Nursing management of patientswitli a ciiest drain

Ben Sullivan

AbstractChest drains incorporate the use ofa one-way valve to drain fluidor air from the pleural cavity. The valve prevents back-flow of airand fluid into the pleural cavity. They are indicated for use whencollections of fluid or air are present in the pleural space, and bydraining the collection they restore eÖScient gaseous exchange. Littlehas heen written on the nursing managetnent of chest drains andthe literature highlights a lack of national standardized guidelines fordue to the range of thoracic conditions encountered hy clinical staff.Themes such as pain management and mechanism of breathing occurfrequently; however, there is a lack of up-to-date literature for thenurse to refer to. This article examines the nursing role in chest drainmanagement from insertion to removal and includes aspects of painmanagement and features of a functioning chest drain.

Key words: Chest drain • Critical care • Pleural cavity • Ttiorax

Chest drains are one-way drains aUowing fluid orair to be drained from the pleural cavity. They areindicated for use when there is X-ray confirmationof fluid or air in the pleural cavity.They may also be

inserted post cardio-thoracic surgery (Dougherty and Lister,2004). Indications for inserting a chest dtain can be seen inTable /.The insertion ofthe drain will aid the re-expansionofthe lung by allowing the drainage ofthe collection of fluidor air. This re-expansion will alleviate the breathlessness ofthe compromised patient by allowing for more efficient gasexchange through increased inspired tidal volumes, resultingin increased alveolar ventilation (Gallon, 1998; Laws et al,2003; Sheppard and Wright, 2006).

The conditions indicated for chest drain insertion willcause the patient to suffer from breathing difficulty andbreathlessness. This results from increased intrathoracicpressure and decreased alveolar ventilation due to decreasedinspired volumes (Thorn, 2006). Chest drains are routinelyinserted post-thoracic and cardiac surgery, where there hasbeen lung injury through surgical procedures. As a result,fluid and air collect in the thorax and needs draining (Hydeet al, 1997; Kumar and Clarke, 2002;Tooley, 2002). Patientswith chest drains can be found hospital-wide; however.

Ben Sullivan is a Staff Nurse at Guy's Main Theatres. Guy's andSt Thomas' NHS Foundarion Trust, London

Accepted for publication: February 2008

they are predominantly found in critical care wards andcardiothoracic units.

The focus of this article is to look at the rationale for chestdrain insertion and the nursing role within the multidisciplinaryteam. It includes preparing the patient, assessment ofthe drain,pain management, and safety considerations for the parient witha chest drain. Relevant supporting literature was sourced usingthe Cuniularive Index for Nursing and Allied Health CareLiterature (CINAHL). the British Nursing Index. Medlineand the Cochrane Database.The search terms used were:'chestdrains', 'pleural cavity', 'nursing management' and 'guidelines'.The search initially covered the years 200O-2007; however, thisonly yielded 15 papers, thus to increase the number of arriciesthe date range was extended to cover from 1995.

Mechanism of breathingWhen breathing, the diaphragm descends and contracts, whilethe lower ribs move upwards and outwards, and the upperribs and sternum move upwards and forwards. This createsincreased intrathoracic volume and negative intrapulmonaryand intrapleural pressure, drawing outside air into the lungs{Figure 1). Expirarion is a passive procedure whereby themuscles relax expelling air from the lungs (Marieb, 2004).This process allows oxygénation of haemoglobin in thered blood cells via diffijsion across the alveolar membraneand expulsion of carbon dioxide. When trauma to the limgoccurs and intrathoracic pressure is increased, lung expansionbecomes compromised and gas exchange cannot take placeefficiently. This results in under perfusion of tissues, leadingto breathlessness, as the person tires witli the increased effortof breathing (Adam and Osbourne, 2003).

Table 1. Indications for drain insertion

Indication Definition

Pneumothorax

Pleura effusion

Hdemothorax

Empyema

Chylothoriix

Routinely post-cardio-

thoracic surgery

Air in the pieural space

Coiiection of fluid in the pleurai space

Coliection of biood in the pleurai

space

Infected fluid-pus in the pleura! space

Qiyle-iymphatic fluid in the pleuraispace

Trauma caused during surgery causescoiiections of fluid and air in tiiepieurai space whilch needs draining

From: Allibone {2003): Uws et al (2003)

388 British Journal of Nursing, 2lX)8.Vol 17. No 6

CRITICAL CARE

Inhalation ExhalationCompromised inhalation

with lung trauma

Intercostalmuscles

Diaphragm

Air flows into lungs due toincreased lung volume followingcontraction of diaphragm and

intercostal muscles

Air expelled from lungs due torelaxation of diaphragm and

intercostal muscles

When trauma to the lungoccurs, and intrathoracic pressure isincreased, lung expansion becomes

compromised

Figure i. Normat

breaftting vs pteurat

pathology.

