Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Chest Drain Managment


Published on

How to manage chest drain in patients?

Published in: Health & Medicine

Chest Drain Managment

  1. 1. Chest Drain Management By : Dr. M. Rezaei Fellowship of Pediatric Pulmonology
  2. 2. 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.
  3. 3. Indications for Insertion of a Chest Drain  Post operatively e.g. cardiac surgery, thoracotomy  Pneumothorax  Haemothorax  Chylothorax  Pleural effusions
  4. 4. 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
  5. 5. Start of shift checks: Patient assessment Pain
  6. 6. 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)
  7. 7. 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
  8. 8. 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.
  9. 9. 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.
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. Complications and Troubleshooting Infection of insertion site  Notify medical staff  Swab wound site  Consider blood cultures
  17. 17. 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.
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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 vacuu m source
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. From bottles to a box Collection chamber Water seal chamber Suction control chambe r from patient Suction control bottle Water seal bottle Collection bottle From patient To suction
  28. 28. From box to bedside
  29. 29. 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
  30. 30. 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
  31. 31. 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