Chest drain management

The aim of these guidelines is to facilitate the safe management of chest drainage for patients at Great Ormond Street Hospital (GOSH).

This will include:

• preparation for the insertion of the drain
• caring effectively for the drain when in place
• removal of the drain

Note: While this guideline refers to the ‘child’ throughout, all activities are, of course, applicable to young people.

Background

A chest drain will need to be inserted as an invasive procedure to:

• Remove the fluid or air from the pleural space or mediastinum
• Re-expand the lungs and restore normal negative intra-pleural pressure and respiratory function.
• Conditions requiring a chest drain insertion include:

• pneumothorax (Rationale 1)
• haemothorax (Rationale 2)
• pleural effusion (Rationale 3)
• chylothorax (Rationale 4)
• empyema (Rationale 5)
• post-operative cardiac or thoracic surgery (Rationale 6)

Preparation for insertion

Ensure the child and family are informed of the following (Association of Paediatric Anaesthesia of Great Britain and Ireland (APAGBI) 2008):

• that a chest drain will need to be inserted (Rationale 7)
• what a chest drain is (Rationale 8)
• what the procedure and aftercare will entails
• the reasons for inserting a chest drain
• the likely duration of the procedure
• how long the chest drain will stay in situ
• the family are given a copy of the parent fact booklet on chest drains 
  

Insertion of chest drain

The majority of chest drains are inserted in theatre following the guidelines drawn up by the British Thoracic Society (2010) and the APAGBI (2008) (Rationale 9).

The child should be nil by mouth for four hours before the procedure. The nurse must ensure that the latest X-ray, bloods and ultrasound results are available in addition to the normal pre-operative checklist (Rationale 10) (Laws et al 2003).

Immediate post procedure

Before the child returns from theatre, the bed space should be prepared and safety checks carried out (Rationale 11). If the drain is to be on suction a low suction unit should be available. Two chest drain clamps should be with the child at all times and these should come up from theatre (Rationale 12).

On arrival to the ward, a full airway, breathing and circulation assessment should be done and the CEWs (Children Early Warning Score) noted (Rationale 13) (Pearson et al 2011). The nurse should listen to the chest using a stethoscope for bilateral breath sounds and the rate, regularity, depth and ease of breathing noted (Rationale 14). The drain low suction unit, if to be on suction, should be set at no greater than 20mmHg (Rationale 15). The nurse attaching the suction must make sure that the black suction switch is in the ‘on’ position and that the tube to the suction unit is not kinked or obstructed (Rationale 16).

The chest drain should be placed securely on the floor below the child’s chest (Rationale 17). A chest X-ray should be carried out within one hour of arrival on the ward (Rationale 18).

The initial drainage: amount, colour, type should be noted (Rationale 19). The chest entry site should be checked looking for a clean and dry dressing, no signs of redness and an accessible purse string if sited (Rationale 20). The drain should be secure and the tubing may need an extra external tape to the child to prevent pulling and accidental disconnection (Rationale 21).

For a newly sited drain, the drain should be assessed hourly for drainage, water seal and the level of suction. These should be recorded on the fluid balance chart (Rationale 22).

Insertion of a drain is a painful procedure and continues to be painful in the early post procedure period (Bruce et al 2006a).

The child should receive regular analgesia on return and may need to be reviewed by the pain control team if intravenous analgesia is required. A pain assessment tool should be used to assess the child’s pain post procedure and analgesia given to minimise any discomfort (Rationale 23).

The nurse should be able to answer any questions the patient or family may have on return to the ward (Rationale 24).

Specific drain observations

Check the water seal hourly to make sure there is enough water and it is moving to indicate it is working correctly. This water seal acts as a one-way valve and prevents the air or fluid going back into the pleural space. For a child breathing spontaneously, the water level in the water seal chamber should rise with inspiration and fall with expiration.

Observe for fluctuations ("swinging") in the water seal chamber on the left side of the drain (blue water level). If there are no fluctuations in the level of water in the water seal chamber, it could be caused by one of the following factors:

• the tubing is kinked
• the tubing is clamped the child is lying on the tubing
• there is a dependent fluid-filled loop in the tubing (Rationale 25)
• lung tissue or adhesions are blocking the drain during expiration
• no more air is leaking into the pleural space

The medical team should be alerted if it does not start to fluctuate if kinking, clamping and a fluid-filled loop have been eliminated as causes.

