This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The

Transcription

1 Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc.) Guidelines For The Management An Adult Patient With Underwater Seal Chest Drainage. Author: Contact Name and Job Title Lucy Briggs ( Liz Aston (original author) 2009, Holly Scothern PDM 2012) Directorate & Speciality Nursing Development, Corporate Nursing Date of submission November 2015 Explicit definition of patient group to which it applies (e.g. inclusion Chest drainage may be indicated when a lung and exclusion criteria, diagnosis) lesion, chest trauma or cardiac/thoracic surgery punctures the pleura, or when a spontaneous puncture of the pleura occurs This procedure is an aseptic procedure and is undertaken by medical staff with a nurse assisting, under guidance of ultrasound Version 3 If this version supersedes another clinical guideline please be explicit 2 (2012) about which guideline it replaces including version number. Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a 2b 3a 3b meta-analysis of randomised controlled trials at least one randomised controlled trial at least one well-designed controlled study without randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (i.e. comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer 1, 5 and 6 Consultation Process Ratified by: Date: Target audience: Review Date: (to be applied by the Integrated Governance Team) A review date of 5 years will be applied by the Trust. Directorates can choose to apply a shorter review date; however this must be managed through Directorate Governance processes. Nursing Practice Guidelines Group, Ward Sisters/Charge Nurses, Practice Development Matrons (PDMs), Clinical Leads, Matrons, ward managers within respiratory, the matron, Barclay ward manager and deputy and the clinical educator on CICU, Infection Control, Evidence-based practice Council Matron s forum November 2015 Amended and ratified by EBPC 28/09/17 Review 2018 All Registered and non-registered nurses November 2020 This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The ratified by EBPC 28/09/17 Review

2 interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. ratified by EBPC 28/09/17 Review

3 Contents Introduction... 4 Procedure for Insertion of an Underwater Seal Chest Drain... 5 Equipment: For Seldinger (The Most Commonly Used)... 5 Equipment for Wide Bore Chest Drains (I.e. Argyll or Surgical) Preparation of equipment - nursing responsibilities... 6 Ensure informed consent has been obtained from the patient Prepare the drainage system and tubing using an aseptic technique Insertion of the Chest Drain Nursing Responsibilities Management of the Wound Management of the Patient Following Chest Drain Insertion Nursing Management of the Drainage System Changing the Chest Drain Bottle Flushing An Intercostal Chest Drain, With A 3 Way Tap Applying Suction to the Drainage System Removal of the Chest Drain Equipment References and Further Reading Audit Points ratified by EBPC 28/09/17 Review

4 NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST NURSING PRACTICE GUIDELINES MANAGEMENT OF A PATIENT WITH UNDERWATER SEAL CHEST DRAINAGE This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Introduction Chest drainage may be indicated when a lung lesion, chest trauma or cardiac/thoracic surgery punctures the pleura, or when a spontaneous puncture of the pleura occurs. Air or fluid may be drawn into the pleural space by its negative pressure, causing lung recoil and collapse. A chest tube is inserted into the pleural space to drain air, blood or fluid, re-establishing negative pressure and allowing lung re-expansion. A chest drain is usually attached to an underwater seal drainage system which acts as a one-way valve allowing fluid and air to leave the pleural space during expiration and coughing and preventing it from being sucked back in during inspiration (Allibone, 2005). The number and sites of chest tubes inserted will depend on the underlying reason for chest drainage and on what needs to be removed from the pleural space. The medical staff will advise on whether suction needs to be applied to the drainage system. If suction is applied it must be via a thoracic suction system. Best Practice Insertion of a chest drain is reported to be a painful and frightening procedure and patients must be given an explanation of what is going to happen and an assurance that they will receive analgesia before the procedure is carried out (Bourke, 2003; Luketich et al, 1998 cited in Allibone, 2005). ratified by EBPC 28/09/17 Review

