Which action will the nurse take to check for subcutaneous emphysema and a client with a chest tube?

Subcutaneous emphysema occurs when air gets into tissues under the skin. This most often occurs in the skin covering the chest or neck, but can also occur in other parts of the body.

Subcutaneous emphysema can often be seen as a smooth bulging of the skin. When a health care provider feels (palpates) the skin, it produces an unusual crackling sensation (crepitus) as the gas is pushed through the tissue.

This is a rare condition. When it does occur, possible causes include:

• Collapsed lung (pneumothorax), often occurring with a rib fracture
• Facial bone fracture
• Rupture or tear in the airway
• Rupture or tear in the esophagus or gastrointestinal tract

This condition can happen due to:

• Blunt trauma.
• Blast injuries.
• Breathing in cocaine.
• Corrosives or chemical burns of the esophagus or airway.
• Diving injuries.
• Forceful vomiting (Boerhaave syndrome).
• Penetrating trauma, such as gunshot or stab wounds.
• Pertussis (whooping cough).
• Certain medical procedures that insert a tube into the body. These include endoscopy (tube into the esophagus and the stomach through the mouth), a central venous line (thin catheter into a vein close to the heart), endotracheal intubation (tube into the throat and trachea through the mouth or nose), and bronchoscopy (tube into the bronchial tubes through the mouth).

Air can also be found in between skin layers on the arms and legs or torso after certain infections, including gas gangrene, or after scuba diving. (Scuba divers with asthma are more likely to have this problem than other scuba divers.)

Most of the conditions that cause subcutaneous emphysema are severe, and you are likely already being treated by a provider. Sometimes a hospital stay is needed. This is more likely if the problem is due to an infection.

If you feel subcutaneous air in relation to any of the situations described above, particularly after trauma, call 911 or your local emergency services number immediately.

DO NOT administer any fluids. DO NOT move the person unless it is absolutely necessary to remove them from a hazardous environment. Protect the neck and back from further injury when doing so.

The provider will measure and monitor the person's vital signs, including:

• Oxygen saturation
• Temperature
• Pulse
• Breathing rate
• Blood pressure

Symptoms will be treated as needed. The person may receive:

• Airway and/or breathing support -- including oxygen via external delivery device or endotracheal intubation (placement of a breathing tube through the mouth or nose into the airway) with placement on a ventilator (life support breathing machine)
• Blood tests
• Chest tube -- tube through the skin and muscles between the ribs into the pleural space (space between the chest wall and the lung) if there is lung collapse
• CAT/CT scan (computerized axial tomography or advanced imaging) of the chest and abdomen or area with the subcutaneous air
• ECG (electrocardiogram or heart tracing)
• Fluids through a vein (IV)
• Medicines to treat symptoms
• X-rays of chest and abdomen and other body parts that may have been injured

The prognosis depends on the cause of the subcutaneous emphysema. If associated with major trauma, a procedure or infection, the severity of those conditions will determine the outcome.

Subcutaneous emphysema associated with scuba diving is most often less serious.

Crepitus; Subcutaneous air; Tissue emphysema; Surgical emphysema

Byyny RL, Shockley LW. Scuba diving and dysbarism. In: Walls RM, Hockberger RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018:chap 135.

Cheng G-S, Varghese TK, Park DR. Pneumomediastinum and mediastinitis. In: Broaddus VC, Mason RJ, Ernst JD, et al, eds. Murray and Nadel's Textbook of Respiratory Medicine. 6th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 84.

Kosowsky JM, Kimberly HH. Pleural disease. In: Walls RM, Hockberger RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018:chap 67.

Raja AS. Thoracic trauma. In: Walls RM, Hockberger RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018:chap 38.

Updated by: Jesse Borke, MD, FACEP, FAAEM, Attending Physician at FDR Medical Services/Millard Fillmore Suburban Hospital, Buffalo, NY. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Once treated only in high-acuity settings, patients with chest tubes now receive care in inpatient medical-surgical floors, outpatient procedural areas (such as interventional radiology), and other settings. More recently, to help shorten hospital stays and reduce readmissions, patients are being discharged with smaller, more portable chest tubes. This allows them to continue to recover from thoracic surgery at home or, in some cases, to receive palliative care.

Nội dung chính

• Managing air leaks
• Planned and unplanned chest-tube removal
• Planned removal
• Unplanned removal
• Postremoval nursing assessment
• Other complications
• Read more about chest tubes: Chest-tube care: The more you know, the easier it gets
• Which action will the nurse take to check for subcutaneous emphysema and a client with a chest tube?
• How does chest tube cause subcutaneous emphysema?
• What does continuous bubbling in chest tube mean?
• Where should you see bubbling in a chest tube?

