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Intrapleural chest drainage multiple choice questionnaire
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Intrapleural chest drainage NS696 Woodrow P (2013) Intrapleural chest drainage. Nursing Standard. 27, 40, 49-56. Date of submission: November 19 2012; date of acceptance: March 15 2013.
Abstract Abnormal fluid or air between the pleura results in respiratory distress and can cause death, if untreated. Intrapleural chest drains are used to remove abnormal accumulations of fluid or air. Caring for patients with intrapleural chest drains requires knowledge and skill to ensure patient safety. This article describes the pathophysiology, treatment and nursing care of patients who require intrapleural chest drains.
4Explain how intrapleural chest drains work. 4Outline the observations that nurses should record in relation to intrapleural chest drains. 4Describe the nursing care and management of patients with intrapleural chest drains. 4Develop a care plan for a patient with an intrapleural chest drain.
Introduction
Author Philip Woodrow Practice development nurse, critical care, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent Correspondence to: [email protected]
Keywords Chest drains, pneumothorax, patient safety, respiratory diseases
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
Aims and intended learning outcomes The aim of this article is to enhance readers’ understanding of how intrapleural chest drains work, what dangers they can expose patients to, and how to provide safe nursing care for patients with intrapleural chest drains. After reading this article and completing the time out activities you should be able to: 4Describe the pathophysiology of a pneumothorax.
The two main organs in the chest, the heart and lungs, contain potential spaces between their two outer layers, the pericardium in the heart and pleura in the lungs. These potential spaces usually contain only a thin film of serous fluid, but disease, trauma and surgery can cause accumulations of fluid. Large accumulations may be life-threatening, necessitating drainage. While pericardial and mediastinal drains are used commonly after cardiac surgery, nurses working in most areas other than cardiac surgery will be more familiar with drains used to remove air, blood or other fluids from the pleural cavity. This article describes intrapleural chest drainage systems. These are often called intercostal chest drains, but because cardiac chest drains are also usually inserted through the intercostal muscles, this article uses the term intrapleural. Some collections of air or fluid may be small enough to drain using needle aspiration. However, larger collections usually necessitate chest drain insertion into the intrapleural space and connection to a collection chamber. While closed tube drainage was first described in 1876, chest drains only became widely used during the worldwide influenza epidemic of 1917-1919 (Davies et al 2010). The principle of inserting one end of a tube into the pleura, and the other into a bottle of water placed below the patient’s chest level (with height creating gravity
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Learning zone respiratory nursing drainage and water creating a seal), and termed ‘underwater seal drain’, remained essentially unchanged for almost a century, although two or sometimes three bottles were sometimes used to improve drainage of fluid and enable vacuum suction. The late 20th century saw improvements in equipment, but evidence for practice, especially nursing practice, has often been weak, anecdotal, and dated (Charnock and Evans 2001, MacDuff et al 2010, Fremlin et al 2011). This article uses current evidence, specifically the British Thoracic Society (BTS) Pleural Disease Guideline 2010 (BTS 2010) to inform nursing care.
Physiology of the pleura
1 Reflect on a patient for whom you cared who required intrapleural chest drainage. Why was the chest drain required? What caused the pneumothorax or pleural effusion? Outline the nursing care provided, any problems experienced related to the chest drain, and solutions, if problems occurred.
