8.7
PROCEDURE
TITLE:
CARE AND MANAGEMENT OF UNDER WATER SEALED
CHEST DRAINS IN CHILDREN – EXCLUDING NEONATES.
DOCUMENT NUMBER:
8.7
DATE DEVELOPED:
October 2013
DATES REVISED:
NEW
DATE APPROVED:
February 2014
REVIEW DATE:
February 2017
DISTRIBUTION: Paediatric wards-JHCH: J1, J2 and H1
PERSON RESPONSIBLE FOR MONITORING AND REVIEW
Margaret Allwood – Acting Paediatric Surgical CNC
COMMITTEE RESPONSIBLE FOR RATIFICATION AND REVIEW:
Clinical Practice Guidelines Advisory Group
Kaleidoscope Quality & Safety Committee
Keywords:
Chest drain, paediatrics, under water seal drain,
Disclaimer:
It should be noted that this document reflects what is currently regarded as a safe and appropriate approach
to care. However, as in any clinical situation there may be factors that cannot be covered by a single set of
guidelines, this document should be used as a guide, rather than as a complete authorative statement of
procedures to be followed in respect of each individual presentation. It does not replace the need for the
application of clinical judgment to each individual presentation.
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This local clinical procedure has been developed to provide instruction to the healthcare
worker and to ensure that the risks of harm to the patient associated with Under Water
Sealed Chest Drains are identified and managed.
Any unplanned event resulting in, or with the potential for, injury, damage or other loss to
the patient as a result of this clinical procedure must be reported through the Incident
Information Management System. This would include unintended patient injury or
complication from treatment that results in disability, death or prolonged hospital stay and
is caused by health care management.
Open Disclosure procedures must be commenced to ensure the concerns of the patient
are identified and managed in accordance with Ministry of Health Policy Directives. The
Policy Directives and Guidelines for managing complaints and concerns about clinicians
should be used in conjunction with other relevant NSW Health Policy Directives that
govern the behaviour and actions of all staff.
INTRODUCTION
Chest drains are inserted into the thorax and are used for draining air and/or fluid from the
pleural cavity. It is usually attached to an underwater seal drainage system where the
water seal is intended to act as a one way valve allowing fluid and air to leave the pleural
space1,2.
AIM
The purpose of this document is to outline the care and management of the paediatric
patient with a chest drain, and removal of the chest drain. As paediatric chest drains are
usually inserted in theatre, the insertion of chest drains will not be covered in this
document.
ASSESSMENT
Indications for the insertion of a chest drain include pneumothorax, haemothorax,
chylothorax, pleural effusion,empyema3 and as adjuncts to major thoracic surgery.

Pneumothorax: occurs when there is an opening on the surface of the lung, the
chest wall, the airways or all of the above which allows air to enter and accumulate
in the pleural space. The negative pressure of the pleural space is lost and the
lung collapses1,3. Pneumothorax is diagnosed by x-ray, except tension
pneumothorax which is an emergency and is clinically diagnosed.
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
Haemothorax: blood in the pleural space diagnosed by assessing respiratory
distress, breath sounds and chest X-ray1.

Pleural effusion: fluid in the pleural space diagnosed by clinical symptoms and
chest X-ray1.

Chylothorx: lymphatic leakage in the pleural space. It is usually milky white in
colour and is diagnosed by CXR4.