5 Procedure for Insertion of an Underwater Seal Chest Drain This procedure is an aseptic procedure and is undertaken by medical staff with a nurse assisting, under guidance of ultrasound. Analgesia should be prescribed and administered before the procedure wherever possible and effectiveness established on a ward, an example of this would be 10mg of oral morphine solution, i.e. oramorph (BTS 2010). Equipment: For Seldinger (The Most Commonly Used) Ultrasound machine if required (usually on RAU) WHO checklist for pleural procedures Consent form 1 ROCKET complete seldinger pack (12f or 18f: confirm with doctor: kept on southwell) 2 x ChloraPrep skin preparation 3ml wands (Chlorhexidine Gluconate 20mg/ml/Isopropyl Alcohol 0.70ml/ml) 2 pairs sterile gloves Lignocaine 1% (20mls for <75kg/25mls for >75kg) 1 Rocket bottle 1 sterile chest drainage tubing NAVY lid VacSax only. 7mm bubble tubing Sterile water Suture: please check with Dr, often a mersilk 1/0 Clear dressing Chest drain chart Equipment for Wide Bore Chest Drains (I.e. Argyll or Surgical) USS machine WHO checklist for pleural procedures Consent form 1 2 x ChloraPrep skin preparation 3ml wands (Chlorhexidine Gluconate 20mg/ml/Isopropyl Alcohol 0.70ml/ml) 2 pairs sterile gloves Sterile gown Lignocaine 1% (20mls <75kg/25mls for >75kg) Intercostal drain and trochar, (size as requested there is no consensus on the size of the optimal chest tube for drainage) (Davies, et al, 2003) Suture usually 1/0 mersilk ratified by EBPC 28/09/17 Review

6 Needles: 1 x orange, 2 x green Syringes: 1 x 20ml and 1 x 10ml Scalpel CSSD pack: either cut down tray or intercostal drainage pack Chest drain bottle (usually ROCKET) Chest drain tubing (usually ROCKET) Sterile water, for the bottle Chest drain chart Sterile clear dressing Sterile scissors 1. Preparation of equipment - nursing responsibilities 1. Ensure informed consent has been obtained from the patient. 2. Prepare the drainage system and tubing using an aseptic technique. To ensure the patient is fully informed about the procedure and any potential risks associated with the procedure. To minimise the risk of infection. 3. Fill the drainage bottle with sterile water to the prime level. This will ensure the rod end of the tubing is 2cms below the fluid line. The green cap should be inserted into the suction port when suction is not being used as it acts as a dust cover. To ensure that air cannot re-enter the pleural space. The GREEN cap marked V (for vent) is a venting cap, which allows the free flow of air from the bottle IT DOES NOT SEAL THE BOTTLE (Rocket Medical 2011) ratified by EBPC 28/09/17 Review

7 4. If required place the system in a holder/tray. 5. Ensure easy access to an oxygen administration system 6. Record baseline observations of pulse, respirations, blood pressure, oxygen saturation levels and early warning scores (EWS). To minimise the risk of the bottle being overturned and breaking. In case of need in an emergency. For comparison with post-procedure observations. Best Practice In some specialist areas where cell salvage is required e.g. the Emergency department the bottle is filled with saline and not water. Please seek medical advice and refer to local guidelines where this is the case. ratified by EBPC 28/09/17 Review

8 2. Insertion of the Chest Drain Nursing Responsibilities 1. In consultation with the doctor who will be inserting the drain, position the patient sitting up, leaning over a bed table or lying on the unaffected side, according to the patient s general condition. 2. Assist the doctor, who will : a. 3. b. c. d. Cleanse the skin, using ChloraPrep wand with a back and forth motion (chlorhexidine gluconate/isopropyl alcohol) for 30 seconds. Allow to air dry. Inject local anaesthetic into the chosen site allowing time for tissue infiltration. Check effectiveness before proceeding. Usual dose: 20ml 1% lignocaine for patients <75kg, 25ml 1% lignocaine for those >75kg (Max dose = 25mls of 1% = 250mg, 3mg/kg). Insert the chest drain and anchor it. Larger drains may also benefit from the use of a mattress suture, for wound closure. Attach the drainage system ensuring all connections are firmly and securely pushed together. If appropriate, longitudinal strips of tape can be used across connections. A chest X-ray should be performed as soon as possible after chest drain insertion. To help maintain patient comfort and to allow access to the insertion site. To reduce the risk of introducing infection. 1 wand covers an maximum area of 15cm x 15cm. To minimise pain during the procedure. To prevent the drain being dislodged and to maintain the seal. (BTS, 2010) Longitudinal strips of tape allow visual checking of the connection to be made. However, taping of tubing is controversial (Godden, 1998). Some studies show it is unnecessary, whilst others advocate the use of tape to reduce the risk of accidental disconnection of the system and to prevent air leak. To check the position of the chest drain. ratified by EBPC 28/09/17 Review

