Chest Tubes

Chest Tube Tidaling

What is tidaling? Tidaling is a fancy word for the fluctuations seen in the fluid of the water-seal chamber during respirations (think of the ocean). This change occurs due to the changes of pressure in the chest during ventilation. The fluid level will rise with inspiration and fall with expiration. This is reversed if a patient is using positive pressure ventilation. Tidaling is NORMAL and indicates that the chest tube is patent.

If tidaling is not noted, this indicates that your chest tube is not patent. Start by observing the chest tube set up for any kinks or clogs. Begin by assessing the chest tube closest to the patient, and working your way back to the chest tube drainage device.

Chest Tube Bubbling

Bubbling can be observed in the water-seal chamber whenever air enters into the system. Certain types of bubbling can be normal, while others may indicate an issue.

Intermittent bubbling that corresponds with respirations is normal. You may also see increased bubbling when a patient coughs.

Continuous bubbling indicates an air leak. This can be due to a patient’s lung re-expanding from a pneumothorax or a leak in the chest tube system itself. So, how can you tell if the continuous bubbling is normal or not? Well, look at your patient. Was the chest tube just placed two hours prior for a spontaneous pneumothorax? If so, continuous bubbling is expected. Has your patient’s chest tube been in for 48 hours and you suddenly notice a vigorous, continuous bubbling? This probably indicates a new air leak in the system.

It is also important to note that using high amounts of external suction on the chest tube may cause a small, continuous bubble as well. The key here is that the bubbling is NOT vigorous in nature.

Why Are Chest Tubes Inserted?

Why are chest tubes inserted? Most simply, a chest tube is inserted for two main reasons: air or fluid. 

1. Pneumothorax: when the pleural space fills with air causing a collapse in lung

2. Hemothorax (blood), pleural effusion (fluid), empyema (infected fluid): when blood or fluid collects in the pleural space is puts pressure on the lung tissues 

Essentially, too much air or fluid in the pleural space prevents the lung from appropriately expanding, which may indicate the need for a chest tube. Some signs and symptoms your patient may exhibit are: tachypnea, decreased or absent breath sounds, increased pain with respirations, hypotension, and decreased oxygen saturations.

Chest Tube Suction vs. Water-Seal

There are two methods to draining a chest-tube: to suction and to gravity (also called water-seal). When a chest tube is hooked up to suction, suction tubing is connected from the wall suction to the external drainage system. The “amount” of suction is controlled on the external drainage device and typically ranges from -10 to -40 cm H20.

So, how do you know whether your patient’s chest tube needs suction or not? This is typically left up to the patient’s provider, and is based upon how effectively the chest tube is working. A good rule of thumb, though, is that the patient’s chest tube should at least be set to water-seal prior to it being removed, to ensure the patient will tolerate the removal. Here is a great article that analyzes the usage of external suction vs water-seal on chest tubes. Make sure you check it out!

Subcutaneous Emphysema (Creptius)

Subcutaneous emphysema, also called crepitus, occurs when air is trapped underneath the patient’s skin. It is a fairly common complication that occurs with chest tube insertion due to air escaping from the  pleural space into the tissue space. It can range from being a minor issue to a major complication.

When a chest tube is inserted, sometimes air can leak underneath the patient’s skin in the surrounding areas. It is important to assess the patient’s chest tube site by palpating the surrounding skin for subcutaneous emphysema per your hospital’s policy. Subcutaneous emphysema will feel like rice krispies or little bubbles of air directly underneath the skin. If crepitus is noted, mark it with a skin marker and reassess frequently to make sure the air is not spreading. If the crepitus is localized and does not continue to spread, most likely this will just be something the bedside nurse will continue to monitor and it should reabsorb over time; However, if subcutaneous emphysema continues to spread (especially to areas like the chest, neck, and face), it can become life threatening.

Chest Tube Drainage

Regardless of the reason a chest tube is inserted, you can expect some drainage. But, how much drainage is too much, and what should it look like? Well, this depends on the reason(s) why your chest tube was inserted.

Chest tube drainage can range from very minimal to huge quantities. The quality of drainage can vary from purulent, to serous, serosanguineous, or sanguineous. A good rule of thumb is that chest tube drainage should DECREASE in amount and become more serous over time. An unexpected increase in drainage or a significant change in drainage color (example: patient was draining 10 mL/hr of serous fluid and suddenly dumped 300 mL of sanguineous fluid) warrants a call to the provider.

As always, take a step back and look at the big picture when it comes to chest tube drainage. Did your patient just ambulate for the first time since their cardiac surgery? Well, you can probably anticipate a bit more drainage due to the increase in mobility.

Chest Tube Locations

There are two main locations that chest tubes are placed: the pericardial space and the pleural space.

Pericardial tubes (also called mediastinal tubes) are placed to drain fluid/blood from the pericardial space, particularly after cardiothoracic surgery is performed.

Pleural chest tubes are placed to remove air (pneumothorax) or drain fluid/blood (pleural effusion, hemothorax) from the pleural space.

Chest Tube Nursing Assessment

Chest tubes are cool and all, but how do we assess them?

First, start with your patient. Perform a solid respiratory assessment so you can easily identify any changes later on in your shift should they arise. How is your patient breathing? What are their oxygen saturations? How do their lungs sound upon auscultation?

Next, look at the chest tube site. How  does the dressing look? Any abnormal drainage? Is the chest tube appropriately sutured or secured? How does the surrounding skin look? Palpate the site for subcutaneous emphysema and mark it with a skin marker if noted.

Last, assess the functionality of the chest tube. Is it working appropriately? Suction (if ordered) on and working? Do you note any tidaling or bubbling in the water-seal fluid? What is the quality and quantity of drainage from the chest tube? Is this expected?

BONUS! Take a look at your patient’s most recent chest x-ray if they have one and compare it to the x-ray taken prior. Are things improving per the radiology report or provider’s note? Is the chest tube still located in the appropriate location?