clinical protocol muhc -...

Care of neonatal and pediatric patients with a chest tube CPRC Approval Phase April 15th 2019 Revision date:

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CLINICAL PROTOCOL – MUHC

(PROTOCOLE CLINIQUE - CUSM)

Medication included No Medication included

MCH MGH RVH MNH MCI LACHINE

THIS IS NOT A MEDICAL ORDER

Title: Care of neonatal and pediatric patients with a chest tube

This document is attached to:

MUHC patient double identification policy

MUHC hand hygiene related to patient care policy

Clinical protocol: Selection of an antiseptic skin solution for skin preparation for intravascular access and site care in children Clinical protocol: Pediatric intra-facility transport Identification of clinical specimens and criteria for specimen acceptation and rejection

1. PURPOSE

The purpose of this protocol is to provide guidelines for the care of neonatal and pediatric patients with a chest tube (pigtail catheter or rigid tube thoracostomy). This clinical protocol does not provide guidelines for the care of open thoracic drainage systems such as a sump.

This protocol contains the following sections:

A. Preparing the chest tube drainage system

B. Assisting with a chest tube insertion

C. Care of patient with a chest tube drainage system

D. Dressing change

E. Specimen collection

F. Changing the drainage system

G. Assisting with administration of fibrinolytics (Alteplase™) via chest tube

H. Assisting with chest tube removal

2. PROFESSIONALS

Nurses working at the Montreal Children’s Hospital (MCH) who care for patients requiring a chest tube. Nurses are expected to review this protocol and be familiar with its recommendations.

3. PATIENT POPULATION


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Neonatal and pediatric patients cared for at the MCH who require a chest tube

4. ELEMENTS OF CLINICAL ACTIVITY

Professionals are responsible to know the limits and extent of their practice as related to the particular protocol.

Indications:

A chest tube is a flexible hollow drainage tube that is placed in the pleural space to drain air or excess fluid. A mediastinal chest tube is placed into the mediastinum to drain air or fluid (usually serosanguinous fluid following cardiac surgery).

Conditions requiring the insertion of a chest tube include:

Pneumothorax: a collection of air in the pleural space

Hemothorax: a collection of blood in the pleural space

Hemo-pneumo-thorax: a collection of blood and air in the pleural space

Pleural effusion: a collection of fluid (usually serous) in the pleural space

Chylothorax: a collection of lymphatic fluid (chyle) in the pleural space

Empyema: a collection of pus in the pleural space

Post cardiac surgery or chest trauma (mediastinal tube) to prevent cardiac tamponade

A. Preparing the chest tube drainage system

Equipment

Appropriately sized chest tube drainage system. There are two sizes available at the MCH:

Size of chest tube drainage system

Drainage capacity Specifications GRM number

Neonatal 150 mL No sampling port on tubing

3728

Pediatric 2500 mL Sampling port on tubing

34036

Suction manometer that can provide suction up to 160 mmHg

Suction canister

2 suction tubings

Tubing connector

Waterproof tape

Procedure

Note: The chest tube drainage system has 3 main components (see figure 1 ):

o Collection chamber: Collects air and/or fluid

o Water seal: The water seal acts as a one-way valve. It allows air and fluid to leave the pleural cavity, but not to return, thus maintaining negative pressure.


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o Suction control chamber: Suction control chamber controls the amount of suction that can be applied to the pleural cavity.

1. Open chest tube drainage system package and maintain sterility of soft tubing tip (yellow cap should remain in place).

2. Fill the water seal chamber through the suction outlet to the 2 cm level using the bottle of sterile water provided.

3. If need for suction anticipated, ensure manometer in place on wall suction outlet. Connect suction canister to manometer. Test to ensure set up is functional then turn off until required.

4. Attach suction tubing to suction canister (note that most patients will require two lengths of suction tubing joined with tubing connector, solidified with waterproof tape).