Empyema: pus in the pleural space usually as a complication of pneumonia due to
staphylococcus aureus or Streptococcus spp.1,5 Diagnosis is based on patient history,
chest ultrasound, +/- chest CT6,7.
MANAGEMENT
1. Care of the Patient:
1.1 Secure tubing to patient: Ensure that the tubing is securely attached to the
patients so the tube will not pull, kink or move when the patient moves. This
dressing needs to be changed when visibly unclean, soaked or if it begins to fall
off. A pair of Spencer Wells forceps should be kept at the patient bedside at all
times, and are readily available if there is a sudden disconnection or air leak3
(See section on clamping of chest drains). The dressing of choice is Hyperfix.
1.2 Maintain patency of the system: ensure the patency of the system is
maintained at all times by gently tapping the tube regularly to remove any clots
or thick drainage3. Milking the chest drain is NOT recommended as this practice
generates negative pressure in the pleural space1. Ensure the tubing is not
kinked (a common problem) , and that any tapes do not impede drainage of the
tube8.
1.3 Maintain the underwater seal: ensure the underwater seal is maintained by
keeping the drain unit upright and the water level adequate. The drain must
NOT be raised above the level of the patient’s chest – if this is necessary for
positioning the tube must be temporarily clamped (see section on clamping of
chest drains).
1.4 Suction Settings: the standard setting is -10cm H2O to -20kPa and will be
determined by the paediatric surgeon caring for the patient8. Commercial
drainage systems allow for the suction to be between 0 and -40kPa, and the
amount of suction used depends upon the indication9. The suction unit can be
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safely disconnected and the unit placed on free-drainage for transfers or short
walks. The maximum amount of suction for a paediatric patient is -20kPa.
1.5 Position the patient: ensure the patient is positioned to enable drainage of
fluid/air, and that the tube is not kinked. Encourage position changes and deep
breathing and coughing exercises to encourage drainage3,8,10.
1.6 Pain management: ensure the patient’s pain is well managed, as having a
chest drain can be a painful and uncomfortable procedure. Pain should be
assessed using an age appropriate pain scale.
1.7 Observations: Vital signs (Temperature, respiratory rate, pulse, oxygen
saturations, blood pressure and pain scores are attended every 4 hours and
recorded on the Standard paediatric Observation Chart (SPOC) chart. Hourly
fluid observations are attended are recorded on the Chest Drainage Observation
Record:

Amount of drainage (read at eye level)

Type of drainage

Suction setting

Oscillation/swing (fluid in the tube will move on inspiration). There will be
no oscillation if suction is used1,3 .

Air leak indicated by bubbling in the container11.
The insertion site needs to be checked 4th hourly for signs of redness,
leakage, bleeding, condition of dressing and ooze.
1.8 Education: Parent and child needs to be educated regarding positioning, pain
relief, maintaining the system below the level of the child’s chest, purpose of the
drain and signs of deterioration.
1.9 When to Initiate a Clinical Review:

If patient observations in the yellow zone as per SPOC

A sudden and unexpected increase in the amount of drainage

A change in the type of drainage

A sudden cessation of drainage accompanied by a change in the vital
signs

Development of subcutaneous emphysema in the area around the site of
the entry of the drain

A sudden change in the patients vital signs

Commencement of air bubbles and signs of pneumothorax3.

Accidental disconnection
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
Chest drain becomes dislodged
2. Procedure for Chest Drain Unit Change:
2.1 Gather equipment

Drainage unit with tubing and drainage connections

Sterile gloves

Spencer Wells Forceps

Alcohol 70% (chlorhexidine 0.5%)

Gauze

Goggles
2.2 Procedure for changing drainage unit

Attend 5 Moments of hand Hygiene

Unwrap new unit and leave on sterile wrap

Connect tubing and connectors if needed. Follow manufacturer’s
instructions regarding inserting water to create water seal.

Turn off suction and clamp chest drain as close to the drainage unit as
possible. When using metal clamps, protect the tubing by placing gauze
between the metal clamps and the tube.

Wash hands and apply sterile gloves

Using chlorhexidine soaked gauze, swab connection between the tube
and the unit 3 times and disconnect.

Attach the new chest drain unit and connect to suction if required.

Ensure the system is secured and set up correctly before removing the
clamps and restarting suction.

Document
2.3 Preparing ATRIUM EXPRESS™ Dry Seal Chest Drain System
The water seal drainage system is comprised of a one piece, 3 chamber set-up,
which separates the functions of fluid collection, water seal (which serves as a
simple one way valve), and suction control.
Equipment:

Sterile oasis /atrium drainage pack

Clean suction tubing

Cook’s™ multipurpose tubing adaptor with luer lock

Sterile scissors
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Procedure for setting up Atrium Express™ dry seal chest drain system:
1. Open Atrium pack (Figure 1)
Figure 1
2. Draw up solution from ampoule supplied and insert into suction port at the back
of system –see figure 2 and 3 (fluid will fill to 2cm line)
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Figure 2
Figure 3 – filled with solution to 2cm line
3. With sterile scissors cut end of drainage tubing to remove clear adaptor and
discard
4. Insert Cook™ multipurpose adaptor (blue) into drainage tubing (with white end
facing out)
5. Attach suction tubing to suction port on drainage system and attach other end
to the wall suction
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6. Set drain suction to ordered setting by moving the rotary dial – located behind
(A) on left side of drain – to a maximum of -20kPa
7. Set wall suction at required setting at –10 kPa (80mmHg).
8. Watch bellows (E) expanding when suction is operating
9. Observe (C) for initial active bubbling. The system will initially bubble if draining
a pneumothorax. The bubbling should not continue after the initial insertion, and
continued bubbling may indicate a leak.
10. Monitor drainage at (D) Refer to figure 1 for the location of A,B,C,D,E 12 and
document hourly.
3. Clamping of Drains

NEVER CLAMP THE CHEST DRAIN UNLESS ORDERED BY THE
MEDICAL OFFICER OR THERE IS A CLINICAL REASON.

