To promote evacuation of air and fluid, the nurse encourages coughing and deep breathing as well as use of an incentive spirometer. Teach or assist the patient with splinting the chest to enhance respiratory excursion. Place the patient in Fowler's position to facilitate lung expansion and change position every 2 hours to facilitate drainage. While the patient should not lie on the tube, the patient can be positioned on the affected side if towels or small pillows are placed on either side of the tube to prevent compression.
Avoid dependent loops in the tubing by loosely coiling the tube on the bed and allowing the rest of the tubing to fall in a straight line toward the drainage unit. Tape all connections securely. Ensure the occlusive dressing is intact. Traditionally petrolatum gauze has been used to prevent air from entering the pleural space, however, some institutions avoid this type of dressing due continued moisture and skin maceration.
The nurse should assess pain and offer medication as required; narcotic analgesics, NSAIDs or the lidocaine patch may be used.4 Tape the drainage unit to the floor or secure to the bed lower than the patient's chest with the hooks provided.
Resolving Common Problems
Drainage Slows or Stops. Studies show that drainage from the pleural space is impeded when tubing has a dependent loop; ensure the tubing is straight or loosely coiled for optimal drainage.5 Drainage accumulating in the tubing will impede suction. If there is no way to position the tubing as described, physically lift the tubing and empty drainage into the device every 15 minutes or as it accumulates.
If drainage abruptly slows or stops, the nurse should suspect occlusion, perhaps by a clot. Newer tubing contains a non-thrombogenic coating to prevent clotting.2 Use a gentle squeeze and release motion to small segments to the tubing to help the drainage move through. If drainage cannot be reestablished, consult with the surgeon.
Stripping. Current evidence related to routine stripping of chest tubes states this practice is not indicated as increased intrathoracic pressures can entrap lung tissue in chest tube eyelets and potentially increasing bleeding.5 Increased intrathoracic pressures also impairs left ventricular function. If a clot is seen in the tubing, gently squeeze or pinch the tubing between the fingers in the direction of the drainage device.1,5
Clamping. Chest tubes should not be clamped except when ordered as outlined in the following or to determine the source of an air leak. Chest tubes may be clamped, momentarilty, to determine the source of an air leak. Begin clamping close to the patients' chest. If bubbling in the water seal stops, the leaking air was coming from inside the patient. If the bubbling in the water seal continues, the nurse moves the clamp several inches closer to the drainage device, increment by increment. When the bubbling stops, the air leak is in the area between the current placement and previous placement of the clamp. If the leak is in the device or tubing, changing the device is indicated.
Clamping may be ordered by the physician on a trial basis to determine if the chest tube is ready to be removed. Clamp the chest tube close to the patient and frequently observe for shortness of breath or dyspnea, apprehension, chest pain or cyanosis indicating a tension pneumothorax. A tension pneumothorax is a emergent condition as air entering the pleural cavity with each inspiration is unable to escape, causing the trachea and mediastinal contents to shift toward the unaffected side. The affected lung collapses, the normal lung is compressed and cardiac output is severely reduced. If this occurs, unclamp the tube, administer oxygen, and notify the physician; the tension pneumothorax must be relieved immediately. One last reason to clamp a chest tube is momentarily, when changing the drainage device. Do not clamp the chest tube to transport the patient.
Accidental Disconnection. If the chest tube becomes accidently separated from the drainage unit tubing , wipe the exposed end of the tube with an antiseptic and reconnect. Alternatively, cut off the contaminated end and re-insert.1 If the tube is accidently removed, place an occlusive dressing over the area and notify the physician. If the drainage unit cracks, breaks or malfunctions, keep a bottle of sterile water at the bedside, insert the chest tube 2 cm below the level of the water to prevent air from entering the pleural space and call for assistance; the assistant will need to set up a new drainage device.
Transporting Patients. Patients may be transported so long as the drainage device is kept lower than the patient's chest. Generally, suction can be discontinued for short periods of time during transport. Obtain a physician order if that is the practice at your institution. Portable suction can be used if suction is required during transport or at the destination.