5. Attach remaining end of suction tubing to suction outlet on chest tube drainage system.

6. Proceed to next section (assisting with a chest tube insertion) prior to setting suction level or turning suction on.

Figure 1. Chest tube drainage system

**NOTE: In NICU, suction tubing should be attached DIRECTLY to the manometer. DO NOT USE SUCTION CANISTER. Blue manometers used in the NICU do not provide sufficient suction with the suction canister in place.


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B. Assisting with a chest tube insertion

Chest tube insertions outside the operating room are done in the critical care areas (PICU, NICU and ED), in the procedure room or in medical imaging. This description of the insertion procedure does not apply to chest tubes inserted in the operating room or in medical imaging.

Equipment

Chest tube insertion tray

Chest tube: There are two types of chest tubes used at the MCH:

o A rigid, large bore, straight tube (trocar catheter)

o A soft, small bore, flexible catheter with a tightly curled end (pigtail catheter).

Personal protective equipment (PPE): gown, mask

Sterile gloves for inserter

Non-sterile gloves for assistant

Prepared chest tube drainage system (see part A)

Local anesthetic as per physician order (eg. xylocaine 1% without epinephrine)

10 mL syringe

18 gauge needle

26 gauge needle

Sedation and analgesia as per physician order

Skin disinfection as per Clinical protocol: Selection of an antiseptic skin solution for skin preparation for intravascular site access and site care in children

2 non-toothed clamps

Waterproof tape

Fixation device such as a Grip Lok™ (optional)

Safety pins

Blue protective pad

2.0 silk sutures if inserting a trocar catheter

Disposable scalpel

Disinfectant wipes

Dressing supplies:

o For trocar catheter: dry 2 X 2 sterile gauze and adhesive dressing such as Hypafix™ or a transparent dressing

o For pigtail catheter: Drain-Fix™ fixation device or for smaller patients selected transparent dressing (such as Sorbaview™ or Tegaderm ™)

Note that pigtails are generally better tolerated, and associated with less discomfort and less use of analgesia once in place. However, if the condition of the patient requires drainage of viscous bodily fluid, a larger bore trocar catheter is required. The physician determines the type and size of the tube to be placed, depending on the size and condition of the patient, and the indication.


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Procedure

1. Verify patient identify as per MUHC patient identification policy.

2. Explain procedure to patient and family.

3. Ensure emergency suction and oxygen equipment are available and functional. Clean work surface with a disinfectant wipe and gather equipment.

4. Wash hands according to MUHC hand hygiene policy.

5. Undress patient and place blue protective pad under the side of thorax where the chest tube will be inserted.

6. Perform baseline respiratory assessment and place patient on cardiorespiratory monitor (if not already in place). See Table 1 for details of assessment, monitoring, and documentation during insertion and in the immediate post-procedure period.

7. Administer sedation and/or pain medication as ordered. Provide non-pharmacological pain control as appropriate throughout procedure (eg. non-nutritive sucking, sucrose and distraction)

8. Wash hands according to MUHC hand hygiene policy and don PPE

9. Position patient as per inserter: either sitting, in a lateral position or supine with arm up.

10. Once the chest tube is inserted, remove yellow cap of soft tubing on chest tube drainage system. Using no-touch technique (NTT), connect the adapter of the soft tubing to the chest tube. Note: If tube inserted is a pigtail catheter, the soft tubing must be cut with sterile scissors below the adapter to remove it as it will not fit on pigtail. A special luer-lock connector (provided in package with pigtail tube) must be attached to the pigtail catheter to enable connection to the soft tubing (See Figure 2). This blue adapter should be placed on the distal end of the pigtail catheter by the chest tube inserter while sterile.

