1. Management of chest drains

2. 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

3. 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

4. The pleural space

5. 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

6. 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

7. Mediastinal DRAIN

8. 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.

9. 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

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

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

12. Indication-empyema .
Pus collected in the pleural cavity

13. Insertion
‘Safety triangle’

14. 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.

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

16. Monitoring
Bubbling?
Swinging?
Draining?

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

18. 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. .

19. Purse String Sutures

20. 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..

21. Clamping of drains?

22. ANY QUESTIONS ?

23. 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.