9 3. Management of the Wound 1. The drain must be safely secured to the skin. A clear dressing is often enough to secure, and to allow nursing staff to inspect for both leakage and infection. Some may use an omental tag of tape; this allows the drain to sit off the chest wall and hence reduces the chance of kinking/tension. Drain needs to be secure, to prevent it falling out. Large amounts of tape/padding are unnecessary as may movement and may contribute to excessive moisture (BTS 2010) Re-dress the wound as necessary e.g. if it becomes moist with exudate. Swab site if clinically indicated. Observe the area around the tube insertion for signs of air infiltration e.g. swelling or crackling on palpation. To ensure patient comfort and to detect signs of infection. Subcutaneous emphysema is a possibility and, if this travels to the neck or face, it can compromise airway patency and cause respiratory distress (O Hanlon-Nicols, 1996). If present, report to medical staff, monitor closely and document. ratified by EBPC 28/09/17 Review

10 4. Management of the Patient Following Chest Drain Insertion 1. Take and record the patient s Early Warning Score (EWS). The frequency of subsequent observations should be determined according to the patient s clinical condition/ews. 2. Assess the patency of the chest drainage system by: a. Noting the fluctuation of the fluid level in the drainage tubing ( swinging ) and/ or bubbling during normal respiration and following a deep breath. b. Asking the patient to cough whilst observing for swinging in the bottle or movement in the drainage tube To provide a comparison with baseline observations. Noting the respiratory rate, depth and rhythm and the patient s skin colour are particularly important in assessing the effectiveness of the chest drainage treatment and early detection of complications. Swinging indicates the tube is in the correct position. Bubbling indicates continued air leak. If a drain stops swinging, this should be reported to medical staff (drain may be blocked). Swinging in the bottle following a cough indicates the tube is in the correct position. 4. Administer further prescribed analgesia following insertion of drain if required. There may be considerable discomfort because of the drain presence and analgesia is required (Hilton, 2004). Discomfort and pain may also interfere with adequate lung ventilation and patient mobility. 5. Encourage mobilisation according to the patient s condition reminding patient to keep bottle below insertion site (see 5.1 below). Also see section on suction (page 12). This facilitates optimum drainage from the pleural cavity and so promotes lung ventilation and gaseous exchange. Patients will often not mobilise if they are in pain. ratified by EBPC 28/09/17 Review

11 5. Nursing Management of the Drainage System 1. The chest drainage system must be kept below the drain insertion site. 2. DO NOT clamp/shut 3 way tap the chest drain unless a It is at the direct request of a. senior doctor. The Doctor should document length of time for drain to be clamped. NB: When clamped the patient must be monitored for signs of respiratory distress. A bubbling chest drain should never be clamped. To prevent backflow of fluid into the pleural space and to promote gravity drainage. The chest drain is sometimes clamped before removal to assess how the patient will tolerate removal and to ensure that the lung will remain reexpanded. Shutting the 3 way tap/clamping/raising tubes will also occur during pleurodesis (SEE GUIDELINE : care of patient undergoing pleurodesis Or sometimes just to slow the flow of fluid (in the case of large pleural effusions). Bubbling indicates an active leak of air from the pleural space. Clamping may cause a tension pneumothorax ratified by EBPC 28/09/17 Review

12 3. Routinely assess the patency of the system when carrying out EWS or when clinical condition indicates. To insure that drainage of the pleural space is maintained. If fluctuation or bubbling of the fluid level stops either the lung has fully expanded, the system is obstructed (Schuster, 1998) or the air leak has stopped. This should be documented and reported to medical staff. 4. Ensure the tubing is free of kinks, there are no dependent loops and that all connections are secured. Dependent loops have a negative effect on fluid and air drainage from the pleural space (Gordon, Norton and Merrell, 1995; Carroll 1995). This loop should not become dependent, that is, below the fluid level in the bottle. ratified by EBPC 28/09/17 Review

