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    Chest tube removal

    Your patient's chest tube is ready to come out. Are you prepared to assist?

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    A small amount of fluid in the space between the lungs and the chest helps the lungs move without friction during respiration. But a buildup of air (pneumothorax), blood (hemothorax), or pus (pyothorax) from injury, disease, or surgery can prevent the lungs from fully expanding.

    Partial or total collapse of the lungs compromises breathing and can lead to respiratory arrest. Insertion of a chest tube, also known as a thoracostomy tube or thoracic catheter, can bring rapid relief.

    Most problems resolve within a few days, as the closed water-seal drainage device that's attached to the tube suctions off the abnormal accumulation of fluid or air and helps restore the negative pressure in the affected lung. The question then becomes: When is it time for tube removal?

    Assessing patients for signs of readiness for tube removal is a key nursing function, as is assisting with the procedure. This review will better prepare you to do both.

    Chest tube removal: What to look for No matter what the reason for the insertion, a chest tube must be removed within a week. (For a list of indications for chest tubes.) Leaving it in place longer than seven days raises the risk for infection along the chest tube tract. A number of clinical indicators will tell you when a patient is ready for his chest tube to be removed.

    An improvement in respiratory status is one of the first signs. The patient will no longer be short of breath, and his breathing won't be labored. You'll hear bilateral breath sounds and see a symmetrical rise of the chest on inspiration. A respiratory rate of less than 24 breaths per minute is another indication that the tube can come out.

    If the chest tube was inserted because of excess fluid, it can be safely removed when the drainage is <200 ml in 24 hours. If blood precipitated tube insertion, minimal output and a change in drainage from bloody to serous or serosanguinous is also a key indicator. In the case of pneumothorax, the tube can safely be removed when bubbling or fluctuation in the water-seal chamber ceases during expiration or during a cough.

    A chest X-ray should be done prior to tube removal to confirm re-expansion of the affected lung and to assure that the timing is right. Clamp the chest tube before obtaining the X-ray, which simulates its actual removal. If the patient's lung is fully expanded, he won't develop respiratory distress when the tube is actually removed.

    Extra care is required if your patient is mechanically ventilated and has a chest tube that's otherwise ready to be discontinued. In this instance, the tube should remain in place until he's extubated—or until the risk for injury to the lung is minimized by reducing the amount of positive pressure. High positive pressure poses a risk for recurrent barotrauma and lung collapse.

    Take ample time to prepare the patient Your patient will likely be both relieved and anxious at the prospect of having his chest tube removed: relieved because a chest tube is uncomfortable and restrictive and anxious because he will remember how painful insertion was and anticipate the same kind of pain on removal.

    Explain that the actual removal takes only seconds and that once the tube is out, he will have minimal discomfort. Assure the patient that you'll give him something for pain prior to removal. Knowing that he'll be premedicated should help reduce his anxiety.

    The drugs of choice include IV narcotics such as morphine or a nonsteroidal anti-inflammatory agent such as ketorolac (Toradol). Whichever agent is prescribed, time its administration so that peak pain relief correlates with the actual tube removal. Shortly before medicating him, teach your patient Valsalva's maneuver. Instruct him to take a deep breath and bear down as if he's forcibly exhaling while still holding his breath. Let him try it a few times and tell him that when you give the sign, he should perform Valsalva's maneuver. Explain that this will prevent air from being pulled back into the pleural space as the tube is removed.

    Collect the supplies for tube removal Gather sterile gloves, goggles, gown, and mask; a disposable underpad; a sterile suture removal kit; rubber-tipped Kelly clamps; petroleum gauze or Tegaderm dressing ready for application; and 2" wide occlusive tape.

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    Sally Beattie, RN, MS, CNS, GNP
    Sally Beattie, is an RN editorial board member and an advanced practice nurse at the University of Missouri Hospital and Clinics, ...