Clinical Guidelines (Nursing)

Chest Drain Management

  • Note: This guideline is currently under review. 


    Introduction

    Chest drains also known as under water sealed drains (UWSD) are inserted to allow draining of the pleural spaces of air, blood or fluid, allowing expansion of the lungs and restoration of negative pressure in the thoracic cavity. The underwater seal also prevents backflow of air or fluid into the pleural cavity. Appropriate chest drain management is required to maintain respiratory function and haemodynamic stability.Chest drains may be placed routinely in theatre, PICU & NNU; or in the emergency department and ward areas in emergency situations.

    Some cardiac surgical patients will have Redivac drains in the chest and these are different from UWSD.

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    Aim

    To describe safe and competent management of (UWSD) chest drainsby the health care team

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    Definition of terms

    Chylothorax: Collection of lymph fluid in the pleural space

    Haemothorax:  Collection of blood in the pleural space

    Pneumothorax :Collection of air in the pleural space

    Tension Pneumothorax:One way valve effect allowing air to enter the pleural space, but not to leave. Air builds up forcing a mediastinal shift. This leads to decreased venous return to the heart and lung collapse/compression causing acute life-threatening respiratory and cardiovascular compromise. Ventilated patients are particularly high risk due to the positive pressure forcing more air into the pleural space. Tension pneumothorax can result in rapid clinical deterioration and is an emergency situation

    Pleural effusion: Exudate or transudate in the pleural space

    Under Water Seal Drain (UWSD):Drainage system of 3 chambers consisting of a water seal, suction control & drainage collection chamber. UWSD are designed to allow air or fluid to be removed from the pleural cavity, while also preventing backflow of air or fluid into the pleural space.

    Flutter valve (e.g. pneumostat, Heimlich valve):One way valve system that is small & portable for transport or ambulant patients. Allows air or fluid to drain, but not to backflow into pleural cavity.

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    Indications for Insertion of a Chest Drain

    • Post operatively e.g. cardiac surgery, thoracotomy
    • Pneumothorax
    • Haemothorax
    • Chylothorax
    • Pleural effusions

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    Insertion of a Chest Drain

    See the Chest Drain (Intercostal Catheter) Insertion Clinical Practice Guideline.

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    Chest Drain Set Up

    • Perform Hand Hygiene
    • Open drain packaging in a clean, 'no-touch' manner
    • Prepare drain as per manufacturers instructions
    • Pass sterile end of tubing to Doctor inserting drain when they are ready
    • Apply suction to drain if ordered
    • Secure drain & tubing to bed and patient
    • Secure all connections with cable ties
    • Perform hand Hygiene

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    Management

    Chest drains should not be clamped

    • There is a risk of the patient developing a tension pneumothorax if a drain is clamped while an air leak is present

    Start of shift checks

    • Patient assessment
    • Chest drain assessment
    • Equipment
    • Other considerations e.g physiotherapy referral

    Patient Assessment

    Vital signs

    • PICU and NNU patients should be on continuous monitoring
      • HR, SaO2, BP, RR
      • Routine vital signs:
    • For ward areas:
      • On insertion of chest drain monitor patient observations of HR, SaO2, BP, RR:
        • 15 minutely for 1 hour
        • 1 hourly for 4 hours
        • Includes HR, SaO2, BP, RR and temperature
        • 1-4 hourly as indicated by patient condition

    Pain

    • Chest tubes are painful as the parietal pleura is very sensitive. Patients require regular pain relief for comfort, and to allow them to complete physiotherapy or mobilise
    • Pain assessment should be conducted frequently and documented

    Drain insertion site

    • Observe for signs of infection and inflammation and document findings
    • Check dressing is clean and intact
    • Observe sutures remain intact & secure (particularly long term drains where sutures may erode over time)

    Assessment of chest tube and system tubing should occur at the beginning of the shift and every hour throughout the shift

    UWSD Unit & tubing

    • Never lift drain above chest level
    • The unit and all tubing should be below patients chest level to facilitate drainage
    • Tubing should have no kinks or obstructions that may inhibit drainage
    • Ensure all connections between chest tubes and drainage unit are tight and secure
      • Connections should have cable ties in place
    • Tubing should be anchored to the patients skin to prevent pulling of the drain
    • In PICU and NNU tubing should also be secured to patient bed to prevent accidental removal
    • Ensure the unit is securely positioned on its stand or hanging on the bed
    • Ensure the water seal is maintained at 2cm at all times

    Suction

    • Suction is not always required, and may lead to tissue trauma and prolongation of an air leak in some patients
    • If suction is required orders should be written by medical staff
      • Some clinical areas may use the orange 'Chest Drain Orders" sticker. This should be placed in the patient progress notes.