The outer layer of the lung is formed of two membranes called pleura, between which is a thin film of serous fluid of typically 2-5mL (Roskelly and Smith 2011). The outer, or parietal, pleura adheres to the rib cage, while the inner, or visceral, pleura adheres to the lung tissue. Active muscle movement of inspiration draws the intercostal muscles outwards, drawing the parietal pleura with them. The serous fluid allows the pleura to glide over each other, while ensuring both pleura expand and contract together (Marieb and Hoehn 2012). Thus, the visceral pleura is also drawn outwards on inspiration, creating negative pressure in the lungs (van Miert et al 2012), which causes the airways to open during inspiration (Marieb and Hoehn 2012). Damage to either of the pleura allows air, blood, or other fluids to accumulate in the usually small intrapleural space. Since the parietal pleura adheres to the rib cage, abnormal collections of fluid or air force the visceral pleura inwards, causing the lung to collapse and resulting in respiratory distress. Collections may include: 4A pneumothorax (air). 4A haemothorax (blood). 4A pyothorax (pus). 4Mixed (any combination of the above). Although a pneumothorax is formed of air, the term is often used generically, to refer to any or all of these. This article uses the term generically. A slightly different pathology that may result in the same effect is a pleural effusion, where inflammation results in excessive plasma leakage, which accumulates in the pleural space. The pleura, however, remain intact. Pleural effusions may be divided into transudate (protein poor) or exudate (protein rich). The only significance of this difference for nurses is that samples of
drainage may be requested to diagnose the cause. Pleural effusions are often smaller than pneumothoraces, and are less likely to necessitate drainage to remain in place. Care of the patient and management of chest drainage are the same as with a pneumothorax. Complete time out activity 1
Pneumothoraces A pneumothorax may be either spontaneous or traumatic (wound). However it is caused, the result may be either simple (‘closed’) or tension (‘open’). Spontaneous pneumothoraces often occur with chronic lung disease, where a bleb (blister) at the apex of the lungs ruptures, allowing air to enter the pleural space (MacDuff et al 2010). Traumatic pneumothoraces include those caused by surgery or other invasive treatments. A simple pneumothorax causes lung collapse. However, after the initial injury, further accumulation is usually relatively slow. In contrast, a tension pneumothorax is a life-threatening emergency, with the ruptured pleura creating a one-way valve that entrains more air with each breath. As the pneumothorax enlarges, the lung, and often the heart, becomes progressively compressed. Tension pneumothorax is one of the reversible causes of pulseless electrical activity cardiac arrest (Resuscitation Council 2011). Tension pneumothoraces are most likely to occur in (MacDuff et al 2010): 4Artificially (positive pressure) ventilated patients, invasive or non-invasive. 4Trauma patients. 4Patients resuscitated using cardiopulmonary resuscitation. 4Patients with lung disease, especially acute asthma and chronic obstructive pulmonary disease (COPD). 4Patients with blocked, clamped or displaced chest drains. Inserting a chest drain converts a tension pneumothorax into a simple pneumothorax. Until this can be achieved, the patient’s systems should be supported – for example, breathlessness can be reduced by supporting patients in an upright position and administering supplementary oxygen.
Intrapleural chest drain equipment In the past, wide bore drains (20-24 French gauge (FG)) were generally inserted in
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patients to allow drainage of blood and fluid. However, these restricted mobility and caused many other complications such as pain and shallow breathing, which predispose patients to chest infections, venous stasis that may result in deep vein thrombosis, and potential pulmonary embolism. Near the end of the 20th century, the use of smaller bore drains (10-14 FG) and single plastic collection chambers (Figure 1) became standard practice (Roskelly and Smith 2011). Complete time out activity 2 Smaller intrapleural chest drains have proved as effective as larger devices for most pneumothoraces (Davies et al 2010, Fysh et al 2010, Galbois et al 2012), although larger diameter drains may be required to drain haemothoraces (Light et al 2011). Where conditions such as COPD cause recurrent pleural effusions, small ‘pig-tailed’ drains and collection bags with a one-way ‘flutter’ valve (Figure 2) allow mobilisation and therefore discharge home with, if necessary, a chest drain in place (MacDuff et al 2010). More recently, dry collection chambers with one-way valves have been introduced to replace underwater seal systems (Figure 3). There are many sophisticated custom-made collection chambers available commercially, and nurses should familiarise themselves with manufacturers’ instructions for products used. Complete time out activity 3
Observations In addition to general observations of vital signs in patients with intrapleural chest drains, respiratory function should be monitored closely, specifically in terms of rate, depth, symmetry of breathing, skin colour and responsiveness, using the AVPU (Alert, Voice, Pain, Unresponsive) scale. There are a number of observations specifically related to the care of patients with chest drains that nurses should monitor and record. These have been abbreviated as: 4S (Swinging). 4B (Bubbling). 4D (Draining). If mechanical suction is used, these chest drains should not swing, but SBD can also stand for: 4Suction. 4Bubbling. 4Draining.
Swinging
Provided suction is not used, fluid in the drainage tube should swing with the patient’s respiratory pattern, even if the pneumothorax has resolved, as negative pressure created during inspiration causes the fluid to rise slightly back towards the patient. Cessation of swinging therefore suggests blockage, which needs to be resolved urgently to prevent a tension pneumothorax developing.
FIGURE 1 Underwater seal collection chamber
FIGURE 2 Example of a portable collection bag
2 Discuss with your medical colleagues what size of intrapleural chest drains they usually use and the reasons for their choice. 3 Identify the manufacturer and model of the intrapleural chest drain used in your organisation. Read through the manufacturer’s instructions and note the aspects you consider will be useful for your practice.