11. Apply gauze and adhesive dressing to the insertion site using NTT

12. Secure chest tube to the chest wall with waterproof tape or fixation device such as a Grip Lok™ (See Figure 3).

Figure 3. Securement of pigtail catheter

Figure 2. Special luer-lock connector for pigtail (blue adapter)


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13. If suction is ordered, turn the suction control dial on the chest tube drainage system to the ordered pressure level. Turn the suction on via the manometer. Increase suction on manometer until the orange float appears in the suction indicator window. The position of the suction control dial determines the amount of suction regardless of how much suction is applied as long as the orange float appears in the indicator window.

14. Wrap connection between trocar catheter and soft tubing with waterproof tape. The waterproof tape is folded around the tubing to form a flag to which the safety pin can be attached.

15. Secure tubing to the bed linen using waterproof tape and safety pins.

16. A chest X-ray is usually requested to verify tube placement

Table 1. Assessment, Monitoring, and Documentation: At time of insertion and in the immediate post-procedure period

Assessment, monitoring, & documentation

Parameters Frequency Rationale

Respiratory assessment

Air entry, work of breathing

Prior to procedure as baseline

Q15 minutes for 1 hour after procedure

Then, if patient stable, see Table 2 for ongoing monitoring.

Subtle changes in respiratory status can be indicative of complications associated with chest tube insertion, including iatrogenic pneumothorax

Vital signs

(Note that patients should be on continuous cardiorespiratory monitoring for the procedure and for at least 1 hour after)

Respiratory rate

Oxygen saturation

Heart rate

Blood pressure

Pain score using age-appropriate validated scale

Sedation score

Temperature *



Then, if patient stable, see Table 2 for ongoing monitoring

*A baseline temperature should be obtained, but can be done as per unit protocol thereafter

Changes in vital signs can be indicative of complications associated with chest tube insertion, including uncontrolled pain, over-sedation from analgesic medications, and iatrogenic pneumothorax

Drainage Quantity

Notify MD/neonatal nurse practitioner (NNP) if:

Drainage is greater than 5 mL/kg in one hour


Then, if patient stable, see Table 2 for ongoing monitoring.

High levels of drainage occurring rapidly can lead to hemodynamic instability

Functioning of chest tube drainage system

Water seal Q15 minutes for 1 hour after procedure

Then, if patient stable, see

When a chest tube is inserted for a pneumothorax, bubbling in the water seal chamber is


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Table 2 for ongoing monitoring

expected. However, this bubbling should stop once the air has been drained from the pleural cavity. Thereafter, any bubbling in the water seal chamber is indicative of a continuous air leak (either from the system, at the insertion site, or from the lung itself).

Ensuring that the water seal is intact and that suction is functioning as ordered are key to avoiding complications and patient deterioration.

17. Additional documentation:

o Any interventions to control pain

o Initiation of suction and suction level

o Patient tolerance of procedure

o Dressing integrity

o Medications administered during the procedure

o Patient or family concerns

C. Care of patient with a chest tube drainage system

General Considerations

Two non-toothed clamps must remain with the patient at all times in case of accidental disconnection while the chest tube is in place

Clamping the chest tube requires a medical order except for when managing an accidental disconnection, assessing an air leak or changing the chest tube drainage system. For these interventions, the tube should be clamped as briefly as possible. Clamping a chest tube in the context of a pneumothorax can lead to a tension pneumothorax and patient deterioration.

All connections must be secured with waterproof tape.

The chest tube drainage system must remain below the level of the chest at all times. Tubing must not be draped over bedrail

The chest tube drainage system should be hung from bed. If unable to hang from bed, the swing out floor stand should be taped to the floor using waterproof tape to prevent disruption of the water seal by knocking it over.

Do not strip or milk the tubing as this creates excessive negative pressure and could damage lung tissue.

Suction or flushing of a chest tube is done by the physician only.

Administration of medication (Alteplase or talc) via chest tube is done by the physician only.

Patients with chest tubes requiring transport off the unit must be accompanied by a nurse. Refer to the Clinical protocol: Pediatric intra-facility transport.