     

    • Wall suction should be set at >80mmHg or higher
    • Suction on the Drainage unit should be set to the prescribed level
      • -5 cmH20 is commonly used for neonates
      • -10 cmH20 to -20 cmH20 is usually used by convention for children
    • To check suction:
      • Atrium Oasis UWSD:
        • The bellows should be out to the '?' mark @ 20 cmH20
        • Any visible expansion of the bellows is adequate for suction <20 cmH20
        • If the bellows deflate, check the wall suction is still working, set to > 80mmHg and that the suction tubing is not kinked
    • Atrium Ocean UWSD:
      • The water level in the suction chamber should be at prescribed level
      • The level may drop due to evaporation, top up as per manufacturers instructions

    Drainage

    • Milking of chest drains is only to be done with written orders from medical staff. Milking drains creates a high negative pressure that can cause pain, tissue trauma and bleeding
    • Volume
      • Document hourly the amount of fluid in the drainage chamber on the Fluid Balance Chart
        • Calculate and document total hourly output if multiple drains
        • Calculate and document cumulative total output
      • Notify medical staff if there is a sudden increase in amount of drainage
        • greater than 5mls/kg in 1 hour
        • greater than 3mls/kg consistently for 3 hours
      • Blocked drains are a major concern for cardiac surgical patients due to the risk of cardiac tamponade
        • notify medical staff if a drain with ongoing loss suddenly stops draining
      • If the chamber tips over and blood has spilt into next chamber, simply tip the chamber up to allow blood to flow to original chamber
    • Colour and Consistency
      • Monitor the colour/type of the drainage. If there is a change eg. Haemoserous to bright red or serous to creamy, notify medical staff.

    Air Leak (bubbling)

    • An air leak will be characterised by intermittent bubbling in the water seal chamber when the patient with a pneumothorax exhales or coughs.
    • The severity of the leak will be indicated by numerical grading on the UWSD (1-small leak 5-large leak)
    • Continuous bubbling of this chamber indicates large air leak between the drain & the patient. Check drain for disconnection, dislodgement and loose connection, and assess patient condition. Notify medical staff immediately if problem cannot be remedied.
    • Document on Fluid Balance Chart

    Oscillation (swing)

    • The water in the water seal chamber will rise and fall (swing) with respirations. This will diminish as the pneumothorax resolves.
    • Watch for unexpected cessation of swing as this may indicate the tube is blocked or kinked.
    • Cardiac surgical patients may have some of their drains in the mediastinum in which case there will be no swing in the water seal chamber.
    • Document on Fluid Balance Chart 

    Equipment by the bedside

    • Drain Clamps: At least 2 drain clamps per drain
    • For use in emergency only e.g. accidental disconnection
    • Two suction outlets: One for chest drain & one for airway management

    Other Considerations

    • Referral to physiotherapist should be made to enhance chest movement and prevent a chest infection

    Patient Positioning

    • Patients who are ambulant post operatively will have fewer complications and shorter lengths of stay. Consider converting to a portable flutter valve system such as the pneumostat to facilitate this If chest drain will be required for prolonged period
    • If a patient is on strict bed rest or is an infant, regular changes in position should be encouraged to promote drainage, unless clinical condition prevents doing so

    Patient  Transport

    • If the patient needs to be transferred to another department or is ambulant, the suction should be disconnected and left open to air.
    • DO NOT CLAMP THE TUBE
      • Clamps must not be used on the patient for transport because of the risk of tension pneumothorax
    • Ensure the chamber is below the patients chest level during transport
    • Flutter Valve systems (pneumostat, Heimlich) may be used for patient interhospital transfers (e.g. NETS and PETS)