13 5. If the drain is patent then the fluid level will move with respiration. If it is not moving, the following should be checked: the drainage tubing for kinks and/or blood clots. If present, reposition the patient and encourage him/her to breathe deeply. Then re-check for fluctuations in fluid level. the patient s respiratory rate, depth and volume, the pulse rate, blood pressure and ask the patient if they have any chest pain. Regularly check the tubing for air leaks. It is possible that a tension pneumothorax may be developing which is a life threatening condition. A rapid increase in pressure within the chest can cause mediastinal shift which can impair venous return to the heart and will affect cardiac function (Mattson Porth, 2005). Cardio-respiratory distress may be indicated by a low BP, increased pulse rate and reduced oxygen saturation levels, increased CVP, distended neck veins, increased dyspnoea and chest pain (Gallon, 1998). To ensure the system remains functional (Gallon, 1998). Best Practice Studies have shown that routine milking or stripping of tubing to maintain the patency of the drainage system should be avoided as this increases the negative pressure in the intra-thoracic cavity (Kirkwood, 2002). Avery (2000) suggests replacing the tubing if it becomes blocked. 8. Identify and record the amount and colour of any fluid draining (if appropriate) at least daily but more frequently if requested by the medical staff or local protocols. To monitor the amount and type of drainage. ratified by EBPC 28/09/17 Review

14 9 Large pleural effusions should be drained in a controlled fashion to reduce the risk of re-expansion pulmonary oedema. Only allow the amount specified and documented by medical staff to drain off at one time. It is recommended that this should be a maximum of 1500 ml in the first hour and then 1500ml in two hour intervals (Roberts et al 2010). The rate of fluid removal may be controlled by elevation of the tubing over pillows. However, some drains (Seldinger type) have a 3 way tap in the circuit. This can be used to control drainage, where specified by a medic. 10 When drainage falls below approx. 150 ml per day, a chest x-ray may be ordered. If there is still pleural fluid on the chest X- ray, the doctor may request suction. When mobilising, ensure the 11. drainage system is kept below waist level. If large volumes of fluid are drained quickly this can cause re-expansion pulmonary oedema. If this occurs, stop draining, record EWS, contact medical staff ASAP. NOTE: a bubbling chest drain should never be clamped, and if drain is present for a pneumothorax any shortness of breath/ chest discomfort needs prompt action. Patency of tubes/drain need to be observed. Patients need to be encouraged to breathe deeply. Seek prompt medical advice, and monitor EWS.. To assess re inflation of the lung and to assist the removal of air/fluid from the pleural space To prevent backflow of fluid into the pleural space. 12. In an emergency, such as the chest drainage bottle breaking or drainage tube disconnection, reestablish a sterile system as soon as possible (Schuster, 1998). To prevent infection and maintain the drainage system. ratified by EBPC 28/09/17 Review

15 If the tube accidentally falls out get help and ask for the medical staff and /or Critical care outreach to be alerted urgently. Apply dressing to chest drain site and record full set of observations If an air leak is present, only apply tape to 3 sides of the dressing to allow air to escape whilst seeking urgent medical/ CCOT advice. Monitor EWS. Trauma patients with a haemothorax require drainage to be measured hourly or according to medical instruction. Inform medical staff if blood drainage exceeds agreed parameters. Ensure parameters documented by medical staff To prevent air entering the potential lumen created by the drain and causing a tension pneumothorax (Allibone, 2005). To allow any air to escape from the pleural space, Significant blood loss must be addressed. Problem Cause Action Rationale Drain not bubbling or swinging Lack of drainage The absence of a swing may indicate that the tube is blocked. The lack of drainage may indicate that the drain is blocked or Assess the patient Check for kinks in the tubing If a clot is seen in the tubing, gently squeeze or pinch the tubing between the fingers in the direction of the drainage device. If there is no improvement change the tubing GET SENIOR HELP Assess the patient Check the entire If the dranage in the tube is impeded, there is potential risk for a tension pneumothorax or surgical emphysema to occur Tension pneumothorax ratified by EBPC 28/09/17 Review

16 Problem Cause Action Rationale kinked Tube Connections not becomes adequately secured disconnected Leakage from drain site Continuous bubbling Sudden increased blood or fluid a. Incomplete closure of sutures b. bleeding c. infection a. Leak from chest drain connections b. Persistent air leak within the lung a. Drain previously blocked b. Thoracic bleeding system for kinks and obstructions Straighten the tube If unresolved GET SENIOR HELP Clamp tubing to prevent air entering the pleural space Air will enter Ask another the pleural member of staff to space casing a assess the patient worsening Replace with new pneumothorax tubing and/or tension Ask the patient to pneumothorax cough gently to remove air GET SENIOR HELP Remove dressing, check wound and send swab. Check integrity of sutures Assess the patient Inform medical team and consider blood cultures and antibiotics Assess the patient Check drain, connections and tubing GET SENIOR HELP IMMEDIATELY GET SENIOR HELP Surgical emphysema, sepsis and empyema Unresolved pneumothorax Hypovolaemic shock ratified by EBPC 28/09/17 Review

