Title of Guideline (must include the word “Guideline” (not protocol,
policy, procedure etc.)
Author: Contact Name and Job Title
Directorate & Speciality
Date of submission
Explicit definition of patient group to which it applies (e.g. inclusion
and exclusion criteria, diagnosis)
Version
If this version supersedes another clinical guideline please be explicit
about which guideline it replaces including version number.
Statement of the evidence base of the guideline – has the guideline
been peer reviewed by colleagues?
Evidence base: (1-6)
1
NICE Guidance, Royal College Guideline, SIGN
(please state which source).
2a
2b
3a
meta-analysis of randomised controlled trials
at least one randomised controlled trial
at least one well-designed controlled study without
randomisation
3b
at least one other type of well-designed quasiexperimental study
well –designed non-experimental descriptive
studies (i.e. comparative / correlation and case
studies)
expert committee reports or opinions and / or
clinical experiences of respected authorities
recommended best practise based on the clinical
experience of the guideline developer
4
5
6
Consultation Process
Ratified by:
Date:
Target audience:
Review Date: (to be applied by the Integrated Governance Team)
A review date of 5 years will be applied by the Trust. Directorates
can choose to apply a shorter review date; however this must be
managed through Directorate Governance processes.
Guidelines For The Management An Adult
Patient With Underwater Seal Chest
Drainage.
Lucy Briggs ( Liz Aston (original author) 2009,
Holly Scothern PDM 2012)
Nursing Development, Corporate Nursing
November 2015
Chest drainage may be indicated when a lung
lesion, chest trauma or cardiac/thoracic
surgery punctures the pleura, or when a
spontaneous puncture of the pleura occurs
This procedure is an aseptic procedure
and is undertaken by medical staff with a
nurse assisting, under guidance of
ultrasound
3
2 (2012)
1, 5 and 6
Nursing Practice Guidelines Group, Ward
Sisters/Charge Nurses, Practice Development
Matrons (PDMs), Clinical Leads, Matrons,
ward managers within respiratory, the matron,
Barclay ward manager and deputy and the
clinical educator on CICU, Infection Control,
Evidence-based practice Council
Matron’s forum
November 2015
All Registered and non-registered nurses
November 2020
This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The
interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If
in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
Guidelines For The Management A Patient With Underwater Seal Chest Drainage Final November 2015 Review
November 2020 (amended and agreed June 2016 EBPC)
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Contents
Introduction ....................................................................................................... 3
Procedure for Insertion of an Underwater Seal Chest Drain .............................. 4
Equipment: For Seldinger (The Most Commonly Used) .................................. 4
Equipment for Wide Bore Chest Drains (I.e. Argyll or Surgical) ...................... 4
1. Preparation of equipment - nursing responsibilities ....................................... 5
Ensure informed consent has been obtained from the patient. ....................... 5
Prepare the drainage system and tubing using an aseptic technique. ............ 5
2. Insertion of the Chest Drain – Nursing Responsibilities ................................. 7
3. Management of the Wound ........................................................................... 8
4. Management of the Patient Following Chest Drain Insertion ......................... 9
5. Nursing Management of the Drainage System ............................................ 10
6. Changing the Chest Drain Bottle ................................................................. 14
7. Flushing An Intercostal Chest Drain, With A 3 Way Tap. ............................. 14
8. Applying Suction to the Drainage System ................................................... 17
9. Removal of the Chest Drain......................................................................... 21
Equipment .................................................................................................... 21
References and Further Reading .................................................................... 24
Audit Points ..................................................................................................... 25
Guidelines For The Management A Patient With Underwater Seal Chest Drainage Final November 2015 Review
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2
NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST
NURSING PRACTICE GUIDELINES
MANAGEMENT OF A PATIENT WITH UNDERWATER
SEAL CHEST DRAINAGE
“This guideline has been registered with the Trust. However, clinical
guidelines are guidelines only. The interpretation and application of
clinical guidelines will remain the responsibility of the individual clinician.
If in doubt contact a senior colleague or expert. Caution is advised when
using guidelines after the review date.”
Introduction
Chest drainage may be indicated when a lung lesion, chest trauma or
cardiac/thoracic surgery punctures the pleura, or when a spontaneous puncture
of the pleura occurs. Air or fluid may be drawn into the pleural space by its
negative pressure, causing lung recoil and collapse. A chest tube is inserted
into the pleural space to drain air, blood or fluid, re-establishing negative
pressure and allowing lung re-expansion (O’Hanlon-Nicols, 1996).
A chest drain is usually attached to an underwater seal drainage system which
acts as a one-way valve allowing fluid and air to leave the pleural space during
expiration and coughing and preventing it from being sucked back in during
inspiration (Allibone, 2005).