    Specimen Collection

    • Collect drainage specimens for culture through the needless sampling port located by the in line connector.
    • Equipment Required
      • Specimen container
      • Alcohol swab
      • 10ml syringe
      • Dressing pack
      • Gloves
      • Eye Protection
    • Procedure:
      1. Wait for the fluid to collect in a loop of the tubing
      2. Perform hand hygiene, then don gloves & eye protection
      3. Clean the sampling port with an alcohol wipe and leave to dry for 20 seconds
      4. Clamp the tubing above where the fluid has collected
      5. Connect a 10ml Luer lock syringe to the sampling port and aspirate the fluid out of the tubing
      6. Place fluid in sterile specimen container
      7. Once the syringe is disconnected remove all clamps and kinks
      8. Perform hand hygiene

    Chest Drain Dressings

    • Dressings should be changed if:
      • no longer dry and intact, or signs of infection e.g. redness, swelling, exudate
      • Infected drain sites require daily changing, or when wet or soiled
      • No evidence for routine dressing change after 3 or 7 days
      • This procedure is a risk for accidental drain removal so avoid unnecessary dressing changes
    • Exact type of dressing may depend on treating medical team
      • For cardiac surgical patients with drains inserted intraoperatively:
        • use split gauze & mefix dressing
        • ensure dressing does not communicate with sternotomy dressing or wound
      • For all other chest drains
        • Sandwich between occlusive dressing
          • Allows site visibility & prevents pressure on skin
        • If site oozing dress with split gauze and occlusive dressing
    • Ensure drain is secure
      • To prevent it falling out use a 'tag' of tape to secure to skin
      • Apply comfeel™ or similar to protect fragile skin from 'tag' of tape

    Changing the Chamber

    • Indications
      • The chest drain chamber needs to be replaced when it is ¾ full or when the UWSD system sterility has been compromised eg. Accidental disconnection.
    • Equipment Required
      • New UWSD
      • Dressing pack
      • Gloves
      • Eye Protection
    • Procedure
      1. Perform hand hygiene
      2. Use personal protective equipment to protect from possible body fluid exposure
      3. Using an aseptic technique, remove the unit from packaging and place adjacent to old chamber
      4. Prepare the new UWSD as per manufacturers directions supplied with drain
      5. Ensure patients drain is clamped to prevent air being sucked back into chest
      6. Disconnect old chamber by holding down the clip on the in line connector to pull the tubing away from the chamber.
      7. Insert the tubing into the new chamber until you hear it click Unclamp the chest drain
      8. Check drain is back on suction
      9. Place old chamber into yellow infectious waste bag & tie
      10. Perform hand hygiene

    Splitting the UWSD Chambers

    • Indications
      • When 2 chest drains are connected via a Y-connector into 1 drainage chamber there may be a need to have them split into 2 chambers to determine if 1 drain is draining more than the other
    • Equipment Required
      • New UWSD
      • Dressing pack
      • Gloves
      • Eye Protection
      • Chlorhexidine
      • Scissors
      • Connector
      • Cable tie wraps
      • Cable tie gun
      • Pliers
    • Procedure (also see figure below)
      1. Perform hand hygiene
      2. Use personal protective equipment to protect from possible body fluid exposure
      3. Place newly prepared drainage system in a position adjacent to the old system as set up as per chest drain set up.
      4. Clamp all tubing
      5. Cut the tie wraps with the Pliers
      6. Remove the Y connector and attached tubing
      7. Clean ends of exposed drains And wait 20 seconds
      8. Attach drainage system to chest drain
      9. Repeat with second chamber
      10. Place tie wraps around connection site and pull to tighten
      11. Tighten further using Cable tie Gun
      12. Once secure remove clamps and check for signs suction has returned

    splitting chest drain

    Removal of Chest Drains

    • Must be a written order by medical staff
    • Indications
      • Absence of an air leak (pneumothorax)
      • Drainage diminishes to little or nothing
      • No evidence of respiratory compromise
      • Chest x-ray showing lung re-expansion
    • Equipment required
      • Dressing trolley with Yellow Infectious waste bag attached
      • Dressing pack (sterile towel, sterile gauze)
      • Sterile Gloves
      • Steristrips
      • Suture Cutter
      • Band Aids
      • Normal Saline
      • Clamps
      • Eye Protection
      • Occlusive dressing
      • Sharps container
    • Patient preparation
      • Inform patient and parent about removal and possible associated pain.  Explain the removal process to the patient and carer
      • Discuss the plan for procedural pain management and non-pharmacological pain management to assist with comfort throughout procedure, assess analgesic requirements first and then consider the need for procedural sedation; please refer to the Procedural Sedation Ward and Ambulatory Areas at RCH policy for more information.