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Learning zone respiratory nursing If air only is being drained and a dry drainage system (Figure 3) is used, then there will be no fluid in the tube to swing. If swinging is seen when suction is being used, then the vacuum should be checked. For example, it may have been turned off inadvertently or become disconnected. If turned on and connected, then the suction pressure should be increased.
Suction
Technically, gravity drainage applies suction to enable any siphon system to work. Historically, additional mechanical suction was thought to increase drainage by removing fluid that had already drained into the first collection chamber, thereby reducing resistance to further drainage. However, there is no evidence for or against the use of additional suction (Havelock et al 2010). A Cochrane review is investigating whether suction is beneficial; so far only the protocol for this review has been published (van Miert et al 2012). Adding mechanical suction is usually achieved through wall unit suction. High negative pressure from the wall unit should be avoided, as this pressure could be relayed to the intrapleural space, and perpetuate the leak, causing or prolonging hypoxia (MacDuff et al 2010). Therefore, a thoracic (also called ‘low’) suction unit rather than a high suction unit should be used – a unit that exerts only low, rather than high, negative pressures. In underwater seal drainage systems, the height of the water in the chamber determines
the negative pressure in the intrapleural space, hence suction is measured in centimetres of water. It is therefore important to ensure that the water level is that recommended by the manufacturer, whether or not additional suction is used. Some collection chambers, such as the dry system illustrated in Figure 3, include a suction regulator. If using additional suction, the BTS guideline recommends 10-20cmH2O (Havelock et al 2010), which is approximately 1-2 kilopascals (kPa) (1cmH2O = 0.0981kPa; 1kPa = 10.197cmH2O). The unit of measurement used by equipment should be checked before use, as many mechanical suction units in the UK use the Syste`me international d’unités (SI) unit of kPa. Suction pressure should be checked at least once each shift, the pressure recorded, and the pressure changed if different from that required.
Bubbling
Systems draining air will bubble. However, if only fluid is drained, bubbling will not occur. If a drain ceases to bubble, then air is no longer draining, either because the tube is blocked or the pneumothorax has resolved. Any drain that has stopped bubbling should be reported urgently to medical staff. Gallon (1998) recommends that if a drain stops bubbling, the patient should be asked to take a deep breath and cough, as this may dislodge any blockage. Presence, absence, or any change with bubbling should be documented (Havelock et al 2010) and reported.
Draining
FIGURE 3 Example of a dry collection chamber
Volume drained should be measured and recorded at least once daily (Havelock et al 2010). Collection chambers should not be emptied or changed just to measure drainage – most can be written on, but if this is not possible then paper tape can be applied to the chamber instead. It is recommended to mark, date and time the fluid level at the start of each shift, and also whenever any significant volumes of drainage occur. The colour and type of drainage should be recorded in the nursing notes and on a dedicated chest drain observation chart. Volume drained should also be included on the fluid balance chart. If only air is being drained, fluid levels should not change visibly.
Oxygen
Patients with a pneumothorax may be hypoxic and require supplementary oxygen. 52Downloaded june 5 :: vol 27rcnpublishing.com no 40 :: 2013 by ${individualUser.displayName} on Feb 10, 2015. © NURSING STANDARD / RCN from For personal use only. No other PUBLISHING uses without permission. Copyright © 2015 RCN Publishing Ltd. All rights reserved.
O’Driscoll et al (2008) and MacDuff et al (2010) acknowledged that the evidence is weak that high concentration oxygen (for example, 100% oxygen) increases absorption of air from the pleural cavity. There is also evidence that high concentration oxygen may be toxic (Cabello et al 2010). If supplementary oxygen is used, it should always be prescribed (O’Driscoll et al 2008). Nurses should monitor pulse oximetry to ensure prescribed target oxygen saturations are achieved.
