Management of chest drains

Objectives of this session Anatomy & physiology of the chest relating to chest drainage What is a chest drain? Conditions requiring chest drain insertion Procedure for insertion How to care for a patient with a chest drain Removal of a chest drain

Physiological principles 3 compartments: mediastinum, right and left pleural cavity parietal pleura lines each pleural cavity The visceral pleura covers the lung Pleural space Negative intrapleural pressure

The pleural space

Definition of Chest drains A chest drain is a length of tubing, made of clear, plastic, which is connected to an underwater / one way valve drainage system AIM: To remove a collection of air, fluid, pus or blood from the pleural space To restore normal lung expansion and function Made of fairly rigid yet pliable plastic which may have a radiopaque strip incorporated into it, which enables X-ray detection. Proximal end is inserted into pleura and has a number of holes at insertion end which facilitate drainage. Other end connected to underwater/one way valve drainage system

Pleural Drains Prevents lung collapse & promotes re-expansion A one-way mechanism underwater seal flutter valve Made plastic, various sizes, distance markers, drainage holes, radiopaque strip

Mediastinal DRAIN

Indication-Pleural Effusion Excessive amount of fluid in pleural space Occurs as a result of a disease process or inflammation Does not necessarily cause S&S However is it expands and presses on lung, develop resp. sighsn and symptons, such as sharp localised pain that worsens with coughing and breathing. Infection in pelural space may cause sipsis, empyema may cuase fistuals into the bronchi or through the ches wall. Pleural effusion of 150ml or more, can be id on CXR, If compromised, need to perform thoracentesis and remove up to 1,5 L of fluid. If large and reoccurs after above, insert chest drain. Transudate: protein free. Caused by heart failure, liver disease, renal disease and pneumonia are common triggers. Exudate - contains proteins. Can deplete bodies protein stores. Inflammation, infection, malignansy or disruption of chest’s lymph drainaige Inflammation or infection in pelural space also incresase the potential for adhesions, which can isoate the effusion to one lung segment and complicate treatment.

Indication-CARDIAC surgery/TAMPONADE Clinical signs: Hypotension Raised CVP Distended neck veins Dyspnoea Fatigue Tachycardia Muffled heart sounds QRS voltage Widened mediastinum on Chest X-ray Observation of chest drainage important Coagulation profiles

Indication-Pneumothorax Air in the pleural space Occurs as a result of trauma, lung disease, invasive procedures, coughing or as a result of surgery

Indication-haemothorax Blood in the pleural space causing the lung to collapse Risk of tension pneumothorax

Indication-empyema . Pus collected in the pleural cavity

Insertion ‘Safety triangle’

Insertion site & drain site In case of air removal: 2nd, 3rd, or 4th intercostal space in mid-clavicular line (Position is high as air will rise) In case of fluid: 5th, or 6th intercostal space in mid-axillary line in posterior and basal part of chest. Fluid and blood are heavier (gravity) Size of tube: air: 16-24FR gauge fluid: 28-40FR gauge Triangle of safety: ant. Axillary line, mid-axillary line and horizontal line at level of nipples which is furthest away from abdominal contents an jaor vessels Fluid: larger size is required due to thicker consistency of fluid, blood or pus.

Insertion of chest drain Positioning of patient Observations during procedure? Dressing? Observations after insertion?

Monitoring Bubbling? Swinging? Draining?

Nursing care Bottle care Observations Dressings Suction . Bottle care Observations Dressings Suction Patient comfort/analgesia Documentation Review/ Removal Positioning

Removal Procedure When? Who? Explain procedure Practice breathing with patient Disconnect suction! Position patient comfortably Wash hands Remove dressing and examine suture Wash hands again and apply clean gloves ON DOCTORS INSTRUCTIONS.BASED ON PATIENTS CONDITION. 2 NURSES, ONE MUST BE EXPERIENCED IN THE PROCEDURE OFF SUCTION, TO PREVENT TENSION PNEUMOTHORAX. .

Purse String Sutures

Cont. Inform assistant to tie purse string suture on immediate removal. Cut anchor suture, not purse string Instruct the patient to take 2 deep breaths in and out On the third breath hold breath in, remove drain on this breath Exhale following removal Clean site and apply dressing. Observe patients vital signs. Chest x-ray. PURSE STRING TIED IMMEDIATELY TO PREVENT AIR ENTERING THE PLEURAL SPACE. TO PREVENT AIR ENTRY INTO THE PLEURAL SPACE. NORMAL SALINE AND OCCLUSIVE DRESSING. RR,COLOUR, SATS,HR AND BP XRAY TO CHECK REEXPANSION..

Clamping of drains?

ANY QUESTIONS ?

Readings: Allibone L., (2005) Principles for inserting and managing chest drains. Nursing times, VOL: 101, ISSUE: 42, PAGE NO: 45. British Thoracic Society Pleural Disease Guideline (2010) Mallett et al., (2013) Critical Care Manual of Clinical Procedures and Competencies. John Wiley & Sons Ltd. UK.