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Procedure

Follow the assessment, monitoring, and documentation guidelines outlined in Table 2 below.

Table 2. Assessment, Monitoring & Documentation: For duration of time that chest tube remains in place




Air entry, work of breathing Q4H + PRN Subtle changes in respiratory status can be indicative of complications associated with chest tube(s), including air leak or blockage

Vital signs Respiratory rate

Oxygen saturation

Heart rate

Blood pressure

Temperature


Minimally

Q4H + PRN

Note: Frequency of vital sign monitoring is based on patient’s condition

Changes in vital signs can be indicative of complications associated with chest tube(s), including infection, air leak, blockage, and/or pain

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Insertion site & dressing integrity

Assess area around the insertion site for air infiltration (subcutaneous emphysema), redness, leakage, or swelling.

(For patients with a Drain-Fix™ fixation device in place, site will not be visible. In these patients, the site can be gently palpated to assess for subcutaneous emphysema and/or increasing pain).

Assess dressing for integrity

Q4H + PRN Complications at insertion site may occur and may require treatment

An intact dressing can protect against infection and displacement of the chest tube.


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Functioning of chest tube drainage system

Fluctuation of water seal. In older patients, fluctuation should occur with respiration in patent tubes. In younger patients, this fluctuation may not be visible.

Integrity of system (all connections taped, no kinks in tubing)

Suction control set as ordered, and orange float visible

Water seal (should remain at 2 cm, without bubbling unless patient known for air leak*)

Q1H + PRN Ensuring that the water seal is intact and that suction is functioning as ordered are key to avoiding complications and patient deterioration.

Drainage Quality of drainage (colour, type)

Quantity of drainage (hourly and accumulated since midnight)

Notify MD/NNP if:

Drainage is greater than 5 mL/kg in one hour

Drainage is greater than 3 mL/kg in 3 hours

There is a sudden increase or sudden decrease in the amount of drainage

Q1H + PRN Quality and quantity of drainage will dictate diagnosis and care.

High levels of drainage occurring rapidly can lead to hemodynamic instability

If drainage stops and patient shows signs of deterioration, this may be indicative of blockage.

Ongoing high levels of drainage may require replacement

*When a chest tube is inserted for a pneumothorax, bubbling in the water seal chamber is expected. However, this bubbling should stop once the air has been drained from the pleural cavity. Thereafter, any bubbling in the water seal chamber is indicative of a continuous air leak (either from the system, at the insertion site, or from the lung itself).

D. Dressing change

Change dressing only if soiled, loose or no longer occlusive. Routine dressing change is no longer recommended. For pigtail catheters, a second person with sterile gloves will be required to maintain the catheter in place while the dressing is removed as this type of tube is usually not sutured.

Equipment

Skin disinfectant swabs as per Clinical protocol: Selection of an antiseptic skin solution for skin preparation for intravascular site access and site care in children

Suture kit

Sterile gloves (2 pairs if pigtail catheter)


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Non-sterile gloves

Dressing supplies

o For trocar catheter: dry 2 X 2 sterile gauze and adhesive dressing such as Hypafix™ or a transparent dressing

o For pigtail catheter: Drain-Fix™ fixation device or for smaller patients, selected transparent dressing (such as Sorbaview™ or Tegaderm ™)

Disinfectant wipes

Procedure


2. Clean work surface with a disinfectant wipe and gather equipment.


4. Open suture kit. Open disinfectant swabs and new dressing material onto suture kit.

5. Don non-sterile gloves. (If pigtail catheter in place, a second person should don sterile gloves and be ready to hold catheter in place once dressing is removed).

6. Remove old dressing. Maintain any fixation device in place that is outside of the dressing area. Assess chest tube insertion site for signs of infection, presence of drainage or bleeding and intactness of sutures if applicable.

7. Wash hands and don sterile gloves.

8. Cleanse the skin using skin disinfectant swab. Cleanse skin using a circular motion around the tube starting at the insertion site.