A chest tube is indicated when negative pressure in the pleural space is disrupted, as from thoracic surgery or unanticipated trauma. The tube helps restore negative pressure, preventing further respiratory complications. (See Chest-tube indications.)

Although they can save lives, chest tubes can pose significant risks unless assessed and managed properly. To help prevent complications, clinicians must be familiar with basic thoracic and pleural anatomy, insertion-site care, dressing changes, and proper chest-tube management. Even then, unanticipated events and complications can occur.

This article can help you feel more confident when caring for patients with chest tubes. It discusses several complications and describes how to prevent and manage problems during tube removal. (The authors assume readers have basic knowledge about chest-tube function and care.)

Managing air leaks

Although air leaks commonly resolve without intervention, they must be evaluated fully before chest-tube removal to ensure adequate restoration of negative pressure in the pleural space. Prolonged leaks—those lasting more than 5 days after thoracic surgery—are more dangerous than acute leaks. They indicate that negative pressure hasn’t been restored and the injury isn’t resolving. Such leaks can increase hospital stays and lead to pneumonia, infection, and other complications. The patient may require a long-term chest tube or replacement of the current tube if it’s malpositioned. In some cases, chemical or mechanical pleurodesis may be indicated.

Assess for air leaks at least once per shift and as needed, based on your patient’s respiratory status. Start by examining the air-leak detection chamber in the water seal of the drain­age device. An air leak presents as small air bubbles; the amount of bubbling indicates the degree of the leak. If you notice bubbling, determine location of the leak. Leaks can occur outside the patient’s body (such as within the drain or tubing connections) or within the patient (for instance, at the tube insertion site or inside the chest cavity).

To determine where the leak is, clamp the tubing as close as possible to the patient. If bubbling continues, suspect a leak in the tubing or damage to the drainage device (as from inadvertent lowering of the bed onto the drain). Commonly, air leaks occur at the point where the distal end of the tube connects to the drainage device tubing. Check this juncture to ensure it hasn’t become loose. Consider using securements, such as plastic fasteners (zip ties), to help prevent accidental disconnection here.

If bubbling disappears when you clamp the tubing, suspect an air leak at the insertion site or from within the chest wall. Assess the insertion site; if you detect a leak, apply petroleum gauze and a sterile occlusive dressing to seal it off. If the leak persists, suspect it’s coming from air remaining in the pleural space (an unresolved pneumothorax), a pleural injury, an exposed tube eyelet, or inappropriate communication between the bronchial and pleural spaces. With a significant internal air leak, you may be able to palpate subcutaneous emphysema or “crackling” under the skin. Whatever its source, an air leak must be addressed and resolved before the chest tube is removed. A large, persistent leak with no evacuation outlet can lead to tension pneumothorax, in turn causing cardiac tamponade—a life-threatening emergency.

Planned and unplanned chest-tube removal

A chest tube can be discontinued in two ways—planned or unplanned (accidental). Unplanned removal can be considered an emergency, but with quick action you can prevent patient harm.

Planned removal

Clinicians use various indicators to determine when a chest tube is no longer necessary— for instance, if drainage has become minimal and no longer concerning or if an air leak or the initial indication for the chest tube has resolved. If permitted by the state board of nursing or facility policy, clinical nurses with dem­on­strated competence in removing chest tubes can perform this procedure.

Here are the basic steps of chest-tube removal:

1. Discontinue wall suction from the chest drainage unit. Some literature suggests you should do this at least 24 hours before tube removal to eliminate a possible air leak.

2. To reduce pain caused by chest-tube removal, premedicate your patient as ordered; allow adequate time for the drug to take effect. (See Managing pain during chest-tube insertion and
removal.)

3. Know that chest-tube removal is a sterile procedure. Gather needed supplies, including a mask, sterile gloves, suture removal kit, petroleum gauze, dry gauze, tape, hazardous waste bag, and disposable pad.

4. Explain the procedure to the patient. Instruct the patient to practice taking deep breaths and holding them. To prevent air from re-entering the pleural space during tube removal, instruct the patient to hold the breath or to hum as you remove the tube.

5. After you’ve removed the dressing and sutures, clamp the tube. Ask the patient to take one more deep breath and hold it. With one hand, simultaneously remove the tube swiftly and place it on the disposable pad. Keep your other hand at the insertion site, covering the hole. If purse-string sutures are present, tie them off into several square knots. If desired, ask a colleague to hold the sutures while you pull the tube out. If these sutures aren’t present, immediately apply an occlusive dressing, such as petroleum gauze. Again, the goal is to prevent air from reentering the pleural space.

6. Dress the site with a dry occlusive dressing and discard the chest tube and drainage device in the hazardous waste bag.

7. Obtain a postremoval chest X-ray if the physician has ordered it or facility protocol requires it. (How-­ever, know that increasing evidence no longer supports routine postremoval chest X-rays.)