Nursing care and management Wound care
Like any wound, the intrapleural chest drain insertion site is a potential source for infection. The dressing should therefore be inspected at least daily (Havelock et al 2010). Jones (2011) recommends covering the insertion site with a dry dressing; dry dressings should preferably have a pre-cut incision and hole, such as dressings manufactured for cannulae or tracheostomy tubes, and should be hypoallergenic. Depending on the type of dressing used, an adhesive (preferably transparent) covering may be necessary (Jones 2011). Any dressing or heavy strapping that may restrict breathing should be avoided (Roskelly and Smith 2011). Dressings used should be recorded in the nursing care plan. Provided they are clean and intact, dressings should only be changed if there is a specific indication, or at the frequency recommended by the manufacturer of the dressing. The dressing should be removed to inspect the wound if dressings are soiled or not intact, there is new pyrexia or other signs of infection, there is odour from the site and/or there is audible bubbling or sucking beneath the dressing. If infection is suspected, the wound should be swabbed. If skin shows signs of reaction to any dressing, this should be recorded and a different dressing used. Appearance of the wound site should be recorded during each shift in the nursing notes. Complete time out activity 4
Clamping
Clamping an intrapleural chest drain prevents drainage and can create a tension pneumothorax. Clamping should therefore be avoided whenever possible. The only indications for clamping are listed in Box 1. Rapid initial drainage of pleural effusions may cause pulmonary oedema (Roskelly
and Smith 2011). Havelock et al (2010) suggest maximum initial drainage should not exceed 1,500mL in the first hour, although Roskelly and Smith (2011) suggest limiting initial drainage to 500mL, with subsequent clamping time of a further hour. If initial drainage is large, medical help should be summoned urgently. Changing the collection chamber or unit necessitates clamping the chest drain, only for the duration of the changeover. Disconnection of the drain from the collection chamber may allow the pneumothorax to enlarge, so the drain from the patient’s chest should be clamped urgently. A new collection chamber should be attached quickly, and the chest drain unclamped. Moving the collection chamber over the patient’s bed may cause gravity drainage into the pleural space. If possible, chambers should not be raised to, or above, the patient’s chest level, and many commercial chambers have tubing long enough to pass around the ends of beds. If passing the collection chamber over the patient is unavoidable, it should be clamped for as long as it is at, or above, chest level. Patients (and visitors) should be discouraged from touching this equipment, and advised never to lift the collection chamber to, or above, chest level. Following sclerosant or other drug instillation, the intrapleural chest drain should be clamped for one hour (Roberts et al 2010). Instilling drugs into the pleural space should only be performed by medical practitioners or suitably qualified specialist nurses, such as a respiratory nurse specialist. The intrapleural chest drain can be clamped before removal (Gupta 2001), although the necessity of this has been debated. Previously, these drains were often clamped before removal, so that if a pneumothorax recurred, it could be treated by unclamping the drain rather than having to insert a new one. However, there is no evidence that clamping before removal is
4 What intrapleural chest drain dressings are recommended in your trust? Discuss the recommendations with the tissue viability specialist and search the intranet to read local guidelines and policies.
BOX 1 Indications for clamping intrapleural chest drains 4Following rapid initial drainage (>1,500mL in the first hour). 4During collection unit or chamber changeover. 4During disconnection of the drain from the collection chamber. 4While moving the collection chamber over the patient’s bed. 4Following sclerosant or other drug instillation, for a brief period of one hour duration. 4Before removal of the intrapleural chest drain (debatable).
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Learning zone respiratory nursing beneficial, and medical staff who request clamping before removal should clearly document the duration of clamping in the patient’s medical notes (Havelock et al 2010). With the above exceptions, a bubbling intrapleural chest drain should never be clamped (Havelock et al 2010, Roskelly and Smith 2011). In addition, clamps should be removed as soon as possible. Patients with a clamped drain should be supervised closely by nurses familiar with management of chest drains, and the drain should be unclamped if there are any signs of patient deterioration (Havelock et al 2010).
Flushing
Medical literature often discusses flushing intrapleural chest drains to maintain patency (Davies et al 2010). While nurses could reasonably flush tubing away from the patient and towards the collection chamber, provided this is done aseptically, blockage is unlikely to occur in this tubing. Blockage is more likely in the thinner drain, which would necessitate flushing towards the patient’s pleura. This should only be performed by medical staff or suitably qualified specialist nurses.
Changing containers
Chambers should only be changed when full, or there is some other specific indication such as disconnection. Changing chambers requires an aseptic technique. If using an underwater seal drainage system, insert the volume of sterile water indicated by the manufacturer’s instructions. Before removing the old chamber, the drain should be clamped. The new chamber should be connected immediately, and the drain unclamped. The volume drained should be recorded, and the old container should be disposed of according to local infection control guidelines.
