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Respiratory CareAdults

Caring for the patient with a chest drain Part 3: problem solving

Demonstrated by Liz Allibone, Head of Clinical Education and Training andJane Smith, Practice Educator in Cardiothoracic Services, Royal Brompton and Harefield NHS Foundation Trust

©2016 Clinical Skills Limited. All rights reserved

The practitioner needs to be aware of complications and problems that can occur with chest drainage systems and the steps which should be taken to resolve them. It is possible to avoid many common complications caused by a blocked or kinked tube by regularly inspecting the drain and its entry site, and educating your patient. It is important to investigate any new bubbling or any bubbling that has stopped suddenly, and to report any observations of this kind to the medical team.

Patients can find it frightening to have a chest drain and it is therefore important to encourage them to ask questions if they have any concerns and to provide them with adequate explanations. MacDuff et al. (2010) recommend that complex drain management (for example, suction and drain repositioning) is best delivered in areas where specialist medical and nursing expertise is available.

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain his/her consent, in line with the policies of your employer or educational institution.

The tube may become blocked with clots but routine milking and stripping of chest drain tubing, or use of a device of the kind shown, in order to remove clots or promote drainage, is not usually recommended because it may lead to damage of the tissues in the intrathoracic cavity.

Milking or stripping the tube in these ways is not recommended as it can increase the chance of tension pneumothorax occurring (Sheppard and Wright, 2006).

It is usually recommended that the tubing should be changed (see inset) if it is obstructed (Avery, 2000). However, it may be possible to pinch the tubing briefly above the clot to dislodge it and move it towards the bottle and away from the chest.

Problem 1: Blocked tube (a)

(b) Solution: Change the tube

Shouldn’t her right hand be pinching the tubing?

0100

200300400

500mlPRIME LEVEL

Name: WHITE Tim

DOB: 20-Aug-1991

Sex: M

NHS No: 460 955 7867

681207

Respiratory Care

Adults

Care of the patient with a chest drain Part 3: Problem solving Page 2

If the bubbling continues

Reconnect to a new sterile set of drainage tubing Observe the patient and provide reassurance

If you suspect that there is a leak in the tubing, pinch the tubing (or kink it) close to the chest wall. If the bubbling stops, this means that the leak is close to (or from) the insertion site. You should notify a member of the medical team. If the bubbling does not stop, however, a small hole or loose connection may be causing air to escape from the tubing and you may hear a hissing noise. In this case, air can also pass into the drainage bottle, where you will see bubbling.

If the bubbling continues while you are pinching the tubing close to the chest wall, try pinching the tube, working your way along the tubing away from the patient. When the bubbling stops, it means that you have located the leak (which will be just above where you have pinched the tubing). You will need to change the tubing or tighten connections (see Problem 3). If there is no air leak present in the drainage tubing, and all of the above have been checked, the leak may be present in the lung and you should inform the doctor.

If the intrapleural tube has separated from the drainage tube, immediately apply a clamp to the intrapleural tube, using an aseptic technique, in order to avoid air entering the pleural space.

Reconnect to a new sterile set of drainage tubing as soon as possible. Do not use the existing tubing as it may have become contaminated when it became disconnected. Wipe the end of the patient’s tube with 2% chlorhexidine gluconate in 70% isopropyl alcohol and allow to dry before connecting the new tube.

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Problem 3: If the chest tube becomes accidentallydisconnected from the drain, clamp it and rejoin

Problem 2: Suspected air leak/continuous bubbling Solution: Check system for loose connections in tubing or around drainage unit, then bend or pinch the tube to locate the leak

Ask the patient to cough gently to aid air removal. Report the incident to the doctor; reassure the patient. Depending on local policy, you may need to fill in an incident form. A repeat chest radiograph may be needed to check for signs of a pneumothorax and confirm the correct position of the drain. Consider using H-shaped securing tape at the connecting site (Barrett et al., 2015).

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain his/her consent, in line with the policies of your employer or educational institution.

NEWS KEY0 1 2 3

DATETIME

≥2521-2412-20

9-11≤8

230220210200190180170160150140130120110100

9080706050

≥39°38° 37°36°

≤35°

≥9694-95 92-93

≤91%

RESP.RATE

TEMP

NAME: D.O.B.

3

31

2

3

33

1

1

1

2

3

12

22

ADMISSION DATE:

BLOODPRESSURE

Inspired 02%

SpO2

MR WHITE 20/8/199125

3/25

3/25

3/08

14 1412

97

37

130 132128X XX

X XX 7572

37.1

9898

IL ILIL

10 14

NEW SCOREuses Ststolic

BPCOLOURED

NO 7900)

P52270)

LOW VAC

SUCTION-kPa

1520

30 0

10

25 5

225-mmHg

200

150

50

100

ON

Name: WHITE Tim

DOB: 20-Aug-1991

Sex: M

NHS No: 460 955 7867

681207

Help!