9. Cleanse the first 5 cm of the tube with a skin disinfectant swab, starting where the tube exits the skin and moving away from the insertion site

10. Allow disinfectant to dry. Do not blow or fan to accelerate drying.

11. Apply new dressing.

12. Document in nursing notes:

o Procedure

o Assessment of insertion site and surrounding skin

o Patient’s tolerance of procedure

E. Specimen collection

For pediatric chest drainage unit:

Equipment

Sterile specimen container

Specimen label

Luer-lock syringe

2 % chlorhexidine gluconate/ 70% alcohol swab

Non-sterile gloves

Procedure


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1. Ensure some chest drainage has accumulated in soft tubing

2. Wash hands and don non-sterile gloves

3. Verify patient’s identity as per MUHC patient identification policy. Ensure concordance between the patient’s identification bracelet and the specimen label.


5. Prepare sampling equipment

6. Move drainage in soft tubing toward sampling port, ensuring none is lost into drainage unit

7. Clamp soft tubing with integrated plastic clamp, above drainage Swab needleless port with 2% chlorhexidine gluconate/ 70% alcohol swab for 15 seconds and allow to dry for 30 seconds.

8. Attach luer lock syringe directly onto needleless port and withdraw the required amount of fluid. Disconnect syringe and place aspirate into specimen container.

9. Unclamp soft tubing

10. Apply specimen label to specimen container at the bedside.

11. Dispose of equipment appropriately.

12. Send specimen to the lab.

For neonatal chest tube drainage system:

Note: The neonatal chest tube drainage system does not have a sampling port on the drainage tubing. According to the manufacturer, the drainage tubing is re-sealable therefore piercing the tubing with a small gauge needle will not result in loss of system integrity.

Equipment

Specimen container

Specimen label

Luer lock syringe

2 % chlorhexidine gluconate/ 70% alcohol swab

Non-sterile gloves

21 gauge needle

Procedure

1. Ensure some drainage has accumulated in soft tubing

2. Wash hands and don non-sterile gloves

3. Verify patient’s identity as per MUHC patient identification policy. Ensure concordance between the patient’s ID bracelet and the specimen label.


5. Assemble luer lock syringe and needle

6. Choose a sampling area where fluid is visible in the tubing. Swab sampling area with 2% chlorhexidine gluconate/ 70% alcohol swab (CHG/alcohol) for 15 seconds and allow to dry for 30 minute

7. Clamp soft tubing with integrated plastic clamp above drainage

8. Pierce soft tubing with needle at a shallow angle (less than 30 degrees) and withdraw the required amount


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9. Place aspirate into specimen container.

10. Apply specimen label to specimen container at the bedside.

11. Dispose of equipment appropriately.

12. Send specimen to the lab.

F. Changing the drainage system

Change the chest tube drainage system when nearly full, if the drainage system is cracked, or if level in the collection chamber is not easily identifiable (chest tube drainage system accidentally knocked over). The drainage system should also be changed in the context of an unresolved air leak (See troubleshooting section).

Note that this is a 2-person procedure in order to maintain sterility.

Equipment

Prepared pediatric or neonatal chest drainage system (see section A.)

2 non-toothed clamps

Non-sterile gloves

2% chlorhexidine gluconate/70% alcohol swab

Waterproof tape

Disinfectant wipe

Sterile scissors for patients with pigtail catheters

Procedure

If using a neonatal chest drainage system:


2. Clean work surface with a disinfectant wipe and gather supplies

3. Prepare chest tube drainage system as described in Part A.

4. Wash hands and don non-sterile gloves.

5. Double clamp chest tube using two non-toothed clamps.

6. Remove waterproof tape at the connection between the soft tubing and the patient’s chest tube

7. Disinfect outside of tubing at point of junction between the soft tubing and the patient’s chest tube with a 2% chlorhexidine/70% alcohol swab; and allow to dry.