Types of chest drainChest drains function by allowing drainage from the pleuralcavity during expiration, when there is positive pressurewithin the pleura. The fluid or air within the cavity drainsinto the collection chamber (this can be water-sealed orincorporate the use ofa one-way flutter valve). Some ofthedifferent types of drain available can be seen in Figures 2 and .Î.Drains incorporating a 3-bottle system (compartmentahzed)can be found across the NHS, as can the Heimlich device,which utihzes a rubber one-way flutter valve connectedto a standard bottle. This allows the patient more freedomas it does not need to be kept upright like water-sealeddrains. They are, however, bulky and management of fluiddrainage is difficult as the efferent port must be kept opento air (Graham et al, 1992). Water-sealed drains and flutter

valves prevent air being sucked back into the pleural cavityduring inspiration (McMahon-Parkes, 1997; Ailibone, 2005;Sheppard and Wright, 2006), while allowing air and fluidto bubble into the external environment. The drain tubingshould be no more than 3 cm underwater; if greater thanthis, there is an increased resistance to air drainage, and as aconsequence pneumothoracies will not resolve (Laws et al,2003).Therefore, bottles should be changed if there is profusedrainage. It is, however, safe to leave bottles unchanged for6 days if drainage is minimal (Hornick et al, 1992).

Although chest drains are inserted by doctors, it is thenurse who has responsibility for the day-to-day monitoringand management {Ailibone, 2003). There is a varyingstandard of chest drain management throughout the NHS,which is largely the result of a lack of evidence-based

Figure 2. Ftutter-vatve drains are designed for the tonger-ierm management of drainage, altowing the patient to go home and mobiUze with relative ease.Tfte drains use aflutter faire to preveni air being drawn hack into ttte pteural cavity.

British Journal ot" Nursing, 2008.Voi 17. No 6 389

Figure 3. An underwater sealed drain (Rocket Medical, Hertfordshire). This

type of drain uses an underwater seal to prevent air being drawn back into

the pleural cuvity.

guidelines (Charnock and Evans, 20fll; Parkin, 2002). Thediscrepancies include the use of suction to aid removal of airand fluid; the prescription and administration of prophylacticantibiotics to prevent infection; and the positioning ofthe patient. There is also no standard for the removal ofdrains when inserted to resolve a pneumothorax. Somewill he removed on cessation of bubbling, while others, mspecialties such as cardiothoracic surgery, will allow a longerindwelling after bubbling has ceased. Although none ofthese choices have been shown to have adverse effects, thelack of standardized guidelines seems to stem from the rangeof thoracic conditions encountered by clinical staff, ratherthan evidence-based practice (Tang et al, 1999).

Nursing roleThe nursing role is initiated when the decision is made toinsert a chest drain in the ward environment, as opposed topost-surgery. The nune has a role in the positioning of theparient for the procedure - this is vital for the safety andcomfort of the patient throughout (Lazzara, 2002). Althoughthere is no 'one method' decided for positioning of the parient(McMahon-Parkes, 1997; Casson and Johnston, 1999; Lazzara,2(K)2; Laws et al, 2(K)3), doctor preference seems to be the mainfactor determining patient position, thus the nurse must beadaptable (Lehwaldt andTinimins, 2005).The positions whichare advocated, and which the nurse should be aware of, are thepatient being in an upright position, as tliis aids lung expansion{Horsington, 1984; Lazzara, 2002). However, there is limitedevidence to suggest that other posirions are unsuitable. Theguidelines produced by die liritish Thoracic Society (BTS),suggest drains should be inserted on the bed, with the patient'sarm on the side where the drain is to be inserted placed behindtheir head, so as to expose the axilla (Laws et al, 2003).

ft is important for the nurse to reassure the patient duringthe procedure and monitor them for signs of discomfort

and reliiy this to the medical staff, who can administer moreanalgesia if required.

Drain positionThe position of the drain will be influenced by the reason fordrain insertion. If air in the pleural space is indicated, then thedrain tip will be positioned apical and anterior to the chestcavity, as air will rise within the pleural space (Avery, 2000).However, if it is indicated that fluid collection is the reasonfor drain insertion, then this will migrate to the base of thelungs, and thus the drain rip will be positioned posterior andbasal to the chest cavity (Graham, 1996). (F(çwre 4 shows achest drain in silu.)

