PLEURAL TAPPING

Definition:Thoracentesis or chest aspiration is the withdrawal of fluid from the pleural

cavity by the introduction of a hallow needle into the pleural cavity through the chest
wall. An excessive accumulation of fluid in the pleural cavity is due to some diseases
of the lung, and in cardiac decomposition or renal inefficiency. When the effusion is
purulent in nature it is said as empyema. Fluid may also collect in the pleural cavity
as a result of malignant growth in the chest that pressing blood vessels.
Purposes:1) For diagnostic purposes to find out the causative organism in a pleurisy
2) To remove the symptoms of pressure as pain, dyspnoea, cough and other
symptoms.
Aspiration can be done by some type of suction device such as a vacuum bottle
or a large syringe. In empyema when the effusion is of a purulent in nature, it is
difficult to be removed by means of a syringe and needle. So suction is done by
means of an apparatus called Potain's apparatus.
Potains Apparatus:- It consists of a caliberated glass bottle having a rubber
stopper in which there is a metal tube with branches each providing with stop corks.
To each branch is fitted rubber tubing with adapter or metal ends. The sterile
aspiration needle fits the metal end of one piece of tubing and through the other end
air may be exhausted from the bottle by the exhaust pump leaving a vaccum inside
the bottle into which the chest fluid will readily flow.
Position of the patient for the treatment:- may be sitting or lying down.
Sitting Position:- The patient should sit on the side of the bed with his feet resting
1

on a stool and his arms on a pillow laid over the back of a chair. Sometimes the
patient leans over the bedside table.
Lying position:- The patient lies on a semirecumbent position on the side of the bed
most convenient to the doctor. He should lie with his affected side uppermost. A
small pillow is placed under the thorax so as to arch the vertebrae and to widen the
intercostal spaces. The arm of the affected side is held above head or forward with
the hand on opposite shoulder. The patient should not be exposed unnecessarily.
Nurse should remain with the patient.
Preparation of the patient:- The patient should be dressed in loose jacket over the
chest so as to expose the part easily during the procedure. He should be kept warm
throughout. Skin area is washed and cleaned well and painted with iodine and sterile
dressing applied over the part, and fix with binder or bandage.
Equipment
1) Screen for privacy
2) A tray containing:a)
b)
c)
d)
e)

a)
b)
c)
d)
e)

Small rubber sheet and towel to protect the bed.

Bottles of iodine, collodion or Tr. benzoin, Novocaine 2 percent.
Transfer forceps in a jar of lotion,
Kidney tray
Binder or adhesive plaster and scissors.

Sterile tray containing: Sponge holding forceps.

Bowl of cotton swab.
A small bowl for local anaesthetic.
2 cc syringe and needle for local anaesthetic
20 cc syringe and aspiration needles (if aspiration is to be done with syringe)
f) Aspiration apparatus with all its connections sterilized and tested for its efficiency
in working.
2

g) Aspiration needles of different sizes, three way adapters

h) Sterile test tubes for the collection of the specimens.
i) Sterile dressings.
j) Sterile gloves and mask for the surgeon.
k) Sterile towels for draping the patient.
Procedure:Explain the procedure to the patient to win his confidence and cooperation.
Special instruction to be given that he should not cough or move during the
treatment. If coughing is unavoidable he should inform the nurse or the doctor so
that he may withdraw the needle to prevent it from entering the lungs. Screen for
privacy.
Assemble the equipment to the bedside convenient to the doctor. Keep the
patient in position.
Expose only the needed part by removing the jacket and the chest binder.
Doctor gets ready. He prepares the skin area and discard the swab into the
Kidney tray. The area is draped with sterile towel. Local anaesthetic is given if
necessary at the site of introduction of the needle with the 2 cc syringe and the
needle. Doctor may determine the site of puncture by examining the chest sounds
depending upon the level of collection of fluid.
The aspiration bottle should be operated and made ready to connect with the
needle before introducing the needle to the pleural cavity. Doctor introduces the
aspiration needle between the ribs. A three-way adapter is attached to the needle and
he closes the adapter before introducing, to prevent the entrance of air. As soon as
the needle is in position he connects the needle to the rubber tubing of the bottle and
open the stopcock on that side and the fluid will run into the bottle.
If an uncontaminated specimen is needed, it is collected from the needle itself
3