Respiratory Care

Adults

Caring for the patient with a chest drain Part 3: Problem solving Page 3

If the suture is not visible

Alternatively, pinch the wound edges together Observations

Problem 5: If the bottle has fallen over, stand it upright Problem 6: Leakage from around the insertion site

Put on gloves immediately and put on an apron as soon as possible. Check the suture site and pull the mattress suture immediately to close the wound: the aim is to prevent air entering the pleural space. Cover the wound with a sterile dressing and report the incident to the doctor. Check the patient's vital signs and respiratory status.

If the suture is not visible, immediately cover the hole on the patient’s chest with a gloved finger and call for help.

Alternatively, pinch the edges of the hole together. Call for help and notify the doctor immediately.

When help arrives, it may be possible to secure the incision site with adhesive wound-closure strips underneath an occlusive sterile dressing. Perform patient observations immediately. The doctor may order a chest radiograph or may immediately insert a new chest drain.

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Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain his/her consent, in line with the policies of your employer or educational institution.

Problem 4: If the intrapleural tube comes out of the insertion site, pull mattress suture, cover the wound

If fluid is leaking from around the insertion site, remove the dressing (if present) and observe the site. Check that the drain has not become dislodged and that the sutures are intact. Take a swab from the leakage if any signs of local or systemic infection are present.

If the bottle has fallen over, put on gloves immediately and put on an apron as soon as possible. Stand the bottle upright immediately and observe the patient. Examine the bottle to make sure it has not been damaged.

7/5/2014DATETIME

≥2521-2412-209-11≤8

2302202102001901801701601501401301201101009080706050

≥39°38° 37°36°≤35°

≥9694-95 92-93≤91%

ADMISSION DATE:

COLOURED

NO 7900)

P52270)

LOW VAC

SUCTION-kPa

1520

30 0

10

25 5

225-mmHg

200

150

50

100

ON

Name: WHITE Tim

DOB: 20-Aug-1991

Sex: M

NHS No: 460 955 7867

681207

0100

200300400

500

500mlPRIME LEVEL

600

700800900

10001100

120013001400

15001600

17001800

Respiratory Care

Adults

Caring for the patient with a chest drain Part 3: Problem solving Page 4

Problem 7: Lack of drainage/bubbling

Problem 8: Re-expansion pulmonary oedemaDraining large effusions incrementally

Send the swab for microbiological analysis. Report the problem to the medical team. Apply a new dressing of absorbent material, using an aseptic technique; consider protecting the surrounding skin from moisture damage. Document the colour, amount and type of drainage.

If the fluid in the drain is not swinging, or little or no fluid is draining into the bottle, or the fluid in the drain is not bubbling as expected, the drain may be occluded or in the wrong position. This may cause a pneumothorax (collapsed lung). Take time to check the tubing for any obstruction, kinks or loops and that it is hanging freely from the patient. Lift the tubing to see if the blockage will clear. Seek medical advice as it may be necessary to replace the drain (Barrett et al., 2015).

It is acceptable, if carried out by a suitably trained and competent practitioner, to slightly withdraw part of the chest drain to correct poor positioning, but the tube should never be pushed further back in, because of the risk of infection (Roberts et al., 2010).

Monitor the amount of drainage and report to the medical team if there are signs of haemorrhage; causes may include puncture of the lung or other major organ, puncture of the internal mammary artery or pulmonary laceration. Monitor the patient’s cardiovascular parameters and document the blood pressure, pulse, oxygen saturations and respiratory rate. Notify the medical team of any deterioration.

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Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain his/her consent, in line with the policies of your employer or educational institution.

Send the swab to the lab

Large pleural effusions should be drained with close monitoring of the patient, taking blood pressure, heart rate and oxygen saturation readings every 15 minutes. Pleural effusions should be drained incrementally, draining a maximum of 1.5 L on the first occasion. Any remaining fluid should be drained up to 1.5 L at a time, at 2-hourly intervals, stopping if the patient develops chest discomfort, persistent cough or vasovagal symptoms such as a sudden drop in heart rate and blood pressure. The patient may become sweaty and look pale, and can feel dizzy or nauseous (Roberts et al., 2010).

Re-expansion pulmonary oedema is a serious but rare complication following expansion of a collapsed lung through evacuation of large amounts of pleural fluid on a single occasion (Havelock et al., 2010). To control excessive drainage, you may need to clamp the chest drain (see left; see also “Caring for the patient with a chest drain Part 1: Assessment and monitoring”).

0100

200300400

500

500mlPRIME LEVEL

600

700800900

1000

1500

1100

1200 1300

1400If necessary, correct the position of the drain Increased or excessive drainage