Changing the Drainage Device. Prepare the new device. Have the client take a deep breath, bear down or perform the Valsalva maneuver. Momentarily clamp the tube, remove the old tubing and insert the new tubing into the new unit. Immediately release the clamp. Apply suction if indicated. When suction is discontinued, turn off the suction at the wall or suction device. Disconnect the tubing from the suction port, leaving the chest tube attached to the drainage tubing. The system should be open to the atmosphere so that intrapleural air can escape. Some drainage systems have a safety feature, or pressure relief valve, prevent build up of air in the pleural space.
Removing Chest Tubes. The chest tube will be removed when the pneumothorax resolves or when drainage is minimal.4 Tidaling will stop, as demonstrated by lack of bubbling in the water seal. Pre-medicate the patient for pain, as this procedure can produce some discomfort. Have a suture removal kit available. The surgeon will cut the sutures, clamp and remove the tube while simultaneously placing gauze or petroleum gauze tightly over the chest tube site. An occlusive dressing is applied. A chest X-ray will be ordered to ensure the lung remains re-expanded. Monitor the patient for signs and symptoms of recurrent pneumothorax, such as increased respiratory rate or effort, chest pain, decreased breath sounds on the affected side. Vital signs should be obtained every 15 minutes for the first hour, then at increasing intervals if stable according to hospital policy.
In situations where pneumothorax becomes chronic, small chest tubes, less than 14 French may be used. A flutter valve, such as the Heimlich valve, may be used to prevent air entering the pleural space. The valve closes on inspiration and opens to allow air escape the pleural cavity on expiration. This affords patients more mobility and earlier discharge. A large chest drainage unit is not required, making them useful for emergency transport, home care or long-term care.
For chronic pleural effusion, pleurodesis may be performed. This procedure causes adhesion of the visceral and parietal pleura and prevents further fluid accumulation. A chest tube is inserted to drain the effusion, followed by installation of a sclerosing agent. The patient is repositioned to allow the drug to come in contact with all pleural surfaces. Typical medications used to promote sclerosis include pleurodesis, doxycycline or minocycline for injection.2
Evidence in Practice
A full respiratory assessment, interventions for pain, use of incentive spirometer, assessment for subcutaneous emphysema is documented. the amount of suction, presence of an air leak in the water seal, the quality, quantity and characteristic of the drainage, the condition of the dressing is performed according to hospital policy.
Outcomes for patients with or without suction have been explored. Some researchers have found no evidence that suction is superior in facilitating drainage and recovery, especially in the non-trauma population.3,6 Findings indicate suction may limit mobility and prolong recovery.6 Many decisions related to management of patients with chest drains appear to be based on personal preference, rather than evidence.7 National standardized education and guidelines for care have not been developed. Further evidence is needed to confirm best practices in these areas.
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1. Smeltzer, S., Bare, B., Hinkle, J., et al. (2010). Brunner and Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Wolters Kluwer Lippincott Williams and Wilkins.
2. Nettina, S. (2010). Lippicott manual of nursing practice (9th ed). Philadelphia: Wolters Kluwer Lippincott Williams Wilkins.
3. McQuillan, K., Makic, M., & Whalen, E. (2009). Trauma nursing: From resuscitation through rehabilitation. St. Louis: Saunders Elsevier.
4. Morton, P., & Fontaine, D. (2009). (9th ed.). Philadelphia: Wolters Kluwer Lippincott Wiliams & Wilkins.
5. Halm, M. (2007). To strip or not to strip? Physiological effects of chest tube manipulation. American Journal of Critical Care. 16(6), 609-612
6. Gupta, S., Hicks, M., Wallace, M., et al. (2008). Outpatient management of postbiopsy pneumorthorax with small-caliber chest tubes: Factors affecting the need for prolonged drainage and additional intervention. Cardiovascular and Interventional Radiology, 31(2), 342-348
7. Lehwaldt, D., & Timmins, F. (2007). The need for nurses to have in service education to provide the best care for clients with chest drains. Journal of Nursing Management, 15(2), 142-148.
Rushing, J. (2007). Clinical do's & don'ts: Managing a water-seal chest drainage unit. Nursing 2007, 47(12), 12.
Andrea Mann is an instructor at Aria Health School of Nursing, Philadelphia.