The number and sites of chest tubes inserted will depend on the underlying
reason for chest drainage and on what needs to be removed from the pleural
space.
The medical staff will advise on whether suction needs to be applied to the
drainage system. If suction is applied it must be via a thoracic suction system.
Best Practice
Insertion of a chest drain is reported to be a painful and frightening procedure
and patients must be given an explanation of what is going to happen and an
assurance that they will receive analgesia before the procedure is carried out
(Bourke, 2003; Luketich et al, 1998 cited in Allibone, 2005).
Ultrasound guidance is strongly advised when inserting a drain for fluid (NPSA
2008)
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Procedure for Insertion of an Underwater Seal Chest Drain
This procedure is an aseptic procedure and is undertaken by medical staff with
a nurse assisting, under guidance of ultrasound.
Analgesia should be prescribed and administered before the procedure
wherever possible and effectiveness established on a ward, an example of this
would be 10mg of oral morphine solution, i.e. oramorph (BTS 2010).
Equipment: For Seldinger (The Most Commonly Used)
Ultrasound machine if required (usually on RAU)
WHO checklist for pleural procedures
Consent form 1
ROCKET complete seldinger pack (12f or 18f: confirm with doctor: kept on
southwell)
2 x ChloraPrep® skin preparation 3ml wands (Chlorhexidine Gluconate
20mg/ml/Isopropyl Alcohol 0.70ml/ml)
2 pairs sterile gloves
Lignocaine 1% (20mls for <75kg/25mls for >75kg)
1 Rocket bottle
1 sterile chest drainage tubing
Sterile water
Suture: please check with Dr, often a mersilk 1/0
Clear dressing
Chest drain chart
Equipment for Wide Bore Chest Drains (I.e. Argyll or Surgical)
USS machine (usually lives on RAU)
WHO checklist for pleural procedures
Consent form 1
2 x ChloraPrep® skin preparation 3ml wands (Chlorhexidine Gluconate
20mg/ml/Isopropyl Alcohol 0.70ml/ml)
2 pairs sterile gloves
Sterile gown
Lignocaine 1% (20mls <75kg/25mls for >75kg)
Intercostal drain and trochar, (size as requested – there is no consensus on the
size of the optimal chest tube for drainage) (Davies, et al, 2003)
Suture usually 1/0 mersilk
Needles: 1 x orange, 2 x green
Syringes: 1 x 20ml and 1 x 10ml
Scalpel
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CSSD pack: either cut down tray or intercostal drainage pack
Chest drain bottle (usually ROCKET)
Chest drain tubing (usually ROCKET)
Sterile water, for the bottle
Chest drain chart
Sterile clear dressing
Sterile scissors
1. Preparation of equipment - nursing responsibilities
ACTION
RATIONALE
1.
Ensure informed consent has
been obtained from the patient.
To ensure the patient is fully informed
about the procedure and any potential
risks associated with the procedure.
2.
Prepare the drainage system and To minimise the risk of infection.
tubing using an aseptic
technique.
3.
Fill the drainage bottle with sterile
water to the prime level. This will
ensure the rod end of the tubing
is 2cms below the fluid line. The
green cap should be inserted into
the suction port when suction is
not being used as it acts as a
dust cover.
To ensure that air cannot re-enter the
pleural space.
The GREEN cap marked V (for vent) is
a venting cap, which allows the free
flow of air from the bottle IT DOES
NOT SEAL THE BOTTLE (Rocket
Medical 2011)
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ACTION
RATIONALE
4.
To minimise the risk of the bottle being
overturned and breaking.
In case of need in an emergency.
5.
6.
If required place the system in a
holder/tray.
Ensure easy access to an
oxygen administration system
Record baseline observations of
pulse, respirations, blood
pressure, oxygen saturation
levels and early warning scores
(EWS).
For comparison with post-procedure
observations.
Best Practice
In some specialist areas where cell salvage is required e.g. the Emergency
department the bottle is filled with saline and not water. Please seek medical
advice and refer to local guidelines where this is the case.
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2. Insertion of the Chest Drain – Nursing Responsibilities
ACTION
1.
2.
In consultation with the doctor who
will be inserting the drain, position
the patient sitting up, leaning over a
bed table or lying on the unaffected
side, according to the patient’s
general condition.