If the water in the water seal (blue dye) chamber evaporates, add water via the needless access point on the back of the chamber using a luer-lock syringe. In the case of overfilling this chamber water can be removed in the same manner. In the case of a build-up of negative pressure within the chest drain unit, the blue fluid will be raised to the mark: VENT NEGATIVE PRESSURE. In this case press the black button that is located under the red cap on top of the drain until the level returns to normal. NB: Clamp the drain during this manoeuvre (Rationale 26).

Not all drains will need suction but if it is on, check the suction hourly for:

• bubbling in the suction chamber on the far left of the drain
• the correct pressure is set
• the correct water level is in the suction chamber
• there are no loose connections between the drain and the suction unit

If the amount of water has dropped below the desired level, simply disconnect suction, open white cap and top up with sterile water and close again before reapplying suction. This white cap should be checked that it is secure at the commencement of every shift (Rationale 27). The need for suction should be reviewed by the medical team daily and the decision documented. If suction is no longer needed, all suction tubing attached to the drain should be removed, not just turned off at the suction unit.

Check the drainage for amount, colour and consistency. Any change in amount should be reported and any excessive drainage should be replaced (>5mls kg). Any change in colour (such as a milky colour) will require a sample to be sent (Rationale 28).

Check insertion site and surrounding skin for signs of redness, swelling, pain and heat and for signs of subcutaneous emphysema (Rationale 29).

Check for any drain related complications not included above:

• Tension pneumothorax - caused by interpleural pressure exceeding atmospheric which could result from incorrect water seal (Rationale 30).
• Bleeding - around the site and excessive drain loss. May be caused by blood vessel nicked at time of insertion so CXR and ultrasound may be required. Will also require pressure dressing, fluid resuscitation and clotting screen to be sent (Rationale 31).
• Subcutaneous emphysema after initial period - can occur if drainage holes migrate to outside pleural space or if the drain is blocked or kinked. Will require change in position of drain or another insertion (Rationale 32) (Jones et al 2001).
• Infection - can occur at any time while the drain is in situ. Monitor for clinical signs of infection such as pyrexia (Rationale 33).
• Displacement - can occur at any time (see procedure for displacement below).

Further care and prevention of complications

Mobilisation

If the drain is not on suction, the child can mobilise gently, taking care not to pull the tube.  The drain should remain below chest height at all times and two chest drain clamps should be carried at all times. Parents and family should be taught safety care of the drain (Rationale 34).

If the child is immobilised in bed encourage a semi-upright position (Rationale 35). Always ensure the chest tube is supported so that it does not pull and that the collection unit is below the chest (Rationale 36). Regularly manipulate tubing to empty any fluid filled loops into the collection chamber (Rationale 37). Where viscous fluid (blood/pus) is present in the tubing, the tubing may be ‘milked’ to encourage drainage flow (Rationale 38).

Early involvement of the physiotherapist is key to encourage deep breathing exercises in the immobile patient such as encouragement to blowing bubbles in a child old enough to do so.

Dressing

The entry site of the drain should be covered with a dressing such as Opsite 3000™ to enable the site to be reviewed for signs of redness, oozing and swelling. This dressing should be changed if contaminated with blood or aspirate or every seven days if clean and dry and a dressing is still required (Rationale 39).

Use of clamps

A drain should only be clamped if it is necessary to move the drain above chest height (Rationale 40) or if the collection unit needs changing or the drain tube becomes disconnected from the drain. It does not need to be clamped if the child is moved.

Clamps need to be carried at all times in case of accidental disconnection (Rationale 41).

Accidental disconnection

The drain should be clamped, tubing cleaned and reconnected and a chest X-ray carried out (Rationale 42). A full set of observations should be done, taking particular not of the chest movement and work of breathing and a saturation should be taken (Rationale 43).

Accidental removal of drain

An occlusive dressing such as paraffin gauze should be applied (Rationale 44). The medical team should be alerted to assess and plan further care. A child x-ray should be done as soon as possible after the accidental removal (Rationale 45).