8. Disconnect the chest tube drainage system from the chest tube, maintaining sterility of chest tube.

9. Have assistant remove yellow cap of soft tubing on new chest tube drainage system. Using a no-touch technique (NTT), connect the adapter of the soft tubing to the chest tube. Note: If chest tube inserted is a pigtail catheter, the soft tubing must be cut with sterile scissors below the adapter to remove it as it will not fit on pigtail.

10. If suction is ordered, ensure suction control dial set appropriately. Disconnect the suction tubing from the old chest tube drainage system and connect to the new chest tube drainage system. Ensure suction functional by checking for orange float in viewing window.

11. Remove clamps.

12. Tape new connection with waterproof tape.


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13. Note the total volume of drainage in old chest tube drainage system.

14. Dispose of equipment and wash hands.

a. Document:

In nursing progress notes:

o Change of chest tube drainage system


On intake/output sheet or nursing flowsheet:

o Volume of drainage in old chest tube drainage system

If using a pediatric chest drainage system:


2. Clean work surface with a disinfectant wipe and gather supplies

3. Prepare chest tube drainage system as described in Part A.

4. Wash hands and don non-sterile gloves.

5. Double clamp chest tube using two non-toothed clamps.

6. Disinfect junction between the red clip and blue connector with a 2% chlorhexidine/70% alcohol swab; and allow to dry.

7. Disconnect the chest tube drainage system at the red and blue junction maintaining sterility of red clip.

8. Have assistant disconnect the new chest tube drainage system at the red and blue junction; maintain sterility of blue connector and attach to existing red clip.

9. If suction is ordered, ensure suction control dial set appropriately. Disconnect the suction tubing from the old chest tube drainage system and connect to the new chest tube drainage system. Ensure suction functional by checking for orange float in viewing window.

10. Remove clamps.

11. Note the total volume of drainage in old chest tube drainage system.

12. Dispose of equipment and wash hands.

13. Document:

In nursing progress notes:

o Change of chest tube drainage system


On intake/output sheet or nursing flowsheet:

o Volume of drainage in old chest tube drainage system

Red and blue junction


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G. Assisting with administration of fibrinolytics (Alteplase) via chest tube

General considerations

Administration of fibrinolytics may be required for treatment of empyema or pleural effusion, or to unblock smaller gauge tubes that have become clogged with fibrin.

Instillation of fibrinolytics via chest tube is done by the physician only

Instillation of fibrinolytics may be painful/. Patients should be premedicated with analgesia for this procedure.

Procedure

1. The usual dose is 0.4 mL of Alteplase™1 mg/mL in 40 mL of saline, administered once every 24 hours, for 3 days.

2. A small gauge needle and syringe can be used to pierce the tubing to administer the Alteplase™. In some instances, the stopcock is left in place upon insertion of the pigtail catheter. If this is the case, the capped port can then be used to administer Alteplase™.

3. For each dose, the tube is clamped for 1 hour after instillation.

4. The patient is repositioned every 15 minutes during that hour (lateral then supine). The chest tube is then unclamped and suction is re-initiated if applicable. This is repeated every 24 hours for a total of 3 treatments. The above must be detailed in the physician orders, as for certain patients, the prescription may vary.

5. Monitor the patient’s respiratory status closely while the chest tube is clamped for signs of deterioration.

6. Monitor drainage closely – sudden drainage of large amounts of fluid or blood after treatment with Alteplase™ may lead to hemodynamic instability. Advise physician immediately.

H. Assisting with chest tube removal

Note: Removal of a chest tube is done by a surgeon, a critical care physician or a nurse practitioner (NP).