Milking
Historically, drainage tubing was often ‘milked’ with custom-made rollers in the belief this helped maintain patency. However, it often created dangerously negative pressures in the patient’s chest (Roskelly and Smith 2011). Therefore, chest drains should never be milked; custom-made rollers have long been removed from practice and no other means of milking should be attempted. If tubes are blocked, thrombolytic therapy may be used by suitably qualified practitioners, or (more often) the tube should be replaced (Roskelly and Smith 2011).
Complications Despite improvements in equipment used, 30% of patients with intrapleural chest drains experience complications (Ball et al 2007). Jones (2011) suggested there are three main types of complication: 4Insertional (for example, pain or tissue damage). 4Positional (for example, inadequate drainage or emphysema). 4Infection. Although these chest drains are not usually inserted by nurses, where and how they are inserted can result in complications that nurses may be able to alleviate, while many subsequent complications can be prevented, or their effects reduced, by skilled nursing care.
Insertional complications
Pain is a common complication of intrapleural chest drains, especially large bore drains (MacDuff et al 2010). Restrictions from, and the weight of, the drainage tubing may also cause pain. Unnecessary pain caused 15 of the 58 chest drain-related claims to the NHS Litigation Authority between 1995 and 2006 (National Patient Safety Agency (NPSA) 2008). Complete time out activity 5 To reduce pain, patients may tend to breathe shallowly; shallow breathing means distal parts of the lungs are not used, leaving warm, moist but static air in which bacteria may develop in the lungs. Shallow breathing therefore increases the risks of chest infection (Gray 2000). Patients should be prescribed analgesics to encourage deep breathing and mobility. Nurses should assess patients with intrapleural chest drains frequently to see if they have pain. Effectiveness of analgesics should also be assessed, and if regimens are ineffective, nurses should ensure the prescription is reviewed by a qualified prescriber. Nurses can relieve pain by repositioning patients and supporting intrapleural chest drain tubing. Nurses should anticipate any procedures that are likely to cause pain, for example dressing changes or physiotherapy, by administering prophylactic pain relief. Anticipated care, and its effectiveness, should be recorded in the nursing care plan.
Positional complications
Sitting upright improves drainage and breathing. Patients with intrapleural chest
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drains should be encouraged to mobilise and breathe deeply. Analgesia may be required before vigorous movement. Subcutaneous emphysema, more often called ‘surgical emphysema’ and sometimes ‘tissue emphysema’, can be caused by anything that allows air or gas to enter tissue spaces, such as a misplaced (side hole outside the pleural cavity) or blocked intrapleural chest drain (Briggs 2010). Air rises to the uppermost parts of the body, so typically collects in the chest, neck or face. Although subcutaneous emphysema is usually benign (Kesieme et al 2012), it can cause discomfort, inhibit breathing, and potentially obstruct the airway, causing respiratory arrest (Kesieme et al 2012). Patients with surgical emphysema may report various problems, including sore throats, difficulty in breathing or swallowing, and wheezing. When skin over the affected area is touched, subcutaneous emphysema causes a distinctive crackling feeling. If detected, possible causes for the surgical emphysema should be assessed. If nurses can identify an obvious cause and (reasonably) remedy it, such as replacing a blocked drainage system, they should do so. Otherwise, medical staff should be informed urgently.
Infection complications
In addition to wounds being a potential source for infection, various complications increase the risk of infection. These include reduced mobility and shallow breathing. Five of the 17 deaths related to chest drains between 1995 and 2006 were caused by infections that were not related to insertion (NPSA 2008). Infection control is therefore an important aspect of patient care, and any task involving disconnection of the drainage system or removal of the dressing should be performed aseptically.
Psychological care As with all aspects of patient care, patients should be informed about and consent to their treatment. While medical staff should ensure this for the initial procedure, patients, or their relatives, often ask questions later. If nurses can reasonably provide the information, they should do so; if they cannot, they should ask a doctor to speak with the patient and his or her family. Nurses should ensure they provide information and obtain consent for nursing interventions, such as dressing changes. Patients with a pneumothorax are often breathless and anxious. In addition to supporting
patients with activities of daily living, such as ensuring nutrition and hydration, and assisting with hygiene, nurses should seek to comfort and reassure patients, and be prepared to repeat explanations if patients forget. If patients remain anxious despite reassurance, the administration of anxiolytic drugs may be beneficial.