17 Problem Cause Action Rationale losses in drain Tube eyelets are exposed Chest drain falls out Pain Chest drain has moved Drain not secured a. Drain pulling at site b. Immobility c. Pneumothorax Assess the patient >1500ml loss of blood or 200ml/hour may indicate the need for a thoracotomy GET SENIOR HELP Cover the tubing with an occlusive dressing Assess patient GET SENIOR HELP If mattress suture present close the wound and apply an occlusive dressing Assess patient Prepare for a chest drain insertion Assess patient Review and adjust analgesia Refer patient to the physiotherapist Air will enter the pleural space casing a worsening pneumothorax and/or tension pneumothorax Respiratory distress due to pneumothorax Hospital acquired pneumonia Stiff shoulder Respiratory distress ratified by EBPC 28/09/17 Review

18 6. Changing the Chest Drain Bottle 1. The bottle should be changed: a) when 500ml level is reached b) Or after 7 days in situ. If the drain has been in situ for 7 days the tubing should be replaced as well. 2. Fill the new drainage bottle with Sterile water to the prime level. This will ensure the rod end of the tubing is 2cms below the fluid line. 3. Kink the tube and release the tubing from the old bottle by unscrewing the red button. 4. Insert the tubing into the new bottle, ensuring that the end of the rod is under the level of the water. 5. Release the kinked tubing and ensure the tube is patent by observing for fluid movement in the tubing. 6. Seal and dispose of old chest drain bottle and contents into the designated chest drain disposal box according to waste management procedures. 7. Document drainage amount in old bottle on fluid balance chart/nursing records. Too full a bottle leads to a rise in pressure in the system which in turn leads to difficulty in drainage and is therefore counter-productive To minimise the risk of infection. To ensure that air cannot re-enter the pleural space. To prevent air or fluid from entering the pleural space. To create an intact circuit and prevent fluid from entering the pleural space. To allow drainage from the pleural space. To minimise the risk of infection. To maintain accurate records. 7. Flushing An Intercostal Chest Drain, With A 3 Way Tap. Chest drains need to be closely monitored and kept patent. A simple way of doing this is to flush them regularly. It is the responsibility of the named consultant (or registrar in their absence) to decide on frequency and indication. It makes good sense that small bore drains, draining pleural effusions, could block easily, and would benefit from regular flushes. However; safety issues ratified by EBPC 28/09/17 Review

19 associated with a blocked drain in a pneumothorax means that regular flushing may be indicated. An example would be TDS flushes of 10-20mls of normal saline. These need to be prescribed for and then signed for on a patient s drug card. This procedure is should be performed by an individual who is both available, and trained to do this. This may be medical staff, or if the drain contains a 3 way tap, could be a registered nurse Registered nurses, who have been supervised and assessed as competent may undertake this procedure (SEE COMPETENCY STATEMENT/accompanying nursing procedure). 1. In a designated clean area of the ward, draw up10 20mls of normal saline into the 20ml syringe, check and place syringe on the injection tray ensuring that it is checked in accordance with the local policy. To reduce the risk of contaminating the saline flush. 2. Take the syringe of normal To ensure patient safety. saline to the patient, checking the identity of the patient in accordance with the local policy. 3. Position the patient to allow To facilitate the procedure access to the chest drain, ensuring the patient is comfortable. 4. Perform hand hygiene. To minimise the risk of infection. 5. Open the sterile dressing towel and place under the chest drain. 6. Clean the bung on the 3-way tap supplied with the seldinger drain, using the swab and allows drying. 7. Clean hands and apply alcohol gel. To minimise the risk of infection. To minimise the risk of infection. To minimise potential contamination of the drain and/or equipment used. ratified by EBPC 28/09/17 Review