Sampling

Samples of drainage fluid can be taken directly from the drainage tubing for testing the drain fluid for such things as infection markers, white blood cells and the presence of chyle. The following equipment is required:

• small dressing pack
• appropriate cleaning solution
• clean gloves
• syringe and needle
• chest drain clamps
• specimen pot(s)
• specimen form

Sampling: procedure

1. Wash hands and perform aseptic non-touch technique (ANTT) to prepare the equipment.
2. Clamp drainage tubing below fluid level (Rationale 46).
3. Wash hands and put on gloves and clean tubing with chlorhexidine wipe and insert a green needle and aspirate fluid using a 10mls syringe. Take off clamp. Tube is self-sealing.
4. A specimen can also be taken from the back of the drainage unit, not requiring a needle.
5. Ensure the specimen is correctly labelled (Rationale 47).
6. Ensure amount removed is documented (Rationale 48).  

Removal of a chest drain

The indications for removing chest drains include:

• lung re-expansion on chest X-ray
• no evidence of air leak for 24 hours
• fluctuations in water seal chamber stop
• drainage diminishes to little or nothing
• comfortable respiratory effort
• normal breath sounds over both lungs on auscultation (Davis et al 1994)

Pre-removal preparation

It is necessary to inform about the removal and prepare the child/family of the decision and negotiate the timing of the drain removal (Rationale 49).

The decision to remove a chest drain is usually made by the medical team responsible for the patient and should include optimal timing for the child and family. Whenever possible the drain should be removed during the day so that the child can be monitored and observed and go for a departmental chest X-ray post removal.

Members of the multi-disciplinary team may need to be informed or involved such as the physiotherapist. A play specialist may be involved for distraction therapy (Rationale 50) (APAGBI 2008).

Pain relief is important and a bolus should be administered pre procedure, 15 -20 minutes intravenously or half an hour before orally. Alternatively Entonox may be used in certain conditions with an older child but another analgesia may need to be added (Rationale 51) (Bruce et al 2006a; Bruce et al 2006b; Akrofi et al 2005).

Preparation of equipment

Prepare a trolley by collecting the following and then performing ANTT:

• clean gloves
• skin cleansing solution (such as alcoholic betadine^©)
• sterile wound pack
• sterile gauze
• stitch cutter
• appropriate dressing
• paraffin gauze dressing
• sterile skins closure strips, eg Steristrips™

Removal of chest drains: procedure

This is a two person procedure as removal has to be co-ordinated with one removing the drain and the other tying the purse string. One of the health care professionals removing the drain should be experienced in removing a chest drain. Parental presence is encouraged (Rationale 52).

The aim is to remove the drain(s) with minimal risk of air entrainment. If there are two drains to be removed, remove the lower drain first followed by the higher drain (Rationale 53).

• Position the child so you have clear and easy access to the drain.
• Drains remain on suction unless specific instructions to the contrary are given.  For example in the case of a drain removed after a resolved pneumothorax, it is often requested that the drain is taken off suction for a few hours before removal.
• Perform ANTT and bring the trolley close to the patient.
• Expose and clean the drain site and unwrap the purse string from around the drain if in situ.
• Cut off the knot at the distal end of the purse string and give to assistant to tie after removal.
• Prepare the occlusive dressing. 
  
• Clamp the second drain that is not being removed if there are more than two in place.
• Cut the anchoring suture.
• For spontaneously breathing and cooperative children, ask them to practice taking a deep breath in and then remove the drain at the beginning of expiration. If the child is crying intra-thoracic pressure is elevated and it is therefore a good time to remove the drain (Bell 2001).
• Use one hand to withdraw the drain rapidly (within one second). It is sometimes easier to pull the drain vertically so that the drainage holes are pulled out almost together.
• When the drain is out the forefinger and thumb of the other hand to press the skin edges of the drain site together. Alternatively if the skin cannot easily be pinched a finger should press down from above the site directly over the hole.
• The second person now ties the purse string securely, taking care to avoid puckering the skin, with a minimum of three knots.
• Assess the drain site and leave it exposed if possible.
• If it has not been possible to tie the wound edges together, apply an occlusive dressing immediately.
• Occlusive dressings may need to be left in place for at least three days unless soiled or signs of infection are present.
• Settle the child comfortably and conduct and document a full physical assessment including CEWS score (Rationale 54) (Morrison et al 2001).
• Document the procedure (Rationale 55).
• Dispose equipment in accordance with the hospital infection control guidelines.