Although the nurse is not inserting the chest drain, it isimportant to know why the drain has been inserted, what itis draining and where the drain tip is, as this will influence thecare the patient receives with regard to positioning. 13oth fluidand air will migrate within the chest cavity, and thus if theyare away from the rip of the drain, the drain will be inefîecriveand the problem will not resolve as promptly as desired. Itis also an important considerarion when positioning theparient that the drain tubing does not become occludedby kinking, as this will impede the drainage capacity. If thisis left unresolved, it can cause raised intrathoracic pressure,compounding breathlessness and the original condition forwhich the drain was inserted, and may lead to a tensionpneumothorax (Munnel, 1997).

CompllcAtlons of chest drain insertionAlthough chest drain insertion is carried out by the doctor,there are complications the nurse needs to be aware of.It is important that the reason for insertion is clear as anincorrectly placed drain will not resolve the problem (Tanget al, 1999). It is also possible for a tension pneumothorax tooccur fr om incorrectly placed drains - where air enters thepleural cavity during inspirarion but cannot escape duringexpiration. The increased pressure causes compression of thesofi: lung tissue (Thorn, 2006).

As the drain is inserted bhndly it is also possible to causedamage to internal structures such as diaphragm, liver,aorta and the lung tissue itself (AlUbone, 2003). As withall procedures which penetrate the skin there is a risk ofinfection. However, by following aseptic technique this riskis reduced and there is no evidence to suggest prophylacticantibiotics are beneficial, unless the patient has presented witha penetraring chest injury (Nichols et al. 1994). With thechest drain in situ there are potenrialiy emergency situationswhich may occur. The drain may become detached from thebottle - if this occurs clamp the drain tube to the patient andre-establish the connecrion to a new drainage bottle. Informthe medical team. If the drain is pulled out of the pleuralspace accidentally, the purse string suture should be tiedimmediately to prevent air entering the pleural cavity. A fullset of cardiovascular observarions should be carried out andthe medical team should be contacted (Allibone, 2003).

Infection control In chest drain managenentInfection stemming fix)m the chest drain poses a potenrialproblem.Tbe drain should be inserted using aseptic technique

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and this will minimize the risk of infection. However, it isimportant to monitor the drain site for signs of inflammationand redness which could indicate bacterial colonization(Allihone. 2005). If such signs are present a swab should betaken and sent for analysis and identification of infective cause,after which appropriate treatment can be commenced. It isalso important to remember to adhere to aseptic techniquewhen changing dressings or drain tubing (Thorn, 2003).

MonitoringThere are a number of factors to be addressed with regard tomonitoring the chest drain. Post-insertion observations aretaken at KS-minute intervals for 1 hour, then half hourly for2 hours, then hourly until the drain is removed (Doughertyand Lister, 2004). In conjunction with monitoring bloodpressure, pulse, respiratory rate and pattern and oxygensaturations, the drain will be observed for swing, bubbling andair leak.This should be documented on a specific observationsheet and the amount of fluid drained should be recorded onthe patient's fluid balance sheet (Alhbone, 2003). The drainshould be labelled according to site and if multiple drains areinserted they should be numbered.

The fluid within the collection bottle needs to be regularlyassessed for signs of fresb blood, and if present, should bereported immediately to the medical staff (Sheppard andWright, 2006). It is also important to monitor the fluidfor signs oí clouding as this could indicate infection; ifthis is noted, a specimen from the tube should be sent formicrobiology, culture and sensitivity. This will allow foridentification of bacteria and any infection to be treated withthe correct antibiotics 0evon and Ewens, 2002).

When managing chest drains it is important to monitor forfluid swing and bubbling. Fluid swing occurs when the fluidwhich is draining through the tube swings back and forth oninspiration and expiration. This swing shows that the tube ispatent (Dougherty and Lister, 2004). If swing is not presentthe tube should be checked for kinks or loops; if none arepresent, medical advice shouid be sought, as a blocked tubecan lead to a tension pneumothorax or surgical emphysema(Ailibone, 2003).

BubblingBubbling signifies that air is being removed from thc pleuralspace, and will occur with a pneumothorax or followingsurgery where parts ofthe lung have been removed. Bubbhngwill be seen in the drain bottle, under the water seal onexpiration or coughing. If continuous bubbling is seen thetube can be pinched near its insertion to the chest; if bubblingcontinues this signifies a break in the tubing connection; ifbubbling stops then air is leaking from within the pleural spaceand medical advice should be sought (Ailibone, 2003). If thebubbling ceases it is necessary to ask the patient to cough as tliiswill show small air leaks only visible on forced expiration.Thedrain should not be removed until this bubbling has ceased andmedical confirmation of removal has been sought.

