Managing chest drainage system

3-way Bottle System

SINGLE-BOTTLE WATER SEAL SYSTEM

Allows air and fluid to drain from the pleural cavity by gravity via glass rod which extends approx.23 cm below the surface of the water with in the collection bottle.

(1) Connecting or drainage tubing joins the patient's chest tube with a drainage tube (glass rod) that enters the drainage bottle. (2) The end of the glass rod is submerged in water, extending about 2.5 cm (1 inch) below the water level. (3) The water seal permits drainage of air and fluid from the pleural space but does not allow air to reenter the chest. (4) Drainage depends upon gravity, the mechanics of respiration, and, if ordered, the addition of controlled suction. (5) The second tube in the drainage bottle is a vent for the escape of any air drained from the lung. If suction is ordered, it is attached here. (6) Bubbling at the end of the drainage tube may or may not be visible. Bubbling may mean persistent air leaking from the lung or a leak in the system. (7) The water level in the bottle fluctuates as the patient breathes. It rises when the patient inhales and lowers when the patient exhales. (8) Since fluid drains into this bottle, be certain to mark the water level prior to opening the system to the patient. This will allow correct measurement of patient drainage.

TWO BOTTLE WATER SEAL SYSTEM

When the water seal chamber is filled with sterile fluid up to the 2 cm line, a 2 cm water seal is established. To maintain an effective seal, it is important to keep the chest drainage unit upright at all times and to monitor the water level in the water seal to check for evaporation.

The working principle of the 2-bottle system is the same as the 1-bottle system except a trap bottle is interposed between the drain tube and the underwater-seal bottle. In both the 1-bottle and the 2-bottle system, the vent tube may be connected to a highvolume/low-pressure suction system (e.g., the Vernon-Thompson pump) set at a level of -10 to -20 cm H2O. A low-volume pump (e.g., the Roberts pump) is inappropriate.

 Bubbling in the water seal chamber indicates an air leak. The patient air leak meter indicates the approximate degree of air leak from the chest cavity. If there is no air leak, the water level should rise and fall with the patients respirations, reflecting normal pressure changes in the pleural cavity. During spontaneous respirations, the water level should rise during inhalation and fall during exhalation.

 (1) The two-bottle system consists of the same water-seal bottle plus a fluid collection bottle. (2) Pleural fluid accumulates in the collection bottle, and not in the water-seal bottle (as in the single-bottle system). (3) Drainage depends upon gravity or the amount of suction added to the system. (4) When suction is added, it is connected at the vent tube in the water-seal bottle.

THREE- BOTTLE WATER SEAL SYSTEM

 In a 3-bottle system a third bottle, called the manometer bottle, is added after the underwater-seal bottle. This manometer bottle has a vent tube under water to regulate the negative pressure generated by suction. The maximum negative pressure (in cm H2O) generated by suction equals to the distance (in cm) this vent tube is below the water line.

 (1) This system consists of the water-seal bottle, the fluid collection bottle, and a third bottle which controls the amount of suction applied. (2) The third bottle, called the manometer bottle, has three tubes. One short tube above the water level comes from the water-seal bottle. A second short tube leads to the suction. The third tube extends below the water level and opens to the atmosphere outside the bottle. It is this tube that regulates the suction, depending upon the depth the tube is submerged. It is normally submerged 20 cm (7.6 inches). (3) The suction pressure causes outside air to be sucked into the system through the tube, creating a constant pressure. Bubbling in the manometer bottle indicates the system is functioning properly.

 Note: its the height of water, not the setting of the suction source, that actually limits the amount of suction transmitted to the pleural cavity. A suction pressure of 20 cm H2O is commonly recommended. Lower levels may be indicated for infants and for patients with friable lung tissue, or if ordered by the physician.

 Excessive source suction not only causes loud bubbling (which can disturb patients and caregivers), but also hastens evaporation of water from the suction control chamber. This results in a lower amount of suction applied to the patient as the level of water decreases. Selfsealing diaphragms are provided to adjust the water level in this chamber.
>If there has been no bubbling in the
water seal, you can deduce there is no air leak from the lung. Therefore, the tube may be clamped for the short time it takes to reestablish drainage

 You should never clamp a chest tube during patient transport unless the chest drainage system becomes disrupted during patient movement, and then only if there is no air leak.

Procedure
The area is prepared and draped appropriately An incision is made along the upper border of the rib below the intercostal space to be used. The drain track will be directed over the top of the lower rib to avoid the intercostal vessels lying below each rib. >Using a curved clamp the track is developed by blunt dissection only. The clamp is inserted into muscle tissue and spread to split the fibres. The track is developed with the operator's finger. Once the track comes onto the rib, the clamp is angled just over the rib anddissection continued until the pleural is entered.

 A finger is inserted into the pleural cavity and the area explored for pleural adhesions. At this time the lung, diaphragm and heart may be felt, depending on position of the track. A large-bore (32 or 36F) chest tube is mounted on the clamp and passed along the track into the pleural cavity.

 The tube is connected to an underwater seal and sutured / secured in place. If desired, a U-stitch is placed for subsequent drain removal (see below). The chest is re-examined to confirm effect. A chest X-ray is taken to confirm placement & position.