Assist the doctor, who will :
a Cleanse the skin, using
. ChloraPrep® wand with a back
and forth motion (chlorhexidine
gluconate/isopropyl alcohol) for
30 seconds. Allow to air dry.
b Inject local anaesthetic into the
. chosen site allowing time for
tissue infiltration. Check
effectiveness before
proceeding. Usual dose: 20ml
1% lignocaine for patients
<75kg, 25ml 1% lignocaine for
those >75kg (Max dose = 25mls
of 1% = 250mg, 3mg/kg).
c Insert the chest drain and
. anchor it. Larger drains may
also benefit from the use of a
‘mattress’ suture, for wound
closure.
d Attach the drainage system
. ensuring all connections are
firmly and securely pushed
together. If appropriate,
longitudinal strips of tape can be
used across connections.
RATIONALE
To help maintain patient comfort and
to allow access to the insertion site.
To reduce the risk of introducing
infection.
1 wand covers an maximum area of
15cm x 15cm.
To minimise pain during the
procedure.
To prevent the drain being dislodged
and to maintain the seal. (BTS,
2010)
Longitudinal strips of tape allow
visual checking of the connection to
be made. However, taping of tubing
is controversial (Godden, 1998).
Some studies show it is
unnecessary, whilst others advocate
the use of tape to reduce the risk of
accidental disconnection of the
system and to prevent air leak.
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3. Management of the Wound
ACTION
RATIONALE
1.
The drain must be safely secured
to the skin. A clear dressing is
often enough to secure, and to
allow nursing staff to inspect for
both leakage and infection. Some
may use an ‘omental tag’ of tape;
this allows the drain to sit off the
chest wall and hence reduces the
chance of kinking/tension.
Drain needs to be secure, to prevent it
falling out. Large amounts of
tape/padding are unnecessary as may
movement and may contribute to
excessive moisture (BTS 2010).
Re-dress the wound as
necessary e.g. if it becomes
moist with exudate. Swab site if
clinically indicated.
Observe the area around the
tube insertion for signs of air
infiltration e.g. swelling or
“crackling” on palpation.
To ensure patient comfort and to detect
signs of infection.
2.
3.
Subcutaneous emphysema is a
possibility and, if this travels to the
neck or face, it can compromise airway
patency and cause respiratory distress
(O’Hanlon-Nicols, 1996). If present,
report to medical staff, monitor closely
and document.
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4. Management of the Patient Following Chest Drain Insertion
ACTION
1.
2.
3.
4.
5.
Take and record the patient’s
Early Warning Score (EWS).
The frequency of subsequent
observations should be
determined according to the
patient’s clinical condition/EWS.
RATIONALE
To provide a comparison with baseline
observations. Noting the respiratory
rate, depth and rhythm and the
patient’s skin colour are particularly
important in assessing the
effectiveness of the chest drainage
treatment and early detection of
complications.
Assess the patency of the chest
drainage system by:
a. Noting the fluctuation of the
fluid level in the drainage tubing
(“swinging”) and/ or bubbling
during normal respiration and
following a deep breath.
“Swinging” indicates the tube is in the
correct position. Bubbling indicates
continued air leak. If a drain stops
swinging, this should be reported to
medical staff (drain may be blocked).
b. Asking the patient to cough
whilst observing for swinging in
the bottle or movement in the
drainage tube
A chest X-ray should be
performed as soon as possible
after chest drain insertion.
Administer further prescribed
analgesia following insertion of
drain if required.
Swinging in the bottle following a
cough indicates the tube is in the
correct position.
Encourage mobilisation
according to the patient’s
condition reminding patient to
keep bottle below insertion site
(see 5.1 below). Also see
section on suction (page 12).
This facilitates optimum drainage from
the pleural cavity and so promotes lung
ventilation and gaseous exchange.
Patients will often not mobilise if they
are in pain.
To check the position of the chest
drain.
There may be considerable discomfort
because of the drain presence and
analgesia is required (Hilton, 2004).
Discomfort and pain may also interfere
with adequate lung ventilation and
patient mobility (Gallon, 1998).
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5. Nursing Management of the Drainage System
ACTION
1.
2.
RATIONALE
The chest drainage system must
be kept below the drain insertion
site.
DO NOT clamp/shut 3 way tap
the chest drain unless
a It is at the direct request of a
. senior doctor. The Doctor
should document length of
time for drain to be clamped.
NB: When clamped the
patient must be monitored for
signs of respiratory distress
(Carroll, 1995)
A bubbling chest drain should
never be clamped.
3.
Routinely assess the patency of
the system when carrying out
EWS or when clinical condition
indicates.
To prevent backflow of fluid into the
pleural space and to promote gravity
drainage.
The chest drain is sometimes clamped
before removal to assess how the
patient will tolerate removal and to
ensure that the lung will remain reexpanded.
Shutting the 3 way tap/clamping/raising
tubes will also occur during pleurodesis
(SEE GUIDELINE :‘care of patient
undergoing pleurodesis’
Or sometimes just to slow the flow of
fluid (in the case of large pleural
effusions).
