6.4 Troubleshooting Problems and Complications

This is a priority concern for a patient with a chest tube drainage system and can be caused by a variety of conditions. Signs and symptoms may include oxygen saturation level less than 90%, decreased breath sounds from baseline, asymmetric chest movements, hypotension, tachycardia or bradycardia, subcutaneous emphysema around insertion site or neck, tracheal deviation, or patient complaints of chest pain or increased dyspnea.

• Ensure the drainage system is intact with no leaks or blockages such as kinks or clamps.
• Provide oxygen as indicated.
• Immediately notify the provider. An urgent chest X-ray may be ordered to assess for a displaced tube, tension pneumothorax, or other complication.
• Obtain emergency assistance as indicated.

An air leak may be indicated by continuous or intermittent bubbling in the water seal chamber or audible air leaking from the patient’s chest.

To determine the source of the leak (i.e., the patient, the tubing, or the drainage device), momentarily clamp the chest tube:

• Using rubber-tipped clamps, begin at the dressing site and clamp the drainage tubing momentarily. Look at the water seal chamber. If bubbling stops, the air leak is from the chest tube site or inside the client’s thorax. Unclamp the tube, reinforce the dressing, and notify the health care provider immediately.
• If bubbling continues after clamping the tube near the chest wall, gradually move the clamp down the tubing toward the chest drainage system approximately every 10 to 12 inches. Each time the tubing is clamped, observe the water seal chamber. If the bubbling stops, the leak is located in that area of the tubing or the surrounding connections. Replace the tubing or secure the connections. Be sure to release the clamp.
• If bubbling continues despite clamping near the drainage device, the leak is in the drainage system, and it requires replacement.

Dislodgement of the chest tube from the insertion site in the patient’s chest is an emergent situation, and agency policy must be followed. In general, the following actions may be performed:

• Call for assistance and ask a colleague to immediately notify the provider and/or obtain supplies while you stay with the patient.
• Immediately cover the chest tube insertion site with a sterile occlusive dressing and tape it on three sides, allowing air to escape on the fourth side to reduce the risk of a tension pneumothorax.
• If a client develops respiratory distress or a sudden change in vital signs, call the rapid response team.
• Prepare for the reinsertion of a chest tube.

Call for assistance in replacing the drainage system and notifying the provider. Momentarily clamp the tube close to the insertion site on the patient’s chest wall or alternatively place the distal end of the chest tube in a bottle of sterile water.

Bleeding may occur after insertion of the chest tube. Apply pressure to the site, reinforce the dressing, and notify the provider.

Subcutaneous emphysema can indicate a worsening air leak in the chest cavity or a tension pneumothorax as thoracic pressure increases and forces air from the chest cavity out of the tube insertion site and into the tissues. The provider should be notified if subcutaneous emphysema is new or worsening. It may be helpful to mark the area of subcutaneous emphysema to determine if it is extending and worsening.

If drainage suddenly stops in the first 24 hours after chest tube insertion, the tubing may be clogged by a blood clot or by a fluid blockage in a dependent loop:

• Assess the drainage system and the client.
• Inspect for kinks and straighten the tubing along its length to its connection with the collection device.
• Reposition the client in an upright position.
• Ensure the drainage system is below the level of the client’s chest.
• If interventions are not successful, notify the health care provider.

An increase of bright red drainage of more than 200 mL/hour may indicate vascular injury that requires surgical repair^[3]:

• Obtain vital signs and assess the client’s cardiopulmonary status.
• Notify the health care provider and report the amount and color of drainage.

• Position the unit upright.
• Immediately check the fluid level in the water seal for correct volume and replace lost fluid.
• If all chambers are contaminated with blood, consider replacing the entire unit.
• To prevent future tipping, use the attached floor stand that is a part of the drainage unit. If the client is mobile, consider securing the unit to an IV pole.

• Press and hold the negative-pressure relief valve at the top of the chest drainage system to vent excess negative pressure in the water seal chamber. Release the valve when the level of the water returns to the 2-cm mark.
• To remove excess water from the suction control chamber, insert a syringe and withdraw excess.

The suction control chamber should have gentle bubbling. Vigorous bubbling can indicate wall suction is set too high and can cause faster evaporation, requiring water to be added.

• Ensure the suction tubing is connected and the suction source is turned on and set to the prescribed suction amount.