Clinical Reasons to Clamp Drain:
 If tubing is accidentally disconnected
 If the drainage unit is raised above the level of the patient’s chest
during repositioning
 Prior to drainage unit change
 To check for a leak in the system.
3.1 How to clamp the chest drain

Chest drains are usually clamped close to the site of exit from the
patient’s chest proximal to any connections. Spencer Wells forceps with
rubber or plastic protective sheaths are applied as shown.
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4. Trouble Shooting
4.1 Blockage of drain

Sudden cessation of swing or drainage may suggest a blockage

Check for kinks or obstruction

Reposition patient

Observe patient for respiratory distress and initiate clinical review and
increase frequency of observations to hourly if increased respiratory
distress present.
4.2 Accidental disconnection

Immediately clamp drain

Re-establish connection ASAP using sterile technique

Monitor patient for signs of respiratory distress for the length of their stay

Continue 4th hourly vital signs and document on SPOC.

Clinical review must be initiated if drain accidentally disconnected
4.3 Air bubbling

Air bubbling characterized by intermittent bubbling in the water seal
chamber – initiate clinical review

If there is no pneumothorax or the patient has not had a lobectomy, air
bubbling means there is a leak in the unit. Starting from the patient,
systematically clamp the unit until the leak is found and repaired.
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Continuous air bubbling in patients on continuous suction indicates the
drain is partly out of the thorax and one of the tubes drainage holes may
be open to air7.
4.4 Patient deterioration

Attend vital signs

Administer O2

Initiate clinical review
4.5 Chest drain becomes dislodged

Close the site immediately using gloved fingers (if possible) to prevent a
tension pneumothorax

Call for help from other nursing staff for assistance and initiating a clinical
review

Place child in Fowler position (semi-upright sitting position).

Cover hole with non-adherant occlusive dressing or Vaseline
impregnated gauze reinforced by an adhesive wound dressing as soon
as possible

Monitor patient for signs of respiratory distress

Clinical review from paediatric surgical team
5. Removal of Chest Drain
The chest drain is ready to be removed when:

Drainage is low or non-existent (less than 10-15mls per 24 hours)7

A recent CXR demonstrates resolution of collection of fluid or air

As per surgical team’s orders
5.1 Preparation:

The chest drain is to be clamped at 0500hrs at surgical teams orders

Ensure CXR request form has been completed.

A CXR will be performed prior to removal of the drain usually about 2-3
hours after elective clamping of the drain.

Unclamp the drain if the patient develops symptoms of respiratory
distress after clamping, and contact the paediatric surgical team.
Do not re-clamp or remove the tube until the patient has been reviewed.
5.2 Equipment:

Dressing pack

Suture cutter
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
Gauze

Adhesive dressing

Vaseline impregnated gauze

Alcohol 70% (chlorhexidine 0.5%)

Sterile gloves

Appropriate size chest drain pack
5.3 Prepare the patient

Confirm orders with the surgical team

Administer appropriate analgesia to patient, sedation may be necessary
in young children7.

Explain procedure to patient and family3,8.
5.4 Procedure for removal of Chest Drain

Attend to 5 moments of hand hygiene

Open equipment and ensure all drains are clamped

Remove dressing

Wash hands and apply sterile gloves

Fold Vaseline impregnated gauze and place in the centre of occlusive
dressing to form an island

Swab site and chest tube with chlorhexine solution

Remove suture

If age appropriate, instruct child to take a deep breath and hold it. If this
is not possible remove drain on the beginning of expiration.

If there is more than one drain connected to the drainage unit, ensure
each drain to be removed is clamped prior to its removal13.

Holding occlusive dressing over site, remove drain covering site with
occlusive dressing as drain is removed.