Bubbling indicates an active leak of air
from the pleural space. Clamping may
cause a tension pneumothorax
To insure that drainage of the pleural
space is maintained. If fluctuation or
bubbling of the fluid level stops either
the lung has fully expanded, the
system is obstructed (Schuster, 1998)
or the air leak has stopped. This should
be documented and reported to
medical staff.
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4.
5.
ACTION
Ensure the tubing is free of kinks,
there are no dependent loops
and that all connections are
secured.
RATIONALE
Dependent loops have a negative
effect on fluid and air drainage from the
pleural space (Gordon, Norton and
Merrell, 1995; Carroll 1995).
This loop should not become
dependent, that is, below the fluid
level in the bottle.
If the drain is patent then the fluid
level will move with respiration. If
it is not moving, the following
should be checked:
 the drainage tubing for
kinks and/or blood clots. If
present, reposition the
patient and encourage
him/her to breathe deeply.
Then re-check for
fluctuations in fluid level.
It is possible that a tension
pneumothorax may be developing
which is a life threatening condition. A
rapid increase in pressure within the
chest can cause mediastinal shift
which can impair venous return to the
heart and will affect cardiac function
(Mattson Porth, 2005).
 the patient’s respiratory
rate, depth and volume, the
pulse rate, blood pressure
and ask the patient if they
have any chest pain.
Regularly check the tubing for
air leaks.
Cardio-respiratory distress may be
indicated by a low BP, increased pulse
rate and reduced oxygen saturation
levels, increased CVP, distended neck
veins, increased dyspnoea and chest
pain (Gallon, 1998).
To ensure the system remains
functional (Gallon, 1998).
Best Practice
Studies have shown that routine milking or stripping of tubing to maintain the
patency of the drainage system should be avoided as this increases the
negative pressure in the intra-thoracic cavity (Kirkwood, 2002). Avery (2000)
suggests replacing the tubing if it becomes blocked.
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ACTION
8.
9
Identify and record the amount
and colour of any fluid draining (if
appropriate) at least daily but
more frequently if requested by
the medical staff or local
protocols.
Large pleural effusions should be
drained in a controlled fashion to
reduce the risk of re-expansion
pulmonary oedema.
Only allow the amount
specified and documented by
medical staff to drain off at one
time. It is recommended that this
should be a maximum of 1500
ml in the first hour and then
1500ml in two hour intervals
(Roberts et al 2010).
10
11.
The rate of fluid removal may be
controlled by elevation of the
tubing over pillows. However,
some drains (Seldinger type)
have a 3 way tap in the circuit.
This can be used to control
drainage, where specified by a
medic.
When drainage falls below
approx. 150 ml per day, a chest
x-ray may be ordered. If there is
still pleural fluid on the chest Xray, the doctor may request
suction.
When mobilising, ensure the
drainage system is kept below
waist level.
RATIONALE
To monitor the amount and type of
drainage.
If large volumes of fluid are drained
quickly this can cause re-expansion
pulmonary oedema. If this occurs, stop
draining, record EWS, contact medical
staff ASAP.
NOTE: a bubbling chest drain should
never be clamped, and if drain is
present for a pneumothorax any
shortness of breath/ chest discomfort
needs prompt action. Patency of
tubes/drain need to be observed.
Patients need to be encouraged to
breathe deeply. Seek prompt medical
advice, and monitor EWS.
.
To assess re inflation of the lung and to
assist the removal of air/fluid from the
pleural space
To prevent backflow of fluid into the
pleural space.
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12.
13.
ACTION
In an emergency, such as the
chest drainage bottle breaking or
drainage tube disconnection, reestablish a sterile system as
soon as possible (Carroll, 1995;
Schuster, 1998).
If the tube accidentally falls out
get help and ask for the medical
staff and /or Critical care
outreach to be alerted urgently.
Apply dressing to chest drain site
and record full set of
observations
If an air leak is present, only
apply tape to 3 sides of the
dressing to allow air to escape
whilst seeking urgent medical/
CCOT advice. Monitor EWS.
RATIONALE
To prevent infection and maintain the
drainage system.
Trauma patients with a
haemothorax require drainage to
be measured hourly or according
to medical instruction. Inform
medical staff if blood drainage
exceeds agreed parameters.
Ensure parameters documented
by medical staff
Significant blood loss must be
addressed.
To prevent air entering the potential
lumen created by the drain and
causing a tension pneumothorax
(Allibone, 2005).
To allow any air to escape from the
pleural space,
14.
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6. Changing the Chest Drain Bottle
1.