20 8. Apply the sterile gloves and attach the syringe of saline to the clean bung. Ensure the 3 way tap is closed towards the drainage tubing on the chest drain system. Instil the 10-20mls of normal saline into the chest drain. To ensure the normal saline is instilled along the diameter of the chest drain. 9. Remove the empty syringe from the 3-way tap and ensure the 3- way tap is open to the drainage tubing on the chest drain system, checking that the saline is draining from the chest drain. 10. Dispose of all equipment according to local policy. 11. If the drain is attached to an underwater seal drainage system, ensure the drain is patent by: To facilitate drainage of the normal saline and to check the patency of the chest drain. To prevent the risk of cross infection. To assess and monitor the patency of the drainage system. a) ensuring the fluid level is fluctuating in the drainage tubing. (Allibone, 2003) b) asking the patient to cough and observe for fluctuation of the fluid in the drainage tubing. 12. Observe the patient by monitoring the temperature, pulse, respirations and blood pressure 4 hourly (Allibone, 2003). In addition, monitor the patient for chest pain and/or discomfort and continue to assess the patency of the drainage system if the drain is attached to an underwater seal drainage system. To monitor the patient for any ill effects from the procedure and to facilitate the early detection of complications. If any pain occurs, following the flush, seek medical advice, and do not repeat flush until reviewed. ratified by EBPC 28/09/17 Review

21 8. Applying Suction to the Drainage System If the insertion of a chest drain is insufficient for the removal of air/fluid from the pleural space, suction via a thoracic suction regulator, or through specific equipment, may be applied to assist in this process. This is a decision made by medical staff. Suction pressure should be set according to either specific written instructions in the patient s records or locally agreed written protocols. There is currently no consensus on how much suction should be applied (Avery, 2000) nor is there sound evidence or clinical consensus to base specific guidelines in this area (Davies et al, 2003). Note: (if using WALL SUCTION), when suction is applied to a chest drainage system, an intermediate collection jar or canister must be placed between the suction regulator and chest drain bottle. This is to prevent activation of pipeline protection and subsequent loss of suction which could lead to a tension pneumothorax, should the chest drain bottle overflow. (MHRA MDA/2010/040, and Supplementary advice for MDA/2010/040 All chest drains when used with high-flow, low-vacuum suction systems (wall mounted).) In certain areas, for example, respiratory and cardiothoracics, there are specific pieces of equipment that can be used to apply suction. These are the medela Thopaz pumps. Indication for the use of these pumps lies with the medical team, namely the consultant in charge of the patient. In addition, any nursing staff involved in the care of these pumps must have completed the medical devices statement entitled medela Thopaz and cardiothoracic drainage system. ratified by EBPC 28/09/17 Review

22 WALL SUCTION 1. Suction 2. Intermediate collection canister 3. Clear bubble tubing with a minimum diameter of 7mm*. 4. Rocket blue bottle chest drain with underwater seal 5. Patient NAVY lid VacSax only. Thoracic suction unit only NEVER use Black or Green lidded VacSax ** Fill with sterile water to 0 /Prime level line Ensure that the following is adhered to: The Rocket blue bottle chest drain (4) from the patient (5) is the underwater seal, and must have sterile water to the FILL/ 0 line (4). Using 7mm* clear bubble tubing (3), attach the patients underwater seal via the green capped outlet port of the Rocket blue bottle (4) to the Navy VacSax bottle (2). NEVER use green or black lidded VacSax bottles**. Use the minimum length possible but definitely no longer than 3m. If there are supply issues with Navy lidded VacSax, a 2 nd Rocket blue bottle can be used; DO NOT put water in it. Use the 8mm VacSax tubing to connect the intermediate canister (2) to the thoracic suction unit (1). ratified by EBPC 28/09/17 Review

23 *Tubing narrower than this should never be used as it reduces the flowrate which reduces effectiveness of chest drain suction **Green/Black lidded VacSax bottles contain an integrated filter which reduces flowrate which reduces effectiveness of chest drain suction ONLY EVER USE THORACIC SUCTION UNITS ratified by EBPC 28/09/17 Review

24 ATTACHING WALL SUCTION Fix one end of the suction tubing onto the suction unit and the other onto the collection canister between the regulator and the chest drain bottle. Ensure an inline filter is used to protect the piped suction system. Only use thoracic suction systems. Set the suction rate according to the written instructions or local protocol. This will normally be between 10 to 20cm H2O, (1 and 2 Kpa ). The suction pressure assists the drainage of fluid/air from the chest cavity. At NUH we use a rocket bottle as the collection canister, this is for safety. There is a potential risk if the liner system is used eg. serres. The collection/intermediate canister (rocket bottle) does NOT need water in it. SEE PICTURE If the suction is applied at too high a pressure, it can harm lung tissue or trap lung tissue in the chest tube eyelets (Tooley, 2002) Check frequently that the suction is set as instructed. Change the drainage system when fluid levels go above 500mls. Disconnect the suction system before switching off to reduce the risk of mimicking clamping To ensure the correct level of suction is maintained. High fluid levels will affect the efficiency of suction. If the suction unit only is turned off there is no valve in the system to allow air/fluids to travel down to the drain this has the same effect as clamping. ratified by EBPC 28/09/17 Review