Removal of the chest drain The timing of removal of an intrapleural chest drain is usually a medical decision. Removal can be painful, therefore sufficient pain relief should be administered before the removal procedure, and time should be allowed for the medication to be effective. The small bore (10-14 FG) chest drains now used may not need sutures, and often remain secure with just the dressing. If drains are sutured, mattress sutures are recommended (Havelock et al 2010). These sutures and their removal are described by Rashid et al (1998). Before removal of the intrapleural chest drain, the nurse should advise the patient to take some deep breaths. This helps ensure good oxygenation and may help the patient relax. If wall suction is connected to the intrapleural chest drain, this should be stopped. During removal of the intrapleural chest drain, the patient should either perform the Valsalva manoeuvre or hold his or her breath after exhaling. The Valsalva manoeuvre (forced expiratory effort against a closed airway similar to straining at stool) creates positive intrathoracic pressure. After removal of the intrapleural chest drain, the site should be covered with an occlusive dressing, the drainage volume recorded, and hazardous waste disposed of according to local infection control policies. A chest X-ray is usually requested to check re-expansion of the lungs. Respiratory observations should be recorded at least every four hours for the first 24 hours following removal.
Recording care Ensuring accurate and sufficiently detailed records of care are valuable ways to communicate effective strategies to staff on future shifts, especially with aspects such as management of chest drains that may not be familiar to all members of the healthcare team. The BTS recommends using specific charts for recording chest drain observations (Havelock et al 2010). Complete time out activity 6
5 Did the patient you identified in time out activity 1 experience pain related to the intrapleural chest drain? How was this pain managed, or anticipated and prevented? Was the pain management effective? What analgesics were administered, and what non-pharmacological care was given to relieve the patient’s pain? 6 From information contained in this article and your own experience, devise a care plan for a patient requiring an intrapleural chest drain.
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Learning zone respiratory nursing Conclusion
7 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 60
Intrapleural chest drains are a useful means of removing air or abnormal fluid from the pleural cavity, and can be a life-saving intervention. However, these chest drains and drainage collection systems expose patients to various risks and complications, which can prove life-threatening. Nursing care of the patient with an intrapleural chest drain requires skill and
knowledge to promote patient safety and comfort and reduce risks. Observations are central to maintaining a safe environment, while skilled nursing care can prevent many complications, with infection and pain control being particularly important aspects of nursing. Intrapleural chest drains should be managed on wards familiar with these chest drains and their management (Havelock et al 2010) NS Complete time out activity 7
References Ball CG, Lord J, Laupland BK et al (2007) Chest tube complications: how well are we training our residents? Canadian Journal of Surgery. 50, 6, 450-458. Briggs D (2010) Nursing care and management of patients with intrapleural drains. Nursing Standard. 24, 21, 47-55. British Thoracic Society (2010) BTS Pleural Disease Guideline 2010: A Quick Reference Guide. tinyurl.com/ cpf8tt9 (Last accessed: May 14 2013.) Cabello JB, Burls A, Emparanza JI, Bayliss S, Quinn T (2010) Oxygen therapy for acute myocardial infarction. Cochrane Database of Systematic Reviews. Issue 6, CD007160. Charnock Y, Evans D (2001) Nursing management of chest drains: a systematic review. Australian Critical Care. 14, 4, 156-160. Davies HE, Davies RJO, Davies CWH, British Thoracic Society Pleural Disease Guideline Group (2010) Management of pleural infection in adults: British Thoracic Society pleural disease guideline 2010. Thorax. 65, Suppl 2, ii41-ii53.