ACTION
The bottle should be changed:
a) when 500ml level is reached
2.
3.
4.
5.
6.
7.
b) Or after 7 days in situ. If the
drain has been in situ for 7
days the tubing should be
replaced as well.
Fill the new drainage bottle with
Sterile water to the prime level.
This will ensure the rod end of
the tubing is 2cms below the fluid
line.
Kink the tube and release the
tubing from the old bottle by
unscrewing the red button.
Insert the tubing into the new
bottle, ensuring that the end of
the rod is under the level of the
water.
Release the kinked tubing and
ensure the tube is patent by
observing for fluid movement in
the tubing.
Seal and dispose of old chest
drain bottle and contents into the
designated chest drain disposal
box according to waste
management procedures.
Document drainage amount in
old bottle on fluid balance
chart/nursing records.
RATIONALE
Too full a bottle leads to a rise in
pressure in the system which in
turn leads to difficulty in drainage
and is therefore counter-productive
To minimise the risk of infection.
To ensure that air cannot re-enter
the pleural space.
To prevent air or fluid from entering
the pleural space.
To create an intact circuit and
prevent fluid from entering the
pleural space.
To allow drainage from the pleural
space.
To minimise the risk of infection.
To maintain accurate records.
7. Flushing An Intercostal Chest Drain, With A 3 Way Tap.
Chest drains need to be closely monitored and kept patent. A simple way of
doing this is to flush them regularly. It is the responsibility of the named
consultant (or registrar in their absence) to decide on frequency and indication.
It makes good sense that small bore drains, draining pleural effusions, could
block easily, and would benefit from regular flushes. However; safety issues
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associated with a blocked drain in a pneumothorax means that regular flushing
may be indicated. An example would be TDS flushes of 10 -20mls of normal
saline. These need to be prescribed for and then signed for on a patient’s drug
card.
This procedure is should be performed by an individual who is both available,
and trained to do this. This may be medical staff, or if the drain contains a 3 way
tap, could be a registered nurse Registered nurses, who have been
supervised and assessed as competent may undertake this procedure
(SEE COMPETENCY STATEMENT/accompanying nursing procedure).
1.
2.
3.
4.
ACTION
RATIONALE
In a designated clean area of
To reduce the risk of
the ward, draw up10 – 20mls of contaminating the saline flush.
normal saline into the 20ml
syringe, check and place
syringe on the injection tray
ensuring that it is checked in
accordance with the local policy.
Take the syringe of normal
To ensure patient safety.
saline to the patient, checking
the identity of the patient in
accordance with the local policy.
Position the patient to allow
To facilitate the procedure
access to the chest drain,
ensuring the patient is
comfortable.
Perform hand hygiene.
To minimise the risk of
infection.
5.
Open the sterile dressing towel To minimise the risk of
and place under the chest drain. infection.
6.
Clean the bung on the 3-way
tap supplied with the seldinger
drain, using the swab and
allows drying.
Clean hands and apply alcohol
gel.
7.
To minimise the risk of
infection.
To minimise potential
contamination of the drain
and/or equipment used.
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8.
9.
10.
11.
ACTION
Apply the sterile gloves and
attach the syringe of saline to
the clean bung. Ensure the 3
way tap is closed towards the
drainage tubing on the chest
drain system. Instil the 10 20mls of normal saline into the
chest drain.
RATIONALE
To ensure the normal saline is
instilled along the diameter of
the chest drain.
Remove the empty syringe from
the 3-way tap and ensure the 3way tap is open to the drainage
tubing on the chest drain
system, checking that the saline
is draining from the chest drain.
Dispose of all equipment
according to local policy.
If the drain is attached to an
underwater seal drainage
system, ensure the drain is
patent by:
To facilitate drainage of the
normal saline and to check the
patency of the chest drain.
To prevent the risk of cross
infection.
To assess and monitor the
patency of the drainage
system.
a) ensuring the fluid level is
fluctuating in the drainage
tubing. (Allibone, 2003)
12.
b) asking the patient to cough
and observe for fluctuation
of the fluid in the drainage
tubing.
Observe the patient by
monitoring the temperature,
pulse, respirations and blood
pressure 4 hourly (Allibone,
2003). In addition, monitor the
patient for chest pain and/or
discomfort and continue to
assess the patency of the
drainage system if the drain is
attached to an underwater seal
drainage system.
To monitor the patient for any ill
effects from the procedure and
to facilitate the early detection
of complications.
If any pain occurs, following the
flush, seek medical advice, and
do not repeat flush until
reviewed.
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8. Applying Suction to the Drainage System
If the insertion of a chest drain is insufficient for the removal of air/fluid from the
pleural space, suction via a thoracic suction regulator, or through specific
equipment, may be applied to assist in this process. This is a decision made by
medical staff.