or it may be collected into the syringe and then put into the test tube.
Watch the patient's condition during the treatment; colour, pulse, breathing or
any difficulty, fainting or haemorrhage etc, When sufficient amount is taken the
needle is withdrawn, the puncture is sealed, dressings applied and fixed with
adhesive plaster' The patient rests for a prescribed period according to his condition.
Sputum should be watched for the presence of blood, after aspiration. Specimen
should be labelled and sent to the laboratory.
Record the treatments, amount, colour, type of fluid withdrawn, the time of
treatment, coughing any fainting gand any untoward symptoms accompanying or
following the procedure, or any benfical effects observed should be recorded. Note the
collection of specimen and the purpose of which they were sent to the laboratory.
Wash the things properly, sterilize and keep in proper places.
Water seal Chest Drainage
Water Seal Chest Drainage means that a column of water in a bottle seals off the
atmospheric air preventing from entering the chest drainage tube and thereby in the
pleural space. It is a closed drainage system by which the air and fluid in the pleural
space is escaped through the drainage tube during exhalation and prevent their
return flow to the pleural space during inhalation. It acts only on one way flow from
into out and not from out to in, provided the apparatus is in proper working
condition.
The normal breathing mechanism operates in the principle of negative pressure
(the pressure in the chest cavity is lower than the pressure of the outside air, causing

air to rush into the lungs). Whenever the chest is opened, for any cause, there is a
loss of negative pressure which can result in the collapse of the lungs. The collection
of air, fluid, or other substance in the chest can complicate cardiopulmonary function
and even cause collapse or the fung, because these substances take up space. Three
types of pathologic substance collect in the pleural space.
1) Solids (fibrin or clotted blood)
2) Liquids (serous fluids, blood, pus, chyle)
3) Gas (air from the lung, tracheobronchial tree, or Oesophagus)
Surgical incision of the chest wall almost always causes some degree of pneumothorax. Air and fluids collect in the intrapleural space, restricting lung expansion
and reducing air exchange. It is necessary to restore pleural negative pressure and
prevent this from happening. Therefore, during or immediately after thorasic surgery,
chest catheters are positioned strategically in the pleural space, sutured to the skin
and connected to some type of drainage apparatus in order to remove the residual air
and drainage fluid from the pleural or mediastinal space. This assists in the reexpansion of remaining lung tissue.
A chest drainage system must be capable of removing whatever collects in the
pleural space so that a normal pleural space and normal cardiopulmonary function
may be restored and maintained. There are many types of commercial chest drainage
systems in use and most of which work on water seal principle. The chest catheter is
attached to a bottle, using a one-way valve principle. Water act as a seal and permits
air and fluid to drain from the chest, but air cannot re enter the submerged tip, of the
tube. The care of the patient with water-seal chest drainage* is discussed below.
5

Principles of Chest Drainage

Chest drainage can be categorized into three types of mechanical system. The
Single bottle water-seal system.
The end of the drainage tube from the patient's chest is covered by a layer of
water which permits drainage and prevents lung collapse by sealing out the atmosphere. Functionally, drainage depends on gravity, on the mechanics of respiration
and, if desired, on suction by the addition of controlled vaccum.
The tube from the patient extends approximately 2.5cm (1 inch) below the level
of the water in the container. There is a vent for the escape of any air that might be
leaking from the lung. The water level fluctuates as the patient breathes. It goes up
when the patient inhales and down when the patient exhales. At the end of the
drainage tube bubbling may or maynot be visible. Bubbling can mean either
persistent leakage of air from the lung or other tissues or a leak in the system.
The two-bottle system
The two-bottle system consists of the same water-seal chamber puis a fluid
collection bottle. Drainage is similar to that of a single unit, except that when pleural
fluid drains, the underwater seal system is not effected by the volume of drainage.
Effective drainage depends on gravity or on the amount of a suction added to
the system. When (suction) vacuum is added to the system from a vacuum source
such as wall suction, the connection is made at the vent stem of the underwater seal
bottle. The amount of suction applied to the system is regulated to the wall gauge.
The three bottle system
This system is similar in all respects to the two-bottle system; except for the
6