Fremlin G, Baker R, Walters G, Fletcher T (2011) P34 Are nursing staff sufficiently educated and competent in managing patients with a chest drain? Thorax. 66, Suppl 4, A81. Fysh ETH, Smith NA, Lee YC (2010) Optimal chest drain size: the rise of the small-bore pleural catheter. Seminars in Respiratory and Critical Care Medicine. 31, 6, 760-768. Galbois A, Zorzi L, Meurisse S et al (2012) Outcome of spontaneous and iatrogenic pneumothoraces managed with small bore chest tubes. Acta Anaesthesiologica Scandinavica. 56, 4, 507-512. Gallon A (1998) Pneumothorax. Nursing Standard. 13, 10, 35-39. Gray E (2000) Pain management for patients with chest drains. Nursing Standard. 14, 23, 40-44. Gupta N (2001) Pneumothorax: is chest tube clamp necessary before removal? Chest. 119, 4, 1292-1293. Havelock T, Teoh R, Laws D, Gleeson F, British Thoracic Society Pleural Disease Guideline Group (2010) Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease
guideline 2010. Thorax. 65, Suppl 2, i61-i76. Jones SKB (2011) Chest Tube Dressings: A Comparison of Different Methods. gradworks.umi. com/34/89/3489450.html (Last accessed: May 1 2013.) Kesieme EB, Dongo A, Ezemba N, Irekpita E, Jebbin N, Kesieme C (2012) Tube thoracostomy: complications and its management. Pulmonary Medicine. doi: 10.1155/2012/256878. Light RW (2011) Pleural controversy: optimal chest tube size for drainage. Respirology. 16, 2, 244-248. MacDuff A, Arnold A, Harvey J, British Thoracic Society Pleural Disease Guideline Group (2010) Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 65, Suppl 2, ii18-ii31. Marieb EN, Hoehn K (2012) Human Anatomy & Physiology. Ninth edition. Pearson, Boston MA. National Patient Safety Agency (2008) Risks of Chest Drain Insertion. Rapid Response Report 03. NPSA, London.
O’Driscoll BR, Howard LS, Davison AG; British Thoracic Society (2008) BTS guideline for emergency oxygen use in adult patients. Thorax. 63, Suppl 6, vi1-vi68. Rashid MA, Wikström T, Örtenwall P (1998) A simple technique for anchoring chest tubes. European Respiratory Journal. 12, 4, 958-959. Resuscitation Council (2011) Advanced Life Support. Sixth edition. Resuscitation Council, London. Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group (2010) Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax. 65, Suppl 2, ii32-ii40. Roskelly L, Smith AP (2011) Respiratory care. In Dougherty L, Lister S (Eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Eighth edition. Wiley-Blackwell, Oxford, 534-614. van Miert C, Dwan K, Hill R, Hoenig MR, Gruen RL, Semple MG (2012) Suction versus no suction for chest drain management. Cochrane Database of Systematic Reviews. Issue 7, CD009939.
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4 Page 58
Intrapleural chest drainage multiple choice questionnaire
4 Page 59
Read Lisa Scott’s practice profile on respiratory infections
4 Page 60
Guidelines on how to write a practice profile
Intrapleural chest drainage NS696 Woodrow P (2013) Intrapleural chest drainage. Nursing Standard. 27, 40, 49-56. Date of submission: November 19 2012; date of acceptance: March 15 2013.
Abstract Abnormal fluid or air between the pleura results in respiratory distress and can cause death, if untreated. Intrapleural chest drains are used to remove abnormal accumulations of fluid or air. Caring for patients with intrapleural chest drains requires knowledge and skill to ensure patient safety. This article describes the pathophysiology, treatment and nursing care of patients who require intrapleural chest drains.
4Explain how intrapleural chest drains work. 4Outline the observations that nurses should record in relation to intrapleural chest drains. 4Describe the nursing care and management of patients with intrapleural chest drains. 4Develop a care plan for a patient with an intrapleural chest drain.
Introduction
Author Philip Woodrow Practice development nurse, critical care, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent Correspondence to: [email protected]
Keywords Chest drains, pneumothorax, patient safety, respiratory diseases
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Aims and intended learning outcomes The aim of this article is to enhance readers’ understanding of how intrapleural chest drains work, what dangers they can expose patients to, and how to provide safe nursing care for patients with intrapleural chest drains. After reading this article and completing the time out activities you should be able to: 4Describe the pathophysiology of a pneumothorax.
The two main organs in the chest, the heart and lungs, contain potential spaces between their two outer layers, the pericardium in the heart and pleura in the lungs. These potential spaces usually contain only a thin film of serous fluid, but disease, trauma and surgery can cause accumulations of fluid. Large accumulations may be life-threatening, necessitating drainage. While pericardial and mediastinal drains are used commonly after cardiac surgery, nurses working in most areas other than cardiac surgery will be more familiar with drains used to remove air, blood or other fluids from the pleural cavity. This article describes intrapleural chest drainage systems. These are often called intercostal chest drains, but because cardiac chest drains are also usually inserted through the intercostal muscles, this article uses the term intrapleural. Some collections of air or fluid may be small enough to drain using needle aspiration. However, larger collections usually necessitate chest drain insertion into the intrapleural space and connection to a collection chamber. While closed tube drainage was first described in 1876, chest drains only became widely used during the worldwide influenza epidemic of 1917-1919 (Davies et al 2010). The principle of inserting one end of a tube into the pleura, and the other into a bottle of water placed below the patient’s chest level (with height creating gravity
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Learning zone respiratory nursing drainage and water creating a seal), and termed ‘underwater seal drain’, remained essentially unchanged for almost a century, although two or sometimes three bottles were sometimes used to improve drainage of fluid and enable vacuum suction. The late 20th century saw improvements in equipment, but evidence for practice, especially nursing practice, has often been weak, anecdotal, and dated (Charnock and Evans 2001, MacDuff et al 2010, Fremlin et al 2011). This article uses current evidence, specifically the British Thoracic Society (BTS) Pleural Disease Guideline 2010 (BTS 2010) to inform nursing care.