Suction pressure should be set according to either specific written instructions
in the patient’s records or locally agreed written protocols. There is currently no
consensus on how much suction should be applied (Avery, 2000) nor is there
sound evidence or clinical consensus to base specific guidelines in this area
(Davies et al, 2003).
Note: (if using WALL SUCTION), when suction is applied to a chest
drainage system, an intermediate collection jar or canister must be placed
between the suction regulator and chest drain bottle. This is to prevent
activation of pipeline protection and subsequent loss of suction which
could lead to a tension pneumothorax, should the chest drain bottle
overflow. (MHRA MDA/2010/040, and Supplementary advice for
MDA/2010/040 – All chest drains when used with high-flow, low-vacuum
suction systems (wall mounted).)
In certain areas, for example, respiratory and cardiothoracics, there are specific
pieces of equipment that can be used to apply suction. These are the medela
Thopaz ® pumps. Indication for the use of these pumps lies with the medical
team, namely the consultant in charge of the patient. In addition, any nursing
staff involved in the care of these pumps must have completed the medical
devices statement entitled ‘medela – Thopaz and cardiothoracic drainage
system’.
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WALL SUCTION
Patient
Underwater seal chest drain
bottle, with water to ‘0’/PRIME
LEVEL line
Intermediate collection
canister (use a rocket bottle
with NO water)
Thoracic regulator
with pipeline
protection filter
1
2
3
4
Figure 1 Ensure that the following is adhered to:
 The chest drain bottle (2) from the patient (1) is the underwater seal, and must have water to the FILL/
‘0’ line (2).
 The rocket bottle tubing from the 2nd bottle (the intermediate canister) will connect to the patient’s
rocket bottle via the green outlet port. This bottle does NOT need water in it. It is purely for safety.
 You will need to ‘snip’ off the end of the 2nd rocket bottle tubing (3) to allow you to attach this bottle to
the patient’s bottle (2).
 Use non-sterile suction tubing (e.g. 5mm clear ‘bubble’ tubing) to connect the intermediate canister/ 2nd
rocket bottle (3) via the green capped outlet port to the thoracic suction unit (4).
ONLY EVER USE THORACIC SUCTION UNITS
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ATTACHING WALL SUCTION
ACTION
1.
2.
3.
4.
5.
RATIONALE
Fix one end of the suction tubing
onto the suction unit and the
other onto the collection canister
between the regulator and the
chest drain bottle.
Ensure an inline filter is used to
protect the piped suction system.
Only use thoracic suction
systems.
Set the suction rate according to
the written instructions or local
protocol. This will normally be
between 10 to 20cm H2O, (1
and 2 Kpa ).
The suction pressure assists the
drainage of fluid/air from the chest
cavity. At NUH we use a rocket bottle
as the collection canister, this is for
safety. There is a potential risk if the
‘liner’ system is used eg. serres. The
collection/intermediate canister (rocket
bottle) does NOT need water in it.
SEE PICTURE
If the suction is applied at too high a
pressure, it can harm lung tissue or
trap lung tissue in the chest tube
eyelets (Tooley, 2002)
Check frequently that the suction
is set as instructed.
To ensure the correct level of suction is
maintained.
Change the drainage system
when fluid levels go above
500mls.
Disconnect the suction system
before switching off to reduce the
risk of mimicking clamping
High fluid levels will
efficiency of suction.
affect
If the suction unit only is turned off
there is no valve in the system to allow
air/fluids to travel down to the drain –
this has the same effect as
clamping.
Guidelines For The Management A Patient With Underwater Seal Chest Drainage Final November 2015 Review
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the
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ATTACHING THOPAZ SUCTION SYSTEM
1.
Open sterile tubing packaging,
Gets tubing ready, whilst keeping the
keep patient connector in the
patient connector sterile.
internal bag
2.
Inspect machine, check presence Machine will not function properly if
of orange seal. Attach the tubing seal is not present or if tubing not
with care. Keep machine on a flat attached correctly.
surface whilst doing this and take
care not to force or bend end of
tubing.
3.
Insert bottom of the canister first, Ensures safe attachment of canister.
then ‘snap’ the top of the canister
into place. Do this with machine
on a level surface.
4.
Switch Thopaz+ unit on using
This will put machine in ‘standby’
on/off button.
mode.
5.
Confirm if a new patient is being In between patients, the settings
attached.
MUST be cleared.
6.
Check that the correct sized
canister has been identified.
7.
Perform the ‘functional’ check.
The air leak value must DECREASE.