Equipment

Mask and gown

Sterile gloves

Skin disinfecting swabs as per Clinical protocol: Selection of an antiseptic skin solution for skin preparation for intravascular site access and site care in children

Suture kit

Analgesia as per physician order

Dressing supplies: Sterile 2 X 2 dry gauze and an adhesive dressing such as Hypafix™

Procedure

1. Verify patient identify as per MUHC patient identification policy.


3. Ensure emergency suction and oxygen equipment are available.


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4. Clean work surface with a disinfectant wipe and gather equipment.


6. Perform baseline respiratory assessment and place patient on cardiorespiratory monitor (if not already in place). See Table 3 below for details of assessment, monitoring, and documentation during removal and during the immediate post-procedure period.

7. Administer sedation and pain medication as ordered.

8. Wash hands and don PPE.

9. Position patient as per physician or Nurse Practitioner (NP)

10. The chest tube is removed either while the patient performs Valsalva maneuver, or if patient unable to follow instructions, during expiration

11. If removing a trocar catheter, the exit wound will be closed with a suture. For the pigtail catheter, surgical closure of the exit wound is not necessary.

13. Cleanse the skin using skin disinfectant swab. Begin at the insertion site and work outward using a circular motion.

12. Dress exit wound with sterile 2 X 2 dry gauze and an adhesive dressing such as Hypafix™. This dressing should be maintained in place for 48 hours post-removal. If at this point, the site remains open, it should be cleansed as above and a new dressing applied. If the site is dry, it may be left open to air. Sutures should be removed by inserting team once site healed.

13. A chest radiograph is usually requested post-removal.

Table 3. Assessment, Monitoring, and Documentation at time of Removal and During the Immediate Post-procedure Period




Air entry, work of breathing


Q 1 H for 4 hours post-removal

Then as per unit protocol

Subtle changes in respiratory status can be indicative of complications associated with chest tube removal, including iatrogenic pneumothorax

Vital signs

(Note that patients should be on continuous cardiorespiratory monitoring for the procedure and for at least 1 hour after)

Respiratory rate

Saturation

Heart rate

Blood pressure


Sedation score


Q 1 H for 4 hours post-removal

Changes in vital signs can be indicative of complications associated with chest tube insertion, including uncontrolled pain, over-sedation from analgesic medications, and iatrogenic pneumothorax

Insertion site & dressing integrity

Assess area around the insertion site for redness, leakage, or swelling.

Q 12 hours

Dressing should be removed after 2 days

Repeat dressing procedure after 2 days if site remains open or

Complications at old insertion site may occur and may require treatment


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oozing

Leave open to air after 2 days if site dry

Sutures should be removed by inserting team once site healed.

14. Additional documentation:


o Medications administered during the procedure

o Patient or family concerns

I. Troubleshooting

Accidental disconnection Immediately clamp the chest tube

Assess patient’s respiratory status and vital signs.

Decontaminate the tubing connections with 2 % chlorhexidine/70% alcohol swabs and reconnect the chest tube to the drainage system.

Unclamp the chest tube and re-tape connection using waterproof tape.

Advise the physician

Attempt to determine cause of the disconnection and intervene as required:

o Chest tube drainage tubing is heavy and pulling apart the connection.

o Patient is agitated

o Connector does not fit securely

Accidental removal Occlude chest tube insertion site with a gloved hand

Cover with sterile gauze and apply an adhesive dressing such as Hypafix™

Assess patient’s respiratory status and intervene as required

Advise physician immediately

Prepare for potential reinsertion of chest tube

Vigorous bubbling in water seal Continuous vigorous bubbling is indicative of an air leak. Gentle bubbling is normal if draining a pneumothorax.

An air leak can occur as a result of a loss of chest tube drainage system integrity, a leak at the site of insertion or a change within the chest cavity.

To determine the location of the air leak, briefly clamp the tubing close to the patient.


