HONG KONG RESPIRATORY MEDICINE

A website for HK Thoracic Society, ACCP HK & Macau Chapter

2009 Dec - Nursing Management of Chest Drains

Ms. Maggie Lit. APN, Department of Medicine, Queen Elizabeth Hospital. Dec 2009
Introduction


Chest drain can be used to drain abnormal collections of fluid or air from the pleural cavity. It is mostly used to treat pneumothorax and pleural effusions. Although chest drains have been used for over a century, there is surprisingly little research-based evidence. Most literature is largely anecdotal and often based on expert opinions or retrospective series. In the following discussion, a review of the current nursing care and management of chest drains would be made.

Types of chest drainage system
Several drainage systems are available and it is important that the nurse is aware of the function of each one. The most common employed one is the one-bottle system, but traditionally there are two- and three-bottle systems, which are now less commonly used. Instead some manufacturers have produced plastic multi-chamber units. Some knowledge on the design of such systems will enhance the understanding and management of such units.

One-bottle system
The simplest way to set up a single bottle with a tube submerged to a depth of 2cm under water which creates a water seal is illustrated in figure 1a. One tube leads out of the bottle through the plug at the top, allowing air to open into the atmosphere. However, excessive accumulation of fluid inside the bottle might impose resistance and hence the optimal functioning of the unit. The system can also be connected directly to the low regulator suction if negative pressure is required to improve drainage afterwards. (Figure 1b)



Two-bottle system
One form of this system involves separate drainage/collection and water seal units, with air from the pleural space conducted through the tubing that connects the two bottles and “bubbles” through the water seal bottle and exits to the atmosphere, as illustrated in figure 2a. By adding a bottle container before the water-seal bottle, rising resistance from excessive concomitant pleural fluid drainage can be avoided. Another form involves a water-seal bottle connected to a second suction-regulating bottle to gauze the pressure created via external suction (Figure 2b). However, the maximum negative pressure available is usually limited to 10-12 cm H2O due to the limited height of the water column in the commonly available bottles.
 



Three- bottle system
A three bottle system contains a collection chamber, an under water seal & a suction regulating device to maintain constant negative pressure as illustrated in figure 3. The level of fluid in the suction control bottle determines the amount of suction provided to promote drainage from the pleural space. As illustrated, the three bottle system is bulky and therefore hence is seldomly used. The commercially available plastic multi-chamber systems incorporate the three bottle system into one unit with three chambers as illustrated in figure 4
 


Nursing management
Once a chest drain is inserted, it is important for the nursing staff to ensure that the patient and the drain are closely monitored. However, wide variations of practice have been observed, which are based on local policies and individual preferences rather than evidence-based protocols (Avery 2000, Charnock and Evans 2001). The suggestions below have been compiled and highlighted from the literature.

1. Positioning
The patient should be placed in a semi-recumbent position with regular position changes in order to encourage drainage and prevent stiffening of the shoulder joints. These might enhance breathing and expectoration, as well as allowing full lung expansion and possibly preventing complications of prolonged immobilization.

2. Drain patency
Drainage can be impeded by excessive coiling, dependent loops, kinked or blocked tubes, and which potentially might lead to tension pneumothorax or surgical emphysema. The tubing should be lifted regularly to drain the fluid into the collection bottle if the coilings cannot be avoided. The effects of clamping, milking and striping of chest tubes are controversial and are usually not advised. Replacement of tubing is usually advised if blockage is detected. Lung damage from the sharp pressure changes generated during stripping of tubing might be resulted. Although clamping of drains are still observed and practiced in cases where there are no longer any air leakage and when replacement of tubing or bottle is necessary, this is not recommended in the major international guidelines.

3. Observation
Patient’s vital signs, respiratory rate, oxygen saturation as well as the presence of tidaling and bubbling in chest drainage system should be closely monitored. Any deterioration or distress of the patient should be reported to the doctors immediately.

4. Pain management
There are currently no definite guidelines on pain assessment and pain control with regard to chest
drainage. The pain could be substantial and might affect coughing, ventilation, sleep as well as re-expansion of the lung. Nurses should be aware of the potential need for prescribed on-demand pain killers or inform clinicians about the possible requirements.

5. Recording and observing drainage
The drainage system should be kept below the patient’s chest level to prevent fluid re-entering the pleural space. Volume, color, tidaling, bubbling of drainage fluid and level of suction pressure should be regularly evaluated and recorded on patient’s chest drain chart. The frequency of recording will vary depending on the condition of the patients and their underlying disease(s).

6. Drain security and wound management
Using of tape to secure connections has been controversial with no apparent clear recommandation. Some researchers advocated that taping the connections can avoid potential disconnection but others argued that taped tube may mask disconnections. The use of transparent, water-proof and secure tapings might be necessary in a busy and congested ward environment. The insertion site should be checked everyday to ensure that the wound is dry and clean, with no loosen sutures or visible side hole(s) of chest tube (i.e. slipping out). Presence of or increasing surgical emphysema, pus, or excessive bleeding around insertion sites should also be noted.

7. Potentially dangerous conditions that require urgent attention
 Large amount of bubbling in the water seal chamber, which might signify a large patient air leak or a leak in a system
 Sudden or unexpected cessation of bubbling, which may indicate a blockage in the tubing.
 Large amount of bloody discharge might indicate haemothorax or trauma to underlying organ(s)
 Increasing dyspnoea, increased heart rate, lowered blood pressure & low oxygen saturation: may signify recurrent pneumothorax (after drain removal) or insufficient drainage or tube blockage
 Absence of gentle bubbling in suction control bottle/ chamber may indicate disconnection of the suction pressure or inadequate suction force to counteract the large air leakage.

Conclusion
Nursing management of chest drains is important. A comprehensive understanding of the operations of the chest drain systems and areas requiring special attention would be important to reduce the complications arising from chest tube drainage.

References
1. Sullivan B. (2008). .Nursing management of patients with a chest drain. BMJ. 16, 6,.388-393
2. Charnock.. Y., Evans D. (2001) Nursing management of chest drains: a systemic review Australian Critical Care:14 (4), 156-160
3. Avery. S (2000). Insertion and management of chest drains. NTPlus. 96, 37, 3-6.
4. Gould. D., (1999) Patient’s experience of having an underwater seal chest drain: a replication study. Journal of Clinical Nursing: 8, 684-962.
5. Lehwaldt. D., (2007) The need for nurses to have in service education to provide the best care for clients with chest drains. Journal of Nursing Management: 15, 142-148.
6. Allibone. L., (2006). Assessment and management of patients with pleural effusions. Nursing Standard:20(22), 55-64