Position
For blunt trauma patients lying supine, drains should be placed anteriorly in the chest. This pevents a tension pneumothorax developing if the chest tube is blocked by dependent lung tissue. Normal movement of the lungs will allow drainage of a basal haemothorax through an anterior chest tube.

Underwater Seal
An underwater seal is used to allow air to escape through the drain but not to reenter the thoracic cavity. The drainage bottle should always be kept below the level of the patient, otherwise its contents will siphon back into the chest cavity.

 Persistent bubbling of air through the water indicates an air leak from the lung. Chest tubes should NEVER be clamped for any reason, to avoid the development of a tension pneumothorax The air outlet of the underwater seal may be connected to moderate suction (-20cm water) to assist in lung re-expansion. This is more important in the presence of an air leak.

Care of the Patient with Chest Tube

Pre Insertion I. Assessment Assess patient's breath sounds, heart rate, blood pressure, temperature, respiratory rate and rhythm and O2 saturation. Assess patient allergies. Assure O2 and suction are available at bedside.

II. Intervention Instruct the patient regarding the purpose of the procedure, what to expect, and signs and symptoms to report. Administer ordered analgesia as needed.

Post Insertion, Maintenance and Post removal: I. Assessment Immediately after insertion: A. insertion site, location and tube size Immediately after insertion and q 4 hours while chest tube is in place assess drainage collection system for:
A. fluctuations in the air leak indicator B. air bubbles in the air leak indicator C. suction set at ordered level

 Immediately after insertion, q 4 hours while chest tube is in place, and immediately after removal of chest tube assess: A. comfort level B. breath sounds, heart rate, blood pressure, temperature, respiratory rate and rhythm and O saturation

C. drainage for amount, color and consistency D. dressing for occlusiveness and drainage from insertion site E. chest wall at insertion site for subcutaneous emphysema

II. Interventions
Assure chest x-ray is obtained after insertion and after removal Verify patient knows potential complications (dyspnea, hemoptysis, etc.) and what to do should they occur Position the drainage system in upright position, below level of the heart at all times

 Place emergency equipment in patient's room (bottle of sterile NS, 4 x 4, Vaseline gauze, tape & non-toothed padded clamps) Assure that extra drainage collection system is readily available on the unit Reposition patient q 2 hours

 Change dressing q4, or more frequently, if it becomes soiled, saturated, loose, or as otherwise instructed by prescribed. Never clamp a chest tube, except momentarily, when: A. changing the chest tube system B. assessing for location of air leak C. assessing patient's tolerance of chest tube removal

Care of patients with chest tubes / monitoring

a. Assess patient for respiratory distress and chest pain, breath sounds over affected lung area, and stable vital signs b. Observe for increase respiratory distress

c. Observe the following: (1) Chest tube dressing, ensure tubing is patent (2) tubing kinks, dependent loops or clots (3) Chest drainage system, which should be upright and below level of tube insertion

 d. Provide two shodded hemostats for each chest tube, attached to top of patients bed with adhesive tape. Chest tubes are only clamped under specific circumstances: (1) To assess air leak (2) To quickly empty or change collection bottle or chamber; performed by soldier medic who has received training in procedure

 (3) To change disposable systems; have new system ready to be connected before clamping tube so that transfer can be rapid and drainage system reestablished (4) To change a broken water-seal bottle in the event that no sterile solution container is available

 (5) To assess if patient is ready to have chest tube removed (which is done by physicians order); the solider medic must monitor patient for recreation of pneumothorax E. Position the patient to permit optimal drainage (1) Semi-Flowers position to evacuate air (pneumothorax) (2) High Flowers position to drain fluid (hemothorax)

F. Maintain tube connection between chest and drainage tubes intact and taped (1) Water-seal vent must be without occlusion (2) Suction-control chamber vent must be without occlusion when suction is used G.Coil excess tubing on mattress next to patient. Secure with rubber band and safety pin or systems clamp

 H. Adjust tubing to hang in straight line from top of mattress to drainage chamber. If chest tube is draining fluid, indicate time (e.g., 0900) that drainage was begun on drainage bottles adhesive tape or on write-on surface of disposable commercial system (1) Strip or milk chest tube only per MD/PA orders only (2) Follow local policy for this procedure

Management Actions
1. If using a chest drainage system with water seal, fill the water seal chamber with sterile water to the level specified by the manufacturer.

2. When using suction in chest drainage system with water seal, fill the suction control chamber with sterile water to the 20-cm level or as prescribed. In systems without water seal, set the regulator dial at appropriate suction level.

3. Attach the drainage catheter exiting the thoracic cavity to the tubing coming from the collection chamber. Tape securely with adhesive tape.

4. If suction is used, connect the suction control chamber tubing to the suction unit. If using a wet suction system, turn on the suction unit and increase pressure until slow but steady bubbling appears in the suction control chamber. If using chest drainage system with dry suction control chamber, turn the regulator dial to 20 cm h2o.

5. Mark the drainage from the collection chamber with tape on the outside of drainage unit. Mark hourly/daily increments (date and time) at the drainage level.

