainage System Set-Up And Trouble-Shooting

Patient end of tubing is capped but sterile towel also gives a sterile field to work over while connecting tubing.

7. Assist physician/NP in gowning and gloving.

9. Position and comfort infant during procedure.

Position supine or, as with pneumothorax, affected side upright. Arm should be held above the head to expose side of the chest.

10. Ensure chest site is aseptically prepared according to the NICU Skin Cleaning Aseptic procedure.

Scrub site with Dexidin solution using side-to-side motion for 30 seconds. Allow to air dry for 60 seconds.

For infants less than or equal to 1000 grams:

Remove residual Dexidin solution on skin using sterile normal saline or sterile water after the chest insertion procedure is complete

11. Assist with administration of local anesthetic prior to chest tube placement

12. Hand physician patient end of connecting tubing in the sterile drape once chest tube inserted. Assist the physician in cutting the larger adapter off if necessary and inserting smaller adapter. Maintain sterile technique when connecting the chest tube to the chest drainage system

Sterile gloved hand will connect chest tube to connecting tube.

Trochars are always sutured in place.

Pigtail catheters are not typically sutured for securement. Secure the pigtail in place under dressing.

13. Note at the skin surface the cm landmark on the chest tube or mark exit site with a steri-strip or episeal strip.

Allows for easy visualization of chest tube placement.

Document landmark in nursing notes and on BIT.

14. Turn suction regulator on once chest tube is attached to chest drain unit. Check position of suction bellows:

Bellows need to be visible in the suction monitor window. Increase the wall suction regulator if needed.

For a -10 cm H2O setting- the bellows do not need to expand to the mark.

For a -20 cm H2O setting- the bellows do need to expand to the mark

Note positioning of bellows with different suction settings:

15. Secure connection between chest tube and connecting tubing with waterproof tape

Tape placement should allow for an unobstructed view of the connection site.

16. Assist physician with placing Tegaderm dressing.

Occlusive transparent dressing allows for observation of insertion site and early identification of signs of wound infection, air leak or slipping of chest tube.

Secure chest tube to a secondary point on the chest or abdomen using duoderm and waterproof tape.

17. Position infant comfortably to facilitate evacuation of the pleural contents.

To help drain air, head of bed should be at 30-45 degree angle.

18. Anticipate immediate chest x-ray, blood gas and increased monitoring of vital signs.

AP and lateral x-ray views are usually preferred

19. Reassess comfort level of the infant following procedure

Documentation

On Flow Sheet in Registered Nurses notes:Indication for chest tubeInsertion of and infants tolerance,Level of underwater seal in suction control chamberAny air leak and fluid drainageTime and dosage of analgesic doses with double signatures BITLandmark of chest tube position (ideally centimeter or steri-strip mark at skin)Hourly Documentation:Site-to-source checkAir leak or fluid drainageFluctuation in tubing or air leak chamber

References

AAP and American College of Obstetrics and Gynecologists. Guidelines for Perinatal Care. (2002). 5th ed. Philadelphia: Mosby.BC Womens Hospital (2016). Thoracic: Needle Aspiration. Retrieved from http://policyandorders.cw.bc.ca/resource-gallery/Documents/BC%20Women's%20Hospital%20-%20Neonatal%20Program/NN.16.01%20Thoracic%20Needle%20Aspiration%20Procedure.pdfCotton, CM and Goldberg, RN. (2005). Air leak syndromes. In A.R. Spitzer (Ed), Intensive care of the fetus and neonate. 2nd ed. Philadelphia: Elsevier.Gomella, TL, et al. (2003). Neonatology: Management, procedures, on-call problems, diseases and drugs. 5th ed. New York: McGraw-Hill.BC Womens Hospital (2015). Skin Cleaning Aseptic. Retrieved from http://policyandorders.cw.bc.ca/resource-gallery/Documents/BC%20Women's%20Hospital%20-%20Neonatal%20Program/NN.04.04%20Skin%20Cleaning%20Aseptic.pdf

Version History

DATE

DOCUMENT NUMBER and TITLE

ACTION TAKEN

15-Jan-2019

C-06-12-60036 Thoracic: Assisting With Chest Tube Insertion

Approved at: Neonatal Leadership Committee

Disclaimer

This document is intended for usewithinBC Childrens and BC Womens Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document.This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.

C-06-12-60036 Published Date: 27-Feb-2019

Page 4 of 4 Review Date: 27-Feb-2022

This is a controlled document for BCCH& BCW internal use only see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.