Milking and dampingThere i.s a technique called milking, where thc tube ismassaged to try and draw fluid out of the thoracic cavity

and may remove the source of any blockages, such as a clot,if the tube is occluded. However, this technique has beenproved unsafe, as it can cause lung tissue to be drawn intothe drain tubing causing bruising and trauma (Gordon et al,1995; Dougherty and Lister, 2004). Milking can also causean increased rise in intrapleural pressure; this can causecardiac instability and can increase the chance of a tensionpneumothorax (Sheppard and Wright, 2006).

Chest tube clamping is the subject of much debate withinthe medical texts, with an almost even split betw--een thoseadvocating clampii^ and those not (Bauniann et al, 2001).However, drain clamping is not advocated in the nursingtexts Qevon and Ewens, 2002; Ailibone, 2003; Dougherty andLister, 2004; Sheppard and Wright, 2006).The reasons for notclamping in the nursing context are not rationalized; however,anecdotal evidence suggests that it could be due to incidencesof clamps being left on. The only time a chest drain should beclamped is when the bottle is being changed (Dougherty andLister, 2004). For this procedure, two clamps should be used,one above and one below the connection to the drain tubing.On changing the tubing, the clamps should be removed assoon as possible to prevent a rise in intrathoracic pressure fromcollection of air or fluid (Ailibone, 2003). There is no need toclamp the drain when mobilizing the patient in bed, a simplekink of the tube will prevent backflow of fluid or air. It isalso not necessary to clamp the drain when transferring thepatient to other departments, as again, this may cause a rise inintrathoracic pressure if left for too long (Hyde et al, 1997).

SuctionThe use of suction for evacuating air or fluid after chest draininsertion is also a factor the nurse needs to be aware of, eventhough it is usually at the discretion ofthe doctor. It works byincreasing the negative pressure aiding lung re-expansion bysucking out fluid or air. Nursing staff need to ensure the suctionpressure remains between 5 and 15kPa or 10-20cm H2O - any

Chest tube draining bloodfrom pleural cavity

Figure 4. A chest drain in situ.

Uriciihjoiirii«! (if NursirtK-21)118, Vol 17,Nü 6 391

higher than this and lung trauma can be caused {Doughertyand Lister, 2004). Fij 'iirc 5 shows a drain connected to suction,chis is most commonly used posc-thoracic surgery.

Drain managementThere arc some important considerations for managing a chestdrain. The chest drain should always he kept bdow the levelof the patient's chest to prevent back flow of fluid in to thepleural space (Avery, 2000).This could lead to infection and theworsening of the condition for which the drain was inserted.If the drain needs to be raised above the patients' chest, e.g.when moving the patient in bed, the tuhe can be kinked toprevent back flow. The chest drain will be held in place by ananchoring suture and will be dressed with gauze and a non-occlusive dressing.These dressings should be assessed every dayfor oozing and signs of itidanimation and changed if oozing ispresent (Allibone, 2003). Inflammation should be monitoredand if worsening a swah should be sent for analysis.

The drain tubing should never be secured to the patient'sbedding or clothing, as sudden movements by the patientcould cause the drain to become dislodged, allowing air toenter the pleural cavity. It is also important to encourage thepatient to mobilize, this can be in the from of deep breathingfor bed-bound patients, or short walks and raising arms inthe more active patient. The movement will help with fluidand air drainage (Sheppard and Wright, 2006). Physiotherapyinput can be sought to provide a more structured mobilité-programmes.

Pain managementAnalgesic management ofthe patient with a chest drain is anintegral part of holistic drain management. It can be dividedinto three areas:• Insertion ofthe drain• While the drain is m situ• Removal ofthe drain.

Figure S.A drain connected lo suciíoii.

The analgesic requirements for insertion will be managedby the doctors. However, pain management while the drainis if; situ and on removal is the nurse's responsibility. Thereis limited literature to describe the nurse's role in painmanagement regarding chest drains. A literature review byOwen and Gould (1997) found that the need for analgesiahas not been explored; however, they expressed that pain canbe rated as moderate. On the wards, patients with chest drainsare often on paracetamol and dihydrocodeine; these appearto manage their pain effectively However, it is importantto remember that pain is subjective and patients will haveindividual experiences. Therefore, regular pain assessmentsare required to maintain adequate analgesic relief from thediscomfort and pain caused by chest drains.