A chest X-ray will be needed within one hour or earlier if there are signs of respiratory distress (Rationale 56) (Pizano et al 2002; McCormack et al 2002; Pacharn et al 2002). Regular observations of vital signs will continue for four hours. If the child is discharged before five days post drain removal, the family must arrange for the purse string suture to be removed by their community team and they should be made aware of possible signs of infection and who to report it to before the removal. This should be documented in the discharge plan.

Rationale

Rationale 1: Air in the pleural space has caused the lung to collapse so a drain is required to re-expand the lung.
Rationale 2: Blood in the pleural space can compress the lung so a drain is required to evacuate the blood in the pleural space.
Rationale 3: Fluid in the pleural space needs to be drained to allow the lung to expand.
Rationale 4: Lymph fluid in the pleural space occurs after injury or obstruction to the thoracic duct so needs to be drained.
Rationale 5: Pus or infected fluid in the pleural space needs to be drained to allow for lung expansion and the removal of an infection site focus.
Rationale 6: To prevent the build up of blood in the pleural space compromising lung expansion.
Rationale 7: The child and family must be aware of why a drain has to be sited and what this involves.
Rationale 8: The child and family may not have seen or be aware of the purpose of a chest drain.
Rationale 9: To use evidence based practice and a nationally agreed standard procedure.
Rationale 10: To ensure all information is available for the team inserting the chest drain for the safety of the patient.
Rationale 11: To ensure the space has all the equipment and monitoring ready for the care of a child with a chest drain.
Rationale 12: Clamps are necessary in case of accidental disconnection and if the drain has to be moved above head height.
Rationale 13: To have a baseline set of observations on the child and to assess the child is not physically compromised by the insertion of the drain. Any high CEWS score should be reported to the medical team using an Situation, Background, Assessment, Recommendation, Decision (SBARD) report.
Rationale 14: A chest drain, if sited correctly, should not compromise breathing. If this happens the chest drain may have to be resited.
Rationale 15: To prevent trauma to the lungs.
Rationale 16: Suction needs to be patent at all times for the drain to be effective.
Rationale 17: To prevent fluid siphoning back into the chest and compromising the respiratory status.
Rationale 18: To assess that the tube is in the correct position to enable the drain to function.
Rationale 19: To act as a baseline and initial assessment of the drainage.
Rationale 20: To make sure that there are no early signs of infection and that the tube is well sutured in
Rationale 21: To prevent accidental disconnection and trauma and pain to the child if the drain pulls.
Rationale 22: So that there is an accurate record of the drain and the fluid loss.
Rationale 23: Drain insertion is a painful procedure and control of this pain may need specialist advice for a multi-modal approach.
Rationale 24: To reassure the family about the procedure and the after care the child will be receiving.
Rationale 25: This fluid will prevent the tube from draining and functioning, blocking the drainage and causing respiratory compromise.
Rationale 26: This is a rare but potentially dangerous procedure so the drain should be clamped to avoid excess pressure in the chest.
Rationale 27: To make sure the suction water is at the correct level so that the suction exerted on the drain is constant and correct.
Rationale 28: The presence of chylothorax (milky drainage) will require the child to go on a low fat diet. This chyle needs to be analysed to confirm the diagnosis.
Rationale 29: These are signs of the inflammatory response that will be present with infection. Subcutaneous emphysema around the site may indicate and incorrect position of the tube.
Rationale 30: This is a clinical emergency requiring another drain insertion immediately.
Rationale 31: Ultrasound screening is to assess the amount of fluid before inserting another drain recommended by evidence based practice and national guidelines.
Rationale 32: The presence of subcutaneous emphysema indicates the drain is in the incorrect position and that the drain may be blocked.
Rationale 33: A drain site can be a focus for infection. Prophylactic antibiotics may be prescribed to be given before and after insertion in conjunction with local prescribing guidelines.
Rationale 34: Parents need to know what to do in case the drain is accidentally removed or the tubing becomes disconnected.
Rationale 35: In a position to facilitate drainage.
Rationale 36: To allow for drainage and prevent siphoning back into the chest which would compromise the child.
Rationale 37: To allow for free drainage to the collection box.
Rationale 38: Milking allow any thick viscous fluid to clear the tubing but is NOT recommended routinely unless the fluid is of a thick consistency.
Rationale 39: To prevent infection around the site by keeping the entry site clean and dry.
Rationale 40: To prevent siphoning of drainage back into the chest and compromising the respiratory status of the child.
Rationale 41: So that the drain can be clamped immediately if disconnection occurs.
Rationale 42: To assess if another drain is required to be inserted.
Rationale 43: These observations will indicate if respiratory function is deteriorating following accidental removal.
Rationale 44: To prevent air entering the pleural space.
Rationale 45: To assess if another drain is required or if the respiratory condition has deteriorated.
Rationale 46: So that there is a collection of fluid to aspirate to send for analysis.
Rationale 47: So that analysis can be carried out correctly.
Rationale 48: So that accurate fluid balance can be maintained.
Rationale 49: So that the child and family are fully aware of the plan to remove the drain and what this will involve.
Rationale 50: This is to fully prepare the child for the procedure using national guidelines.
Rationale 51: Removal needs full analgesia to prevent a painful procedure. Research has shown that although Entonox is effective another agent should be used in combination using a multi-modal approach.
Rationale 52: To reduce anxiety and promote security and comfort of the child.
Rationale 53: So that apical drain will still function when the lower basal drain is removed.
Rationale 54: To do a full assessment as baseline post procedure and to act as an assessment scale for any problems.
Rationale 55: This invasive procedure should be recorded in both medical and nursing notes.
Rationale 56: To assess the lungs post removal that no collapse has occurred and that both lungs are fully expanded.
Rationale 57: To anticipate any physical problems that may occur as a result of changing vital signs.