addition of a third bottle to control the amount of suction applied.

The amount of

suction is determined by the depth to which the tip of the venting glass tube is
submerged. (For example, submersion to 10 cm below the surface of the water will
equal 10 cm of water suction applied to the patient.)
In the three-bottle system (as in the other two) drainage depends on gravity or
the amount of suction applied. The amount of suction in the system is controlled by
the manometer bottle. The mechanical suction motor or wall suction creates and
maintains a negative pressure through out the entire closed drainage system.
The manometer bottle regulates the amount of vacuum in the system. This bottle
contains three tubes:
1)
2)
3)

A short tube above the water level comes from the water-seal bottle.
Another short tube leads to the vacuum or suction motor or wall suction.
The third tube is a long tube (stand pipe) which extends below the water-level in
the bottle and which is open to the atmosphere outside the bottle. This is the
tube that regulates the amount of vacuum in the system. This is regulated by
the depth to which this tube is submerged-the usual depth is 20 cm (7.6
inches)

When the vacuum in the system becomes greater than the depth to which the
tube is submerged, outside air is sucked into the system. This result in constant
bubbling in the manometer (or pressure-regulator) bottle, which indicates that the
systems is functioning properly.
Management of the patient with water seal chest drainage
Procedure
7

Sl.No
1)

Nursing Action
Rationale Amplification
Attach the drainage tube from Water-seal drainage provides for
the pleural space to the tubing the escape of air and fluid into a
that leads to a long tube with drainage bottle. The water acts as
end submerged in sterile normal a seal and keeps the air from
saline.

2)

being drawn back into the pleural

space.
Tape the places where the tubing Taping the connecting points of
is connected if needed some the tubing will make certain that
connectors hold without taping.

the tubing remains air tight to

reestablish negative (intrapleural)
pressure.

(a) The

tube

should

be

(a) If the tube is submerged too

approximately 2,5 cm (1 Inch)

deep below the water level a

below the water level

higher intrapleural pressure is

(b) The short tube is left open

the atmosphere

required to expel air

(b) Venting

the

short

glass

tube lets the air escape

Mark the original fluid level with

from the bottle

This marking will

tape

the

amount of fluid loss and how fast

on

the

outside

of

show

the

drainage

bottle.

Mark

fluid is collecting in the drainage

hourly/daily

increments

(date

bottle. It serves as a basis for

and time) at the drainage level

blood replacement, if the fluid is

blood. Grossly bloody drainage
will appear in the bottle in the
immediate post operative period
and if excessive, may require reoperation.

Drainage

usually

declines progressively in the first

24 hours.
Fasten tubing to the draw sheet Kinking, looping, or pressure on

with rubber bands and safety the drainage tubing can produce
pin so that flow by gravity will back pressure, and may thus
occur. The tubing should not possibly force drainage back into
loop

or

interfere

with

the the

pleural

space

or

inpede

movements of the patients.

drainage from the pleural space.
Encourage the patient to assume The patient's position should be
a position of comfort. Encourage changed frequently to

promote

good body alignment. When the drainage and the body should be
patient is in the lateral position kept in good alignment to prevent
place a rolled towel under the postural

deformities

and

tubing to protect it from the contractures. Proper positioning

weight of the patient's body. helps

breathing

and

promotes

Encourage the patient to change better air exchange. Medication

position frequently.

