Chest Drain Management

By : Dr. M. Rezaei

Fellowship of Pediatric Pulmonology

UWSD

Also known as Under Water Sealed Drain (UWSD)

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.

underwater seal also prevents backflow of air or fluid into the pleural cavity.

Indications for Insertion of a Chest Drain

Post operatively e.g. cardiac surgery, thoracotomy

Pneumothorax

Haemothorax

Chylothorax

Pleural effusions

Start of shift checks:

Patient assessment

Vital signs In ICU:

Continuous monitoring

HR, SaO2, BP, RR

In 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

Start of shift checks:

Patient assessment

Pain

Start of shift checks:

Patient assessment

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)

Start of shift checks:

Patient assessment

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

Tubing should be anchored to the patients skin to prevent pulling of the drain

In ICUs 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

Start of shift checks:

Patient assessment

Drainage:

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

notify medical staff if there is a sudden increase in amount of drainage

notify medical staff if a drain with ongoing loss suddenly stops draining (Blocked drains are a major concern for cardiac surgical patients due to the risk of cardiac tamponade)

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.

Start of shift checks:

Patient assessment

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.

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

Removal of Chest Drains

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

Removal of Chest Drains Procedure

Perform hand hygiene

Opening dressing pack and add sterile equipment and 0.9% saline

Remove all dressings around the area

Clamp drain tubing

If there are multiple drains insitu, clamp all drains before removal. Once the required drains are removed, unclamp remaining drains

Clean around catheter insertion site and 1-2cm of the tubing with 0.9% Saline

Remove suture securing drain

Instruct patient exhale and hold if they are old enough to cooperate; if not, time removal with exhalation as best as possible.

If there is no purse string present remove drain and quickly seal hole with occlusive dressing

Removal of Chest Drains

CXR should be performed post drain removal

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

Dressing to remain insitu for 24 hours post removal unless dirty

Complications post drain removal include pneumothorax, bleeding and infection of the drain site

Complications and Troubleshooting

Pneumothorax

Signs and symptoms include: Decreased SaO2, increased WOB, diminished breath sounds, decreased chest movement, complaints of chest pain, tachycardia or bradycardia, hypotension

Notify medical staff

Request urgent CXR

Ensure drain system is intact with no leaks, or blockages such as kinks or clamps

Prepare for insertion/ repositioning of chest drain

Complications and Troubleshooting

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

Complications and Troubleshooting

Infection of insertion site

Notify medical staff

Swab wound site

Consider blood cultures

Complications and Troubleshooting

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.

Prevent air & fluid from returning to the pleural space

Most basic concept

Straw attached to chest tube from patient is placed under 2cm of fluid (water seal)

Just like a straw in a drink, air can push through the straw, but air can’t be drawn back up the straw

Tube open to atmosphere vents air

Tube from patient

Prevent air & fluid from returning to the pleural space

This system works if only air is leaving the chest

If fluid is draining, it will add to the fluid in the water seal, and increase the depth

As the depth increases, it becomes harder for the air to push through a higher level of water, and could result in air staying in the chest

UWSD

For drainage, a second bottle was added

The first bottle collects the drainage

The second bottle is the water seal

With an extra bottle for drainage, the water seal will then remain at 2cm

Tube from patient

Tube open to atmosphere vents air

Fluid drainage

2cm fluid

UWSD

The two-bottle system is the key for chest drainage

A place for drainage to collect

A one-way valve that prevents air or fluid from returning to the chest

UWSD

Many years ago, it was believed that suction was always required to pull air and fluid out of the pleural space and pull the lung up against the parietal pleura

However, recent research has shown that suction may actually prolong air leaks from the lung by pulling air through the opening that would otherwise close on its own

If suction is required, a third bottle is added

UWSD

2cm fluid water seal

Collection bottle

Suction control

Tube from patient

Fluid drainage

Tube open to atmosphere vents air

Straw under 20 cmH2O

Tube to vacuum source

UWSD

The straw submerged in the suction control bottle (typically to 20cmH2O) limits the amount of negative pressure that can be applied to the pleural space – in this case -20cmH2O

The submerged straw is open at the top

As the vacuum source is increased, once bubbling begins in this bottle, it means atmospheric pressure is being drawn in to limit the suction level

UWSD

The depth of the water in the suction bottle determines the amount of negative pressure that can be transmitted to the chest, NOT the reading on the vacuum regulator

From bottles to a box

The bottle system worked, but it was bulky at the bedside and with 16 pieces and 17 connections, it was difficult to set up correctly while maintaining sterility of all of the parts

In 1967, a one-piece, disposable plastic box was introduced

The box did everything the bottles did – and more

From bottles to a box

Collection chamber

Water seal chamber

Suction control chamber

from patient

Suction control bottle

Water seal bottle

Collection bottle

From patient

To suction

From box to bedside

At the bedside

Keep drain below the chest for gravity drainage

This will cause a pressure gradient with relatively higher pressure in the chest

Fluid, like air, moves from an area of higher pressure to an area of lower pressure

Same principle as raising an IV bottle to increase flow rate

Setting up the drain

Follow the manufacturer’s instructions for adding water to the 2cm level in the water seal chamber, and to the 20cm level in the suction control chamber (unless a different level is ordered)

Connect 6' patient tube to thoracic catheter

Connect the drain to vacuum, and slowly increase vacuum until gentle bubbling appears in the suction control chamber

Setting up suction

You don’t need to boil spaghetti!

Vigorous bubbling is loud and disturbing to most patients

Will also cause rapid evaporation in the chamber, which will lower suction level

Too much bubbling is not needed clinically in 98% of patients – more is not better

If too much, turn down vacuum source until bubbles go away, then slowly increase until they reappear, then stop