    • Procedure
      The removal of chest drains should be completed using a “Standard Aseptic Technique”, please refer to the Aseptic Technique Policy for more information
      1. Perform hand hygiene
      2. Opening dressing pack and add sterile equipment and 0.9% saline
      3. Don disposable gloves
      4. Remove all dressings around the area
      5. Turn off suction
      6. Clamp drain tubing
        • If there are multiple drains insitu, clamp all drains before removal. Once the required drains are removed, unclamp remaining drains
      7. Remove disposable gloves, perform hand hygiene and don sterile gloves
      8. Place sterile towel under tubes
      9. Clean around catheter insertion site and 1-2cm of the tubing with 0.9% Saline
      10. If purse string present (cardiac patients) unwind in preparation for assistant to tie
      11. Remove suture securing drain (ensuring purse string suture not cut)
      12. Pinching the edges of the skin together, rotate tubing from side to side gently to loosen, then remove the drain using smooth, but fast, continuous traction.
      13. Instruct patient exhale and hold if they are old enough to cooperate; if not, time removal with exhalation as best as possible.
      14. Pinching the edges of the skin together, remove the drain using smooth, but fast, continuous traction.
      15. The assistant pulls purse string suture closed as soon as the drain is removed, tying 2 knots and ensuring the suture is not pulled too tight. Cut tails of suture about 2cm from knot
        • If there is no purse string present remove drain and quickly seal hole with occlusive dressing
      16. Instruct patient to breathe normally again
      17. Apply occlusive dressing (bandaid for cardiac children) over site
      18. Remove and discard equipment into a yellow infectious waste bag and tie
      19. Perform hand hygiene
    • Post Procedure Care
      • Attend to patients comfort and sedation score as per procedural sedation guideline
      • CXR should be performed post drain removal
        • Patients in PICU may wait until routine daily CXR if clinically well
      • Clinical status is the best indicator of a reaccumulation of air or fluid. CXR should be performed if patient condition deteriorates
      • Monitor vital signs closely (HR, SaO2, RR and BP) on removal and then every hour for 4 hours post removal, and then as per clinical condition
      • Document the removal of drain in progress notes and on patient care record
      • Remove sutures 5 days post drain removal
      • Dressing to remain insitu for 24 hours post removal unless dirty
      • Complications post drain removal include pneumothorax, bleeding and infection of the drain site

    Post Removal 

    • Monitor site for signs of infection, obtain swabs or samples if required
    • Monitor and mark dressings to observe leakage, replace dressings as required to minimise risk of infection.
    • Excessive leakage should be reported to AUM or surgeon.
    • Dressing should be removed when wound has healed (3-5days)

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    Complications and Troubleshooting

    Pneumothorax

    • Prepare for insertion/repositioning of chest drain
    • Nurses involved in chest drain insertion must document the drains Lot Number and expiry date in EPIC->LDA Assessment->Placement Date/Time->Comment in “Tube Number
    • Once chest drain is inserted nurses must ensure the drain is able to maintain suction and is adequately secured. 

    Bleeding at the drain site

    • Don gloves
    • Apply pressure to insertion site
    • Place occlusive dressing over site
    • Notify medical staff
    • Check Coagulation results
    • Check drain chamber to ensure no excessive blood loss

    Infection of insertion site

    • Notify medical staff
    • Swab wound site
    • Consider blood cultures

    Accidental disconnection of system

    • Clamp the drain tubing. Clean ends of drain and reconnect. Ensure all connections are cable tied. If a new drainage system is needed cover the exposed patient end of the drain with sterile dressing while new drain is setup. Ensure clamp removed when problem resolved
    • Check vital signs
    • Alert medical staff

    Accidental drain removal

    • Apply pressure to the exit site and seal with steri-strips. Place an occlusive dressing over the top
    • Check vital signs
    • Alert medical staff.