maybe needed to enhance comfort

and breathing.
Pool the arm and shoulder of the Exercise helps to avoid ankylosis
affected side through range of of the shoulder and assists in
motion

exercises

several

time lessening post operative pain and

daily. Some medication may be discomfort

necessary.
"Milk" the tubing in the direction Milking the tubing prevents it
of the drainage bottle hourly

from becoming plugged with clots

and fibrin. Constant attention to
maintaining the patency of the
tube

will

expansion

faciliate
of

the

prompt
lung

and

minimise complication
Make sure there is fluctuation Fluctuation of the water level in
(tidaling) of the fluid level in the the tube shows that there is
long glass tube

effective communication between

the

pleural

drainage

cavity

bottle,

and

provides

the
a

valuable way of checking the

9

0)

1)

drainage system, and is a gauge

of intrapleural pressure.
Fluctuation

of

fluid

in

the

tubing will stop when:

(a) the lung has re-expanded
(b) the tubing

is obstructed by

blood clots or fibrin.

(c) dependent loop develops
(d) suction motor
suction

is

or

not

wall

working

properly.
Watch for leaks of air in the

Leaking and trapping of air in the

drainage system as indicated by

pleural

space

constant bubbling in the water-

tension

pneumothorax.

seal bottle.

leak is in the patient and the

a) Clamp

can

result
If

in
the

tubing

tube is clamped for more than

(Momentarily) close to the

few seconds' air-may back up in

chest to look for air leak

the pleural cavity and extend the

only, if so directed by the

patient's pneumothorax.

physician.
b) Report excessive bubbling
in

the

water-

seal

chamber immediately.
c) Milking of chest tube in
patients

with

air

leak

should only be done if

requested by surgeon.
Observe and report immediately

Many

signs of rapid, shallow breathing

cause these signs and symptoms,

cyanosis, pressure in the chest,

including tension pneumothoroax,

subcutaneous, emphysema, or

mediastinal shift, haemorrhage,

symptoms of haemorrhage.

severe

clincal

chest

conditions

pain,

may

pulmonary

embolus, and cardiac tamponade.

10

2)

3)

4)

5)

Surgical

intervention

necessary.
Encourage the patient to breath Deep breathing
deeply and cough at frequent help

to

raise

and
the

may

be

coughing

intrapleural

intervals. If there are signs of pressure, which allows emptying

pain, adequate

medication is of

indicated.

the

pleural
secretion

accumulation,

in

space

removes

from

and
the

the

tracheob-

ronchial tree, so that the lunges

expands and atelectasis

is

Stabilize the drainage bottle on

prevented.
If any part of the apparatus is

the floor or in a special holder.

damaged, the closed system of

Caution visitors and personnel

drainage will be destroyed and the

against handling equipment or

patient will be endangered by

displacing the drainage bottle.

atmospheric
pleural

pressure

space

and

in

the

resultant

collapse of the lung. The drainage

system must be kept air tight to
restablish
If

the

patient

transported

to

has
another

negative

intrapleural

pressure.
be The drainage apparatus must be

to

area, kept at a level lower than the

place the drainage bottle below

patient's chest to prevent back

the chest level (as close to the

flow of fluid into the pleural space.

floor as possible). If he is lying

on

stretcher.

Hemostats

(clamps) should be attached to

the patients gown while he

is

transported.
When assisting the surgeon in

The chest tube is removed as

removing the tube:

directed when the lung is re-

a) Instruct

tm

patient

to

expanded (usually 24 hours to

11

perform

the

valsalva's

several days). During removal of

(forcible

the tube the chief priorities are

exhalation against a closed

prevention of entrance of air into

glottis,

the pleural cavity as the tube is

maneuver

holding

one's

breath.
b) Chest tube is clamped and
quickly removed.
c) Simultaneously a

withdrawn

and

prevention

of

infection.

small

bandage is applied and

made

air

tight

with

vaseline gauze. Covered by

4"

4"

thoroughly

gauze

and

covered

and

sealed with adhesive tape.