This is done by occluding the
If it does not do not use.
tubing (with sterile gloved finger)
or using clamp and the pressing
‘on’
8.
Switch the machine to ‘standby’
In most cases the machines will be
(press for 3 seconds), and then
preset, for example, on respiratory it
attach to the patient. Check
will be set to 20 cm H20. This can be
clamp is ‘off’. Press ‘on’ to start
altered as per consultant’s
therapy.
wishes/indication.
9.
To replace the canister, clamp
Dispose of canister as per trust
tubing, switch to standby (press
guidelines.
for 3 seconds), remove old
canister and replace with a new
one.
Guidelines For The Management A Patient With Underwater Seal Chest Drainage Final November 2015 Review
November 2020 (amended and agreed June 2016 EBPC)
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9. Removal of the Chest Drain
Once drainage of fluid or air has diminished to little or nothing and/or
fluctuations in the water-seal chamber have ceased, the chest drain may be
removed at the request of the medical staff. The drain may be removed by
medical staff or by nurses who have been assessed as competent in the
procedure.
If using the Thopaz+ ® system decision to remove drain is often based on
the air leak value. This is a clinical decision and will be decided by the
patient’s consultant. A typical value within respiratory medicine might be
an air leak that has be 40ml/minute for a certain amount of time.
A chest X-ray may be performed prior to removal to establish that the lung has
re-expanded. Sometimes, if requested by medical staff, the patient is given a
trial period with the chest drain clamped to ensure that the lung will stay inflated
and respiratory distress avoided.
Equipment
Medium basic pack - if required
Stitch cutter – if required
Sterile dressing
Hypo-allergenic tape
2 pair’s non-sterile gloves
Sterile scissors and specimen container, if required
Clinical waste bag
Gel sachets
ACTION
1.
2.
3.
4.
Administer prescribed analgesia
20 minutes prior to removal, if
appropriate.
Position the patient on the
unaffected side or sitting up wellsupported by pillows.
Ask the patient to practice
holding their breath for 3 –5
seconds.
Perform hand hygiene and apply
gloves.
Remove the dressing.
RATIONALE
The patient may experience shortlasting but intense pain on removal
(Hilton, 2004).
To facilitate the drain removal.
To facilitate the procedure.
To minimise the risk of cross infection.
To allow access to the insertion site.
5.
Guidelines For The Management A Patient With Underwater Seal Chest Drainage Final November 2015 Review
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ACTION
RATIONALE
If the drain is sutured in place, this is a 2 person procedure.
6.
7.
Remove the securing suture if
present. The mattress suture, if
present, can be used to close the
wound. This should be done by
competent staff
Ask the patient to perform a
Valsalva manoeuvre. This
manoeuvre requires the patient
to take a deep breath and then
strain against a closed airway
(most easily achieved by closing
the vocal cords) in order to
increase intra-thoracic pressure.
The nurse should explain this to
the patient (perhaps using the
example of straining to pass a
motion). The patient should
rehearse this procedure to the
nurse’s satisfaction prior to
removal of the tube and then
perform it at the nurse’s request
during the removal of the tube
(Godden, 1998). The tube
should then be removed and
placed on the sterile field on the
trolley.
Allows tube to be removed only when
the least negative pressure can be
generated. Positive pressure is rarely
achieved (Marieb, 2004), thereby
reducing the risk of complications.
If the patient is not able to hold
his/her breath, remove during
expiration.
Guidelines For The Management A Patient With Underwater Seal Chest Drainage Final November 2015 Review
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8
8.
9
9.
10.
11.
12.
The mattress suture can be used
to close the wound.
To prevent air from entering the pleural
space via the drain site.
For small wounds (for example
with seldinger chest drains) the
use if steri strips should be
considered.
To aid wound closure and healing.
ACTION
If there are signs or evidence of
infection, send the end of the
drain for microbiological
investigations and swab the site.
Apply a sterile dressing to the
drain site.
RATIONALE
To detect the presence of any
pathogens.
Monitor the patient’s respiratory
status and wound drainage as
clinically indicated.
Seek urgent medical advice if
clinically indicated.
Any suture, if present, is usually
removed 5-7 days after chest
drain removal once the drain site
has healed.
Check with medical staff if a
chest X-ray is required following
removal of the drain.
Seal and dispose of old chest
drain bottle and contents into the
designated chest drain disposal
box according to waste
management procedures.
To reduce the risk of infection and to
prevent air re-entering the pleural
space until the wound is sealed.
Shortness of breath, sudden chest pain
or deterioration in observations may
indicate collapse of the lung and/or reaccumulation of fluid.
In patients who have had a
pneumonectomy, a large volume of
fluid fills the space. There is a risk of
fluid leakage and infection and so the
suture is normally left in place for 7
days.