Unplanned removal

In an unplanned chest-tube removal, stay calm. With a gloved hand, immediately cover the open insertion site and call for help while staying with the patient. Ask for petroleum gauze to cover the site, along with dry gauze and tape to complete the dressing.

If you didn’t witness chest-tube removal and the patient appears to be in respiratory distress, ask him or her to exhale forcefully as you lift your hand off the insertion site. Before the patient’s next inhalation, quickly cover the site again. Have the patient repeat this a few times. If you suspect air entered the pleural space before you got to the scene, the patient may be at risk for a tension pneumothorax, which can become life-threatening unless the air is expelled from the pleural space quickly. Notify the practitioner, obtain a chest X-ray, and prepare for possible insertion of a new chest tube.

If you’re walking with your patient and the chest tube becomes dislodged where it connects to the drainage tubing, immediately close off the tubing to air with your gloved hand by crimping it or using a clamp, if readily available. Or place the end of the tube in a bottle of sterile water, creating a water seal. Instruct a colleague to prepare a new sterile chest-drainage collection device, or retrieve a new sterile connector while you safely return the patient to bed. Observe the patient for signs and symptoms of respiratory decline. Then reconnect the chest tube to the new drain and unclamp it.

Postremoval nursing assessment

Whether chest-tube removal was planned or unplanned, monitor the patient closely for signs and symptoms of respiratory compromise, using such techniques as pulse oximetry (Spo2), end-tidal carbon dioxide (ETco2) monitoring, and breath sound auscultation. Monitor the patient’s respiratory rate and effort. A repeat chest X-ray (if indicated) may be done to compare to previous films and evaluate for presence or return of a pneumothorax, an effusion, or other problem.

Other complications

Other chest-tube complications also can be dangerous. These include extremely high negative pressures within the system caused by aggressive tube stripping, as well as the re-expansion pulmonary edema phenomenon, which results from rapid removal of large amounts of air or fluid. Rarely, inadvertent chest tube misplacement in the liver, spleen, lung, or great vessel can occur on insertion. (See Chest-tube complications.)

Enhancing your knowledge of chest tubes and gaining the skills needed to manage them improve your confidence in delivering safe patient care.

Selected references

Burt BM, Shrager JB. Prevention and management of postoperative air leaks. Ann Cardiothorac Surg. 2014;3(2):216-8.

Cunningham JP, Knott EM, Gasior AC, et al. Is routine chest radiograph necessary after chest tube removal? J Pediatr Surg. 2014; 49(10):1493-5.

Dias OM, Teixeira LR, Vargas FS. Reexpansion pulmonary edema after therapeutic thoracentesis. Clinics (Sao Paulo). 2010;65(12): 1387-9.

Gorji HM, Nesami BM, Ayyasi M, Ghafari R, Yazdani J. Comparison of ice packs application and relaxation therapy in pain during chest tube removal following cardiac surgery. N Am J Med Sci. 2014;6(1):19-24.

Kane CJ, York NL, Minton LA. Chest tubes in the critically ill patient. Dimens Crit Care Nurs. 2013;32(3):111-7.

Kirkwood P. Chest tube removal (perform). In: Wiegand DLM, ed. AACN Procedure Manual for Critical Care. 6th ed. St. Louis, MO: Saunders; 2011; 171-7.

The authors work at the University of Arizona Medical Center in Tucson. Angela C. Muzzy is a clinical nurse specialist in the cardiovascular intensive care unit (CVICU). Amy K. Butler is a staff nurse in the CVICU and a research assistant in the College of Nursing.

Read more about chest tubes: Chest-tube care: The more you know, the easier it gets

Which action will the nurse take to check for subcutaneous emphysema and a client with a chest tube?

How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes? Palpate around the tube insertion sites for crepitus. Auscultate the breath sounds for crackles and rhonchi. Observe the client for the presence of a barrel-shaped chest.

How does chest tube cause subcutaneous emphysema?

Conclusion: Subcutaneous emphysema can be spontaneous or traumatic, but is associated with avoidable causes such as inadequate chest tube drainage, particularly due to poor tube placement, anchorage and blockage, and also with side-port migration into the subcutaneous tissue.

What does continuous bubbling in chest tube mean?

Continuous bubbling may indicate an air leak, and newer systems have a measurement system for leaks — the higher the number, the greater the air leak. The water-seal chamber can also monitor intrathoracic pressure (Teleflex Medical Incorporated, 2009).

Where should you see bubbling in a chest tube?

In summary, in “wet” suction drains, whether evacuating fluid or air, the only chamber that should be constantly bubbling is the suction control chamber when it is attached to the vacuum regulator.

How do you assess for subcutaneous emphysema?

How does chest tube cause subcutaneous emphysema?

How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of a chest tube?

What does bubbling in chest tube mean?