It is important for the nurse to act as an advocate. Thereare a number of alternative pain relieving strategies, such asdistraction and positioning of the patient, all of which mayproduce non-pharmacological relief. It is also important tomake sure that there is suitable analgesia prescribed on thedrug chart, and if not, then to liaise with the doctors to haveanalgesia prescribed (Gray, 2000).

Drain removalUpon confirmation that the indication for the chest draininsertion has resolved, it is then important to removethe chest drain. This must be carried out in a way whichminimizes the risk of allowing air to enter the thorax, thuscausing a pneumothorax. It may be the responsibility of thenurse to remove the drain, thus it is important to he awareofthe removal technique. Nurses should also be aware ofthepatient's blood results, as low platelets could result in excessivebleeding; it is also important to be aware of any thromholyticdrugs the patient may be on, which could affect their clottingand discuss with doctors before removal ofthe drain.

Chest drain removal is a two-person procedure. The nursesneed to explain to the patient what will happen throughoutthe removal. Evidence advocates that the patient inhalesdeeply and holds their breath while the drain is pulled out(Welch, 1993). However, a study hy Bell et al (2001) showedthat removing the drain at end-inspiration or end-expirationare equally safe. From practice experience, it has been seen thatend inspiration is the preferred method. It is good practice tohave a run through with the patient so that they know whatto expect - ask the patient to take two deep breaths and holdat peak inspiration of the third. The experience of removinga chest drain can be painful for patients. Thus, it is goodpractice to for the nurse to administer prescribed analgesiain accordance with Trust policy and allow this to take effectbefore commencing the procedure.

To start the removal, the securing sutnres and the purse-string suture need identifying {Figure 6). The anchoringsuture needs to be cut and removed while the purse-stringsuture needs to be cut approximately 5 cm from the chestwall - this will leave a suitable length to be tied off. It is thenthe responsibility of one nurse to ask the patient to take twodeep breaths and then hold on the third. Upon the patientholding their breath, the nurse pulls the drain tubing out inone smooth motion. Once the drain has been removed thesecond nurse ties the purse-string suture and then tells the

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patient they can breathe again normally.The drain and tubingshould be discarded in a large yellow waste bin. The woundsite should be cleaned with normal saline and covered with anon-occlusive dressing and observed for signs of oozing. Thesuture can be removed after 7-12 days (Dougherty and Lister,2004). The patient should be observed closely after removalfor signs ofa recurrent pulmonary event.

The patient can mobilize without restriction, the woundsite should also be monitored for tissue necrosis fromover tightened sutures (McMahon-Parkes, 1997). It is alsoimportant to ensure a chest X-ray has been ordered postremoval to check that neither fluid or air has re collected inthe pleural cavity (Avery, 2000).

ConclusionThe tiursing role in the management of chest drains is diverseand important. Chest drains can be inserted for a variety ofreasons and it is important for the nurse to understand whereand why the drain has been inserted, due to the influence ithas on patient positioning.

The different aspects of chest drain management have beenanalysed, showing the importance ot regular observationsand what is normal and abnormal for a chest drain. Thisarticle has shown that the nurse plays a vital role in chestdrain management from insertion to removal; however, theremainder of the Tiiultidisciplinary team are there to offeradvice and support with issues such as pain managemetit andphysiotherapy.

Although most chest drains are found in the critical caresetting and specialist areas, some chest drains will be encounteredon the wards. The nursing management skills shown in thisarticle are transferable to the ward environment. It has beenhighlighted that there is a need for nationally derived guidelinesfor chest drain management. Although the British ThoracicSociety has derived guidelines for the insertion of chest drains,there are no national guidelines for the nursing matiagement.Trusts derive their own standards, but there needs to be genericguidelines set in place, to provide standardized care. DH

Vte author would like to thank Anlbony Hogan.Vioradc Nurse Case Manager, Guy'sHospital, for the promion of pictures.

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Figure 6. Anchoring sutures and the purse-string sutures identified.

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KEY POINTS

I Drains are inserted to remove fiuid and/or air From the pleural cavity.

I There is a lack of standardized national guidelines for nurses to use withregard to the managennent of chest drains.

I The nurse needs to be aware of drain position to comprehensively naanagethe patient's condition.

i The nursing role extends from insertion to removal, to include the bio-psychosocial needs of the patient.

i There are a variety of drains in use that the nurse needs to be aware of.

lirmsh Journal of Nursing, 2llü«.Vol i 7 .No6 393