25 ATTACHING THOPAZ SUCTION SYSTEM 1. Open sterile tubing packaging, keep patient connector in the internal bag 2. Inspect machine, check presence of orange seal. Attach the tubing with care. Keep machine on a flat surface whilst doing this and take care not to force or bend end of tubing. 3. Insert bottom of the canister first, then snap the top of the canister into place. Do this with machine on a level surface. 4. Switch Thopaz+ unit on using on/off button. 5. Confirm if a new patient is being attached. 6. Check that the correct sized canister has been identified. 7. Perform the functional check. This is done by occluding the tubing (with sterile gloved finger) or using clamp and the pressing on 8. Switch the machine to standby (press for 3 seconds), and then attach to the patient. Check clamp is off. Press on to start therapy. 9. To replace the canister, clamp tubing, switch to standby (press for 3 seconds), remove old canister and replace with a new one. Gets tubing ready, whilst keeping the patient connector sterile. Machine will not function properly if seal is not present or if tubing not attached correctly. Ensures safe attachment of canister. This will put machine in standby mode. In between patients, the settings MUST be cleared. The air leak value must DECREASE. If it does not do not use. In most cases the machines will be preset, for example, on respiratory it will be set to 20 cm H20. This can be altered as per consultant s wishes/indication. Dispose of canister as per trust guidelines. ratified by EBPC 28/09/17 Review

26 9. Removal of the Chest Drain Once drainage of fluid or air has diminished to little or nothing and/or fluctuations in the water-seal chamber have ceased, the chest drain may be removed at the request of the medical staff. The drain may be removed by medical staff or by nurses who have been assessed as competent in the procedure. If using the Thopaz+ system decision to remove drain is often based on the air leak value. This is a clinical decision and will be decided by the patient s consultant. A typical value within respiratory medicine might be an air leak that has be 40ml/minute for a certain amount of time. A chest X-ray may be performed prior to removal to establish that the lung has re-expanded. Sometimes, if requested by medical staff, the patient is given a trial period with the chest drain clamped to ensure that the lung will stay inflated and respiratory distress avoided. Equipment Medium basic pack - if required Stitch cutter if required Sterile dressing Hypo-allergenic tape 2 pair s non-sterile gloves Sterile scissors and specimen container, if required Clinical waste bag Gel sachets Administer prescribed analgesia 20 minutes prior to removal, if appropriate. Position the patient on the unaffected side or sitting up wellsupported by pillows. Ask the patient to practice holding their breath for 3 5 seconds. Perform hand hygiene and apply gloves. Remove the dressing. The patient may experience shortlasting but intense pain on removal (Hilton, 2004). To facilitate the drain removal. To facilitate the procedure. To minimise the risk of cross infection. To allow access to the insertion site. ratified by EBPC 28/09/17 Review

27 6. 7. If the drain is sutured in place, this is a 2 person procedure. Remove the securing suture if present. The mattress suture, if present, can be used to close the wound. This should be done by competent staff Ask the patient to perform a Valsalva manoeuvre. This manoeuvre requires the patient to take a deep breath and then strain against a closed airway (most easily achieved by closing the vocal cords) in order to increase intra-thoracic pressure. The nurse should explain this to the patient (perhaps using the example of straining to pass a motion). The patient should rehearse this procedure to the nurse s satisfaction prior to removal of the tube and then perform it at the nurse s request during the removal of the tube (Godden, 1998). The tube should then be removed and placed on the sterile field on the trolley. Allows tube to be removed only when the least negative pressure can be generated. Positive pressure is rarely achieved (Marieb, 2004), thereby reducing the risk of complications. If the patient is not able to hold his/her breath, remove during expiration. ratified by EBPC 28/09/17 Review