Chest Physical Therapy:

Postural Drainage:Because of the patient is usually in an upright position, secretions are likely to
accumulate in the lower part of the lung. When postural drainage-is used, the patient
is positioned sequentially in different postures, so that the force of gravity helps to
drain secretion from the smaller bronchial air ways to the main bronchi and trachea.
The secretions are then removed by coughing. Inhalation of the prescribed
bronchodilators before postural drainage assists in draining the bronchial tree.

Postural drainage exercises can be directed at any of the segments (bilateral) of

the lungs. Usually the lower and middle lobe bronchi empty more effectively when the
12

head is down. The upper lobebronchi empty more effectively when the head is up.
Frequently the patient is placed in five positions.
1 Position for drainage of each lobe.
2 Head down, position.
3 Prone position.
4 Right and left lateral position.
5 Sitting upright position.

Nursing Implication:- The nurse should be aware of the patient's diagnosis as

well as the lung lobes or segments involved, the cardiac status, and any structural
deformites of the chest wall and spine. To determine the area (s) needing treatment
and the effectiveness of the treatment, the chest should be auscultated before and
after the procedure.

Postural drainage is usually done four times daily, before meals and at bed
time. If prescribed bronchodilator aerosol medtcations may be inhaled before postural drainage to reduce bronchospasm, decrease thickness of mucus and sputum
and combat odema of the bronchial walls. The patient should be made as comfortable as possible in each position and an emesis basin or sputum cup and paper
tissue should be available. The patient is instructed to remain 5-10 minutes in each
position and to breath slowly through his nose and blow out through his mouth
while assuming the posture. If he cannot tolerate the position, he should be helped
13

to assume a modified posture.

When the patient changes positions, he should be instructed to cough as

follow:1) Assume a sitting position, and bend slightly forward.
2) Keep the knee and hips flexed to promote relaxation and lessen the strain on
the abdominal muscle while coughing.
3) Inhale slowly through the nose and exhale through pursed lips several times.
4) Cough twice during each inhalation while contracting (pulling in) abdomen
sharply with each cough.
It may be necessary to use chest percusion and vibration to loosen bronchial
secretions and mucus plugs that adhere to the bronchioles and bronchi and to propel
sputum in the direction of gravity drainage.

Following the procedure, the amount, colour, viscosity, and character of the
ejceted sputum is noted; the patient's colour and pulse are evaluated in the first few
times the exercise are performed. It may be necessary to administer oxygen during
postural drainage.
After postural drainage, the patient is made to brush his teeth, or given oral
care before resting in bed.

BIBLIOGRAPHY

1) Theresamma. CP., 2006 Fundamentals of Nursing Procedure manual for

14

General nursing & Midwifery Course. 1st Edition, Jaypee Brothers, Medical
Publishers (p) Ltd., New Delhi.p:192-198.
2) Nancy Sr., 2002, Principles & Practice of Nursing & Nursing arts procedures,
5th edition published & Printed by N.R. Publishers, House, Indore.p:401-412.
3) LC Gupta US, Sahu, Priya Gupta, 2007 Practical Nursing Procedure. 3 rd
Edition, Printed at Para Offset Pvt. Ltd. New Delhi; p: 422-427.
4) Sagunthala Sharma Birpuri 1997 Principles and Practice of Nursing 1 st
edition Printed at Lordson Publishers (P) ltd., New Delhi. p.156-160.
5) Brunner & Siddarths, 2001, Text book of Medical- surgical Nursing- 12 th
edition, volume2, published by Wolters Kluwer (India) pvt. Ltd New Delhi, Page
No: 741-748
6) Lewis, collier, Heitkemper, 1996 Medicalsurgical Nursing, 4 th Edition, Mosby
year book- Inc USA, Page no: 443-448

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