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o If vigorous bubbling persists, this indicates a loss of chest tube system integrity. Check all connections. Ensure the chest tube drainage system is not cracked. If needed, change the chest tube drainage system.

o If the vigorous bubbling stops when the tubing is clamped and resumes when unclamped, this indicates the leak may be at the insertion site. Assess dressing integrity. Inspect insertion site. Continuous bubbling may be caused tube malposition (drain partly out of the thorax) or a loose and no longer occlusive dressing.

If no apparent cause is identified or vigorous bubbling persists after the above interventions, advise physician.

If tube malposition is identified as the cause, advise physician immediately.

Sudden decrease in drainage Assess patient’s respiratory status and vital signs.

Examine the water seal for evidence of tidaling. If there is no movement of the fluid in the water seal chamber that coincides with the patient’s respirations, the tube may be blocked. Note that tidaling may not be visible for young patients.

Ensure there are no kinks in the tubing or the catheter.

Ensure tubing is not disconnected.

Examine the tubing for evidence of a clot.

Advise the physician

Water level rising in the small arm of the water seal

Depress the high negativity valve with caution, a black button on top of the drainage system to vent excessive negative pressure until the preset water level is reached. This should only be done if the chest drainage system is on suction. Depressing the high negativity relief valve when the chest drainage system is not on suction can result in a loss of negative pressure and could lead to the development of a pneumothorax

5. MAIN AUTHORS:

Eren Alexander, Nursing Coordinator

Elissa Remmer, NPDE NICU

6. CONSULTANTS:

Stephanie Mardakis, NPDE NICU

Stephanie Lepage, NPDE Surgery

Valerie-Ann Laforest, NPDE PICU


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Violaine Vastel, NPDE Emergency

Dr. Pramod Puliglanda, Pediatric General Surgery

Dr. Pierre-Luc Bernier, CVT Surgeon

7. APPROVAL PROCESS

Institutional and professional approval

Committees Date approved

[yyyy-mm-dd]

Clinical Practice Review Committee (CPRC) (if applicable)

Adult Pharmacy and Therapeutics (P&T) (if applicable)

Pediatric Medication Administration Policy (PMAP) (if applicable)

Pediatric Pharmacy and Therapeutics (Peds P&T) (if applicable)

Multidisciplinary Council (MDC) (if applicable)

8. REVIEW DATE

To be updated in maximum of 4 years or sooner if presence of new evidence or need for practice change.

9. REFERENCES

Alberta Health Services (2015). Chest tube insertion and removal-Pediatrics. Alberta Health Services Practice Support Document Protocol

Balfour-Lynn, I. M. et al. (2005) BTS guidelines for the management of pleural infection in children. Thorax, 60 (suppl I): i1-i21.

BC Children’s Hospital (2007). Chest tubes. BC Children’s Hospital Child & Youth Health Policy and Procedure Manual.

BC Children’s Hospital (2013). Protocol for the management of pleural effusions in previously healthy pediatric patients. BC Children’s Hospital Child & Youth Health Policy and Procedure Manual.

Crawford, D. (2011). Care and nursing management of a child with a chest drain. Nursing Children and Young People, 23 (10): 27-33.

Flynn Makic, M. B., Rauen, C., Jones, K., Fisk, A. C. (2015). Continuing to challenge practice to be evidence based. Critical Care Nurse, 35 (2): 39-50.

IWK (2016). Chest tube care and maintenance. Clinical Manual Policy and Procedure.

Jeffries, M., Flanagan, J., Davies, D., Knoll, S. (2017). Evidence to support the use of occlusive dry sterile dressings for chest tubes. MedSurg Nursing, 26 (3).

Kane, C. J., York, N. L., Minton, L. A. (2013). Chest tubes in the critically ill patient. Dimensions of Critical Care Nursing, 32 (3): 111-117.

MUHC Interprofessional Protocol (2017). Pleural and mediastinal tube: Care of the adult patient

Muzzy, A. C., Butler, A. K. (2015). Managing chest tubes: Air leaks and unplanned tube removal. American Nurse Today, 10 (5): 10-13


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