28 8 The mattress suture can be used to close the wound. For small wounds (for example with seldinger chest drains) the use if steri strips should be considered. To prevent air from entering the pleural space via the drain site. To aid wound closure and healing. If there are signs or evidence of 8. infection, send the end of the drain for microbiological investigations and swab the site. 9 Apply a sterile dressing to the drain site Monitor the patient s respiratory status and wound drainage as clinically indicated. Seek urgent medical advice if clinically indicated. Any suture, if present, is usually removed 5-7 days after chest drain removal once the drain site has healed. 11. Check with medical staff if a chest X-ray is required following removal of the drain. 12. Seal and dispose of old chest drain bottle and contents into the designated chest drain disposal box according to waste management procedures. To detect the presence of any pathogens. To reduce the risk of infection and to prevent air re-entering the pleural space until the wound is sealed. Shortness of breath, sudden chest pain or deterioration in observations may indicate collapse of the lung and/or reaccumulation of fluid. In patients who have had a pneumonectomy, a large volume of fluid fills the space. There is a risk of fluid leakage and infection and so the suture is normally left in place for 7 days. To check that air has not entered the pleural space during removal of the drain. To minimise the risk of infection ratified by EBPC 28/09/17 Review

29 References and Further Reading Allibone L (2005) Principles for inserting and managing chest drains Nursing Times Vol. 101 No. 42 pp Avery S (2000) Insertion and management of chest drains Nursing Times Plus Vol. 96 No. 37 pp.3-6 British Thoracic Society Management of Pleural Infection in adults: British Thoracic Society Pleural disease guidelines Thorax 2010; 65(suppl 2):ii41-ii53 Pleural disease guidelines 2010 Bourke S J (2003) Lecture Notes on Respiratory Medicine 6th Edition Oxford: Blackwell Gallon A (1998) Pneumothorax Nursing Standard Vol. 13 No. 10 pp Gordon P Norton J, Merrell R (1995) Refining chest tube management: analysis of the state of practice Dimensions of Critical Care Nursing Vol. 14 No. 1 pp Hilton P (2004) Evaluating the treatment options for spontaneous pneumothorax Nursing Times Vol. 100 No. 28 pp Luketich J. D., Kiss, M., Hershey, J., Urso, G.K., Wilson, J., Bookbinder, M., Ginsberg, R., (1998) Chest tube insertion: a prospective evaluation of pain management Clinical Journal of Pain Vol. 14 No. 2 pp Marieb, E. N. (2004) Human anatomy and physiology 6 th Edition Benjamin Cummings, Menlo Park, California, USA. Mattson Porth C (2005) Pathophysiology: Concepts of altered health states 7th edition Philadelphia, USA: Lippincott MHRA MDA/2010/040, and Supplementary advice for MDA/2010/040 All chest drains when used with high-flow, low-vacuum wall mounted suction systems. Mimnaugh L (1999) Sensations experienced during removal of tubes in acute post-operative patients Applied Nursing Research Vol. 12 No. 2 pp NPSA (2008) Risks of chest drain insertion NPSA/2008RRR003 ratified by EBPC 28/09/17 Review

30 O Drisoll Robert and Pyne H (2008) Insertion of a Seldinger intra pleural chest drain (accessed 2011) O Hanlon-Nichols T (1996) Commonly asked questions about chest tubes Rocektmedical(2011) pdf Roberts M E, Neville E, Berrisford R G, Antunes G and Ali N J (2010) Management of a malignant pleural effusion British Thoracic Society Pleural disease guidelines Thorax 2010; 65(suppl 2):ii Schuster P (1998) Chest tubes: to clamp or not to clamp Nurse Educator Vol. 23 No. 3 pp Sullivan B (2008) Nursing management of patients with a chest drain British Journal of Nursing Vol. 17 No. 6 pp Tooley C (2002) The management and care of chest drains Nursing Times Vol 98 No 26 pp NNPDG Link Members: Jill Wakefield/Holly Scothern with thanks to Debbie Raffle, Lucy Briggs and Rhona Al-Bazzaz for their help in compiling this procedure. Audit Points Is the patient s safety assured with respect to chest drain procedures? Has the patient s dignity and comfort been effectively maintained prior to, during and after chest drain procedures? Has the patient received timely analgesia prior to chest drain procedures? Has the patient received appropriate explanation prior to chest drain procedures? Is there evidence of prevention of infection throughout chest drain procedures? ratified by EBPC 28/09/17 Review

31 Is there confirmation that chest drain procedures are successful following removal of a chest drain (i.e. is the patient s breathing pattern and rate within normal adult limits; are oxygen saturations within normal limits for the patient; are vital signs satisfactory?) Is there any evidence of pain associated with breathing following the removal of the chest drain? ratified by EBPC 28/09/17 Review