To check that air has not entered the
pleural space during removal of the
drain.
To minimise the risk of infection
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References and Further Reading
Allibone L (2005) Principles for inserting and managing chest drains Nursing
Times Vol. 101 No. 42 pp. 45-49
Avery S (2000) Insertion and management of chest drains Nursing Times Plus
Vol. 96 No. 37 pp.3-6
British Thoracic Society Management of Pleural Infection in adults: British
Thoracic Society Pleural disease guidelines 2010. Thorax 2010; 65(suppl
2):ii41-ii53
www.brit-thoracic.org.uk Pleural disease guidelines 2010
Bourke S J (2003) Lecture Notes on Respiratory Medicine 6th Edition Oxford:
Blackwell
Carroll P (1995) Chest drains made easy Registered Nurse Vol. 8 No.12 pp.
215-225
Gallon A (1998) Pneumothorax Nursing Standard Vol. 13 No. 10 pp. 35-39
Godden J, Hiley C (1998) Managing the patient with a chest drain: a review
Nursing Standard Vol.12 No. 32 pp. 35-39
Gordon P Norton J, Merrell R (1995) Refining chest tube management: analysis
of the state of practice Dimensions of Critical Care Nursing Vol. 14 No. 1 pp. 613
Hilton P (2004) Evaluating the treatment options for spontaneous pneumothorax
Nursing Times Vol. 100 No. 28 pp. 32-33
Luketich J. D., Kiss, M., Hershey, J., Urso, G.K., Wilson, J., Bookbinder, M.,
Ginsberg, R., (1998) Chest tube insertion: a prospective evaluation of pain
management Clinical Journal of Pain Vol. 14 No. 2 pp. 152-154
Marieb, E. N. (2004) Human anatomy and physiology 6th Edition
Benjamin Cummings, Menlo Park, California, USA.
Mattson Porth C (2005) Pathophysiology: Concepts of altered health states
7th edition Philadelphia, USA: Lippincott
Mimnaugh L (1999) Sensations experienced during removal of tubes in acute
post-operative patients Applied Nursing Research Vol. 12 No. 2 pp. 78-85
Guidelines For The Management A Patient With Underwater Seal Chest Drainage Final November 2015 Review
November 2020 (amended and agreed June 2016 EBPC)
24
NPSA (2008) Risks of chest drain insertion NPSA/2008RRR003
O’Drisoll Robert and Pyne H (2008) Insertion of a Seldinger intra pleural chest
drain www.srft.nhs.uk (accessed 2011)
O’Hanlon-Nichols T (1996) Commonly asked questions about chest tubes
American Journal of Nursing Vol. 96 No 5 pp. 60-64
Rocektmedical(2011)
http://www.rocketmedical.com/pdf/Catalogues/Cardiac%20Products%20Issue%
204.pdf
Roberts M E, Neville E, Berrisford R G, Antunes G and Ali N J (2010)
Management of a malignant pleural effusion British Thoracic Society Pleural
disease guidelines 2010. Thorax 2010; 65(suppl 2):ii 32 – 40.
Schuster P (1998) Chest tubes: to clamp or not to clamp Nurse Educator Vol.
23 No. 3 pp. 9-13
Sullivan B (2008) Nursing management of patients with a chest drain
British Journal of Nursing Vol. 17 No. 6 pp.388-393
http://www.surreyandsussex.nhs.uk/wp-content/uploads/2013/04/How-shouldtalc-be-administered-for-chemical-pleurodesis.pdf
Tooley C (2002) The management and care of chest drains Nursing Times Vol
98 No 26 pp.48-50
NNPDG Link Members: Jill Wakefield/Holly Scothern with thanks to Debbie
Raffle, Lucy Briggs and Rhona Al-Bazzaz for their help in compiling this
procedure.
Audit Points
Is the patient’s safety assured with respect to chest drain procedures?
Has the patient’s dignity and comfort been effectively maintained prior to, during
and after chest drain procedures?
Has the patient received timely analgesia prior to chest drain procedures?
Has the patient received appropriate explanation prior to chest drain
procedures?
Guidelines For The Management A Patient With Underwater Seal Chest Drainage Final November 2015 Review
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Is there evidence of prevention of infection throughout chest drain procedures?
Is there confirmation that chest drain procedures are successful following
removal of a chest drain (i.e. is the patient’s breathing pattern and rate within
normal adult limits; are oxygen saturations within normal limits for the patient;
are vital signs satisfactory?)
Is there any evidence of pain associated with breathing following the removal of
the chest drain?
Guidelines For The Management A Patient With Underwater Seal Chest Drainage Final November 2015 Review
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