    Purse string cut or not present

    • Small bore drains such as pigtails do not require purse strings. Simply apply an occlusive dressing.
    • For large bore drains:
      • Pinch or apply pressure to the exit site
      • Apply steri-strips to close exit site and cover with an occlusive dressing
      • Notify the responsible medical team to review patient and consider need for a suture

    Unable to remove chest drain

    • If there is resistance and no movement of the drain tube despite gentle side-to-side rotation and a firm pull do not proceed further and notify the appropriate surgical team – for example if the patient is managed by the cardiac surgical team contact the cardiac surgical fellow and treating team; if the patient is managed by the general surgical team contact the general surgical resident or registrar.
    • There should be no excessive force when pulling the drain tube, doing so can lead to serious complications such as drain tube fractures or internal tissue damage.


    Drain Tube Fractures

    • If the tube fractures during drain removal and remanent’s of the tubing is left within the patient contact the appropriate surgical team – for example if the patient is managed by the cardiac surgical team contact the cardiac surgical fellow and treating team; if the patient is managed by the general surgical team contact the general surgical resident or registrar.
    • The surgical team should order an immediate chest xray
    • The patient should be prepared for theatre, inform the parents and  keep the child nil by mouth in anticipation for surgical removal of the tube that has been left in the patient
    • The whole drain unit should be kept in the patient’s room until surgical review and will need to be kept for collection to enable quality review
    • The piece of drain tubing that remains in the patient will also be kept once surgically removed to allow for appropriate follow up of the incidents cause
    • A VHIMS must be completed by the nurse delegated to remove the drain.


    Special Considerations 

    For Theatre Staff involved in the surgical removal of the retained drain tube:

    • In theatre, previous surgery is checked on EPIC regarding the LDA’s flowsheet of the drain that was inserted at that operation. NB. There can be multiple drains.
    • After removal of retained drain, instrumentation nurse to superficially clean visible blood /serous fluid off the retained drain.
    • Instrumentation nurse to measure length of retained drain before placing in a yellow top container. -Surgery is completed as planned.
    • Scout RN to record length of retained item on patient’s UR label on container.
    • Retained item's lot number and expiry that has been recorded in EPIC is to be transcribed onto the yellow top container with patient’s UR label
    • Scout RN to record in EPIC retained items details.  Also check LDA's flow sheet for removal of drain/line details and update in comments section that residual item has been removed and record length with date and time stamp.
    • Yellow top container to be kept together with the remaining drains until critical review process is completed and VHIMs documentation finalised.
    • Post op chest X ray to be reviewed by surgeons and open disclosure to family to be undertaken by surgeons. 

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    Family Centred Care

    • Explain purpose of chest drain to family and when it is likely to be removed
    • Discuss the need for pain relief for the child to be comfortable enough to move and participate in physiotherapy

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    Companion Documents

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    References

    • Charnock, Y and Evans,D. (2001). Nursing management of chest drains: a systematic review. Australian Critical Care. 14(4):156-160
    • Curley, M.A. & Moloney-Harmon, P.(2001). Critical care nursing of infants & children. (2nd ed.). Phildelphia: W.B. Saunders Company.
    • Durai R; Hoque H; and Davies T. (2010). Managing a chest tube and drainage system. AORN Journal. 91(2):275-280
    • Laws, D; Neville, E; & Duffy,J. (2003) BTS guidelines for the insertion of a chest drain. Thorax. 58(suppII):ii53-ii59.
    • Newcomb, A; Alphonso N; Norgaard M; Cochrane A; Karl T; Brizard C. (2005) High-vacuum drains rival conventional underwater-seal drains after pediatric heart surgery. European Journal of Cardiothoracic Surgery. 27:395-400
    • Pacharn,P; Hellar,D; Kammen,B; Bryce,T; Reddy,M; Baily,R and Brasch,R. (2002). Are chest radiographs routinely necessary following thoracostomy tube removal? Pediatric Radiology. 32:138-142
    • Tang, A; Velissaris,T; and Weedon,D. (2002). An evidence based approach to drainage of the pleural cavity: evaluation of best practice. Journal of Evaluation in Clinical Practice. 8(3):333-340
    • Van den Boom J; and Battin B. (2007).Chest radiographs after removal of chest drains in neonates: Clinical benefit or common practice? Archives of Disease in Childhood (Neonatal edition). 92:46-48

    Evidence Table

     

    Please remember to read the disclaimer

    The development of this clinical guideline was coordinated by Janine Evans, Rosella - PICU. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published February 2012, reviewed July 2013