Document in patient notes and Chest Drain observation sheet

A chest x-ray should be taken shortly after removal to check for
pneumothorax7.
5.5 Nursing observations post drain removal

Attend vital signs hourly for four hours post removal8

Observe patient for

Tachypnea

Drop in SaO2
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
Anxiety or distress

Unequal chest wall movement

Decreased air entry

If there are any signs of respiratory distress – initiate clinical review
REFERENCES
1. Briggs, D. (2010) Nursing care and management of patients with
intrapleural drains. Nursing Standard, 24 (21), 47-55
2. Nottingham University Hospital (2006). Management of a Patient with
Underwater Seal Chest Drainage.
http://www.nottingham.ac.uk/mhs/documents/clinical-skills/nuhguidelines/chest-drain-underwater-seal.pdf Accessed 1.10.13
3. Children’s Hospital at Westmead (2012). Chest Drains Practice Guideline.
http://www.chw.edu.au/about/policies/pdf/2008-8104.pdf Accessed 1.10.13
4. Heffner, J. (2012) Etiology, clinical presentation, and diagnosis of
chylothorax. www.uptodate.com. Accessed 15.10.13
5. Singh, Singh and Chowdary. (2002). Management of empyema thoracic in
children. Indian Pediatrics, 39, 145-157.
6. Princess Margaret Hospital for Children (2012). Guideline for management
of children & adolescents with pleural empyema.
http://www.pmh.health.wa.gov.au/development/manuals/clinical_practice_gui
delines/documents/empyema_cpg.pdf. Accessed 6.11.13
7. Janahi, I and Fakhoury, K. (2013). Management and prognosis of
parapneumonic effusion and empyema in children. www.uptodate.com.
Accessed 15.10.13
8. The Royal Children’s Hospital Melbourne (2013). Clinical Guidelines
(Nursing): Chest Drain Management.
http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Chest_Drain_
Management/ Accessed 1.10.13
9. Doelken, P. (2013). Placement and management of thoracostomy tubes.
www.uptodate.com. Accessed 15.10.13
10. Nottingham University Hospital.(2012). Guidelines for the Management a
patient with Underwater Seal Chest Drainage.
https://www.nuh.nhs.uk/handlers/downloads.ashx?id=36856 Accessed
1.10.13
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11. JHH (2006). Nursing Guidelines for Care of the Paediatric Patient in John
Hunter Intensive Care Unit.
http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0017/105650/Be
dside_Manual.pdf Accessed 1.10.13
12. Neonatal Intensive Care Unit. John Hunter Children’s Hospital (2013)
Pneumothorax in NICU.
13. JHH (2009). Intercostal, Mediastinal and Pericardial Drains; removal of.
http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0010/65458/Inter
costal,_Mediastinal_and_Pericardial_Drains_removal_of.pdf. Accessed
1.10.2013
14. Royal Prince Alfred Intensive Care Unit (2002). Intercostal Catheter.
http://intensivecare.hsnet.nsw.gov.au/five/doc/icc_uwsd_S_rt_rpa.pdf.
Accessed 1.10.13
15. Hand Hygiene Policy Compliance Procedure (2010). NSW Health Policy
Directive PD2007_36. NSW Health Infection Control Policy PCP number
PD2007_036:PCP 1 (Version Two)
http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0011/64973/PD2
007_036_PCP_1_Hand_Hygiene.pdf
16. NSW Health Policy Directive (2011). 2011_077: Recognition and Management of
Patients who are Clinically Deteriorating.
http://www.health.nsw.gov.au/policies/pd/2011/PD2011_077.html
17. Recognition of the Deteriorating paediatric patient in JHCH/JHH/RNC (2012).
http://www.kaleidoscope.org.au/site/content.cfm?page_id=356575&current_c
ategory_code=8337&leca=930
REVIEWED BY
Name
Raj Kumar
Trish Davidson
Gerard Roy
Bernadette Goddard
Tanya Gulliver
Kerri Sullivan
Aniruddh Deshpande
Position
Director Paediatric Surgery, JHCH
Surgeon, Director Children, Young People
and Families
Surgeon, Paediatric Surgery, JHCH
Respiratory CNC, Kaleidoscope
Staff Specialist JHCH
Paediatric Respiratory and Sleep Medicine
Paediatric Surgical CNC, Kaleidoscope
Fellow, Paediatric Surgery, JHCH
APPROVED BY:
CPGAG – December 2013
Kaleidoscope Quality & Safety Committee – February 2014.
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