6. Ensure that the drainage tubing does not kink, loop, or interfere with patients movements.

7. Encourage patient to assume a comfortable position with good body alignment. With the lateral position, make sure that the patients body does not compress the tubing. The patient should be turned and positioned every 15 to 2 hours. Provide adequate analgesia.

8. Assist the patient with range-of-motion exercises for affected arm and shoulder several times daily. Provide adequate analgesia.

9. Gently milk the tubing in the direction of the drainage chamber as needed.

10. Make sure that there is fluctuation or tidaling of the fluid level in the water seal chamber (in wet systems), or check the air leak indicator for leaks (in dry system with one way valve). note: fluid fluctuations in the water seal chamber or air leak indicator area will stop when: 1. The lung has re-expanded 2. The tubing is obstructed by blood clots, fibrin, or kinks 3. A loop of tubing hangs below the rest of the tubing 4. Suction motor or wall suction is not working properly

11. With a dry system, assess for the presence of the indicator (bellows or float device) when setting the regulator dial to the desired level of suction.

12. Observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by air leak indicator in dry systems with a one way bottle valve. Also assess the chest tube system for correctable external leaks. Notify the physician immediately of excessive bubbling in water seal chamber not due to external leaks.

13. When turning down the dry suction, depress the manual high-negativity vent, and assess for a rise in the water level of the water seal chamber

14. Observe and immediately report rapid and shallow breathing, cyanosis, pressure in the chest, subcutaneous emphysema, symptoms of hemorrhage, or significant changes in the vital signs

15. Encourage the patient to breathe deeply and cough at frequent intervals. Provide adequate analgesia. If needed, request an order for patient-controlled analgesia. Also teach the patient on how to perform incentive spirometry.

16. If the patient lying on the stretcher and must be transported to another area, place the drainage system below the chest level. If the tubing disconnects, cut off the contaminated tips of the tube and tubing, insert a sterile connector in to the cut ends, and reattach to the drainage system. Do not clump the chest tube during transport.

17. When assisting in the chest tubes removal, instruct the patient to perform a valsalva maneuver or to breathe quietly. The chest tube is then clumped and quickly removed. Simultaneously, a small bandage is applied and made airtight with petrolatum gauze covered by 4x4-inch pad and thoroughly covered and sealed with nonporous tape.

Chest drainage management

1. 2. Verify that all connection tubes are patent and connected securely Assess that the water seal is intact when using a wet suction system and assess the regulator dial in dry suction systems. Monitor the characteristics of drainage including color, amount, and consistency. Assess the significant increases or decreases in drainage output. Note fluctuations in the water seal chamber for wet suction systems and the air leak indicator for dry suction systems Keep system below the patients chest level

3.

4.

5.

6. Assess suction control chamber for bubbling in wet suction system 7. Keep suction at prescribed level 8. Maintain appropriate fluid in water seal for wet suction systems 9. Keep air vent open when suction is off.

Problems solving with chest tubes

How should a patient be managed after insertion of a chest drain?

All connections should be secured with adhesive tapes to prevent inadvertent disconnection. A chest x-ray should be obtained after insertion of a chest drain to ascertain its position. Ideally the tip of the drain should point toward the apex of the pleural space when draining air from a pneumothorax and toward the base when draining liquid contents from the pleural space. Previous concern of a drain lodged in a pulmonary fissure is unfounded. Patient should be managed in a ward with nursing staff familiar with management of chest drains.

 Regular assessment of the amount of bubbling (when it is gas) and drainage (when it is liquid) should be made. There have been reports of re-expansion pulmonary edema after rapid drainage of large pleural effusion, which can be fatal. Early signs of re-expansion pulmonary edema include onset of cough and shortness of breath. It is suggested that no more than 1 liter of effusion fluid should be drained at any one time or continuous drainage should be limited to about half a liter per hour

What are the criteria for chest drain removal?

The criteria for chest drain removal vary according to the reason why the chest drain was inserted in the first place: No air leak in the last 24 hours in pneumothorax. No fresh bleeding in the last 24 hours in hemothorax. Fluid loss is < 200 ml/day in effusion. Clinical and radiological evidence of resolution of the infection in empyema.

How to remove chest drain safely?

Always have an assistant skillful in tying surgical knots present. Prepare and drape the insertion site and follow aseptic technique. Put a purse string suture around the drain tube if it has not been done during insertion. Infiltrate the area with local anesthetic only if you have to put in the suture. Otherwise drain removal itself does not require local anesthesia.

 Unwound and cut the suture holding the drain to the skin. Have your gloved assistant form a knot with the purse string suture without pulling it tight. Ask the patient to take a deep breath and perform a mild Valsalva maneuver. Pull the drain tube out in one quick motion while the patient is still holding his breath. Your assistant should pull the purse string knot tight as soon as the tube is out.

 Cover the site with an occlusive dressing. Continue to observe the patient and order a chest x-ray in 4 to 6 hours. Any deterioration in the patients condition in the meantime demands immediate assessment and possible re-insertion of the chest drain.

Removal of chest tube