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PURPOSE OF INTERCOSTAL TUBES (ICC)

To drain air and/or fluid from the pleural cavity to allow full lung re-expansion.

WHERE IS THE CHEST TUBE INSERTED?

Two sites: anterior and lateral.

ANTERIOR CHEST TUBES: Landmarks- Second (2nd) intercostal space in the mid clavicular line (MCL).

LATERAL CHEST TUBES: Landmarks - between the mid - axillary line, the anterior axillary fold and the level of the nipple / 5th intercostal space.

DRESSINGS:

*It is unnecessary, and indeed potentially dangerous, to have major obtrusive dressings around the chest tube which can give rise to kinking of the tube, therfore, rendering the tube useless and potentially allowing the accumulation of air and the formation of a tension pneumothorax.

*A piece of gauze around the tube entry site into the skin is sufficient. Cover the tube and gauze with an opsite or tegaderm dressing.

CHEST XRAY:

Ordered post insertion of the chest tube and daily thereafter. The nurse must ensure that a medical officer competent at inspecting chest x-rays is available to assess the position of the chest tube on the chest x-ray.

OBSERVATIONS:

*ICU: Report immediately chest drainage of >200mls of blood in a 1 to 2 hour time frame.

*Continuous Sa 02 monitoring. Titrate 02 via whatever mode (ie. ventilator, 02 mask or nasal prongs) to keep 02 Sa > 96%.

*Observe the swings of fluid in the chest tube bottle. With inspiration water will rise up into the chest tube, with expiration, water will fall. If the swing is less than 2 cm, the lung is not likely to be fully expanded and therefore suction may need to be increased.

NEVER CLAMP AN INTERCOSTAL TUBE: WHY??

Because somebody may forget to remove the clamp and a tension pneumothorax may develop. Two tubing clamps should be left at the patients bedside to clamp the tube in the event of emergency action being required if the tubing became dislodged from the chest tube bottle and air is at risk of entering the chest cavity.

PATIENT POSITION:

*1ST DAY ON THE WARD:

Lying fully on ICC side 2 - 4 hourly so blood is able to drain from mediastinum drain into ICC.

*2ND DAY ON WARD:

side lying continues until removal of ICC - usually day 2 - 3. Sit patient out of bed to improve coughing, lung volumes and lung compliance.

ASSESS AND REPORT ANY OF THE FOLLOWING:

*Sudden drop of Sa 02 < 90%

*increased restlessness and anxiety of the patient.

*cessation of swing, or swing < 2cm.

*absent or decreased breath sounds on the side of the pneumothorax.

*tympany or hollow sound on chest percussion.

LATE SIGNS OF TENSION PNEUMOTHORAX:

*evidence on chest x-ray of air in pleural space and mediastinal shift.

*ECG-reduction in amplitude of QRST complex.

*Rhythm - electrical mechanical dissociation - normal rhythm with reduced cardiac output.

*tracheal deviation.

The contents of the chest bottle should be sterile solution that is not toxic to the lungs should the fluid inadvertently enter the chest. Therfore, water, saline or dextrose.

*Explain procedure to patient and place in a position of comfort. Remove sterile dressing. Cut suture. Ask patient to take a deep breath and hold it - then remove the tube and place a sterile piece of gauze and airtight over the site.