References

Reference 1:
Davis JW, Mackersie RC, Hoyt DB, Garcia J (1994) Randomized study of algorithms for discontinuing tube thoracostomy drainage. J Am Coll Surg 179 (5): 553-7.

Reference 2:
McCormick JT, O'Mara MS, Papasavas PK, Caushaj PF (2002) The use of routine chest X-ray films after chest tube removal in postoperative cardiac patients. Ann Thorac Surg 74 (6): 2161-4.

Reference 3:
Morrison RR, Kiker MS, Baum VC (2001) What happens when chest tubes are removed in children? Pediatr Crit Care Med 2 (1): 17-9.

Reference 4:
Pizano LR, Houghton DE, Cohn SM, Frisch MS, Grogan RH (2002) When should a chest radiograph be obtained after chest tube removal in mechanically ventilated patients? A prospective study. J Trauma 53 (6): 1073-7.

Reference 5:
Pacharn P, Heller DN, Kammen BF, Bryce TJ, Reddy MV, Bailey RA, Brasch RC (2002) Are chest radiographs routinely necessary following thoracostomy tube removal? Pediatr Radiol 32 (2): 138-42.

Reference 6:
Laws D, Neville E, Duffy J, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society (2003) BTS guidelines for the insertion of a chest drain. Thorax 58 Suppl 2: ii53-9.

Reference 7:
Akrofi M, Miller S, Colfar S, Corry PR, Fabri BM, Pullan MD, Russell GN, Fox MA (2005) A randomized comparison of three methods of analgesia for chest drain removal in postcardiac surgical patients. Anesth Analg 100 (1): 205-9.

Reference 8:
Bruce EA, Howard RF, Franck LS (2006a) Chest drain removal pain and its management: a literature review. J Clin Nurs 15 (2): 145-54.

Reference 9:
Bruce E, Franck L, Howard RF (2006b) The efficacy of morphine and Entonox analgesia during chest drain removal in children. Paediatr Anaesth 16 (3): 302-8.

Reference 10:
Bell RL, Ovadia P, Abdullah F, Spector S, Rabinovici R (2001) Chest tube removal: end-inspiration or end-expiration? J Trauma 50 (4): 674-7.

Reference 11:
Jones PM, Hewer RD, Wolfenden HD, Thomas PS (2001) Subcutaneous emphysema associated with chest tube drainage. Respirology 6 (2): 87-9.

Document control information

Lead author(s)

Angie Scarisbrick, Advanced Nurse Practitioner, Cardiorespiratory Unit

Additional authors
Heather-Elizabeth Hatter, Clinical Educator, Cardiorespiratory Unit
Elizabeth Leonard, Lead Practice Educator, Cardiorespiratory Unit

Document owner
Heather-Elizabeth Hatter, Clinical Educator, Cardiorespiratory Unit

Approved by
Clinical Practice Committee

First introduced: 2 February 2012
Date approved: 2 February 2012
Review schedule: Two years
Next review: 3 February 2014
Document version: 1.0
Replaces version: n/a