Physiology of the pleura
1 Reflect on a patient for whom you cared who required intrapleural chest drainage. Why was the chest drain required? What caused the pneumothorax or pleural effusion? Outline the nursing care provided, any problems experienced related to the chest drain, and solutions, if problems occurred.
The outer layer of the lung is formed of two membranes called pleura, between which is a thin film of serous fluid of typically 2-5mL (Roskelly and Smith 2011). The outer, or parietal, pleura adheres to the rib cage, while the inner, or visceral, pleura adheres to the lung tissue. Active muscle movement of inspiration draws the intercostal muscles outwards, drawing the parietal pleura with them. The serous fluid allows the pleura to glide over each other, while ensuring both pleura expand and contract together (Marieb and Hoehn 2012). Thus, the visceral pleura is also drawn outwards on inspiration, creating negative pressure in the lungs (van Miert et al 2012), which causes the airways to open during inspiration (Marieb and Hoehn 2012). Damage to either of the pleura allows air, blood, or other fluids to accumulate in the usually small intrapleural space. Since the parietal pleura adheres to the rib cage, abnormal collections of fluid or air force the visceral pleura inwards, causing the lung to collapse and resulting in respiratory distress. Collections may include: 4A pneumothorax (air). 4A haemothorax (blood). 4A pyothorax (pus). 4Mixed (any combination of the above). Although a pneumothorax is formed of air, the term is often used generically, to refer to any or all of these. This article uses the term generically. A slightly different pathology that may result in the same effect is a pleural effusion, where inflammation results in excessive plasma leakage, which accumulates in the pleural space. The pleura, however, remain intact. Pleural effusions may be divided into transudate (protein poor) or exudate (protein rich). The only significance of this difference for nurses is that samples of
drainage may be requested to diagnose the cause. Pleural effusions are often smaller than pneumothoraces, and are less likely to necessitate drainage to remain in place. Care of the patient and management of chest drainage are the same as with a pneumothorax. Complete time out activity 1
Pneumothoraces A pneumothorax may be either spontaneous or traumatic (wound). However it is caused, the result may be either simple (‘closed’) or tension (‘open’). Spontaneous pneumothoraces often occur with chronic lung disease, where a bleb (blister) at the apex of the lungs ruptures, allowing air to enter the pleural space (MacDuff et al 2010). Traumatic pneumothoraces include those caused by surgery or other invasive treatments. A simple pneumothorax causes lung collapse. However, after the initial injury, further accumulation is usually relatively slow. In contrast, a tension pneumothorax is a life-threatening emergency, with the ruptured pleura creating a one-way valve that entrains more air with each breath. As the pneumothorax enlarges, the lung, and often the heart, becomes progressively compressed. Tension pneumothorax is one of the reversible causes of pulseless electrical activity cardiac arrest (Resuscitation Council 2011). Tension pneumothoraces are most likely to occur in (MacDuff et al 2010): 4Artificially (positive pressure) ventilated patients, invasive or non-invasive. 4Trauma patients. 4Patients resuscitated using cardiopulmonary resuscitation. 4Patients with lung disease, especially acute asthma and chronic obstructive pulmonary disease (COPD). 4Patients with blocked, clamped or displaced chest drains. Inserting a chest drain converts a tension pneumothorax into a simple pneumothorax. Until this can be achieved, the patient’s systems should be supported – for example, breathlessness can be reduced by supporting patients in an upright position and administering supplementary oxygen.
Intrapleural chest drain equipment In the past, wide bore drains (20-24 French gauge (FG)) were generally inserted in
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patients to allow drainage of blood and fluid. However, these restricted mobility and caused many other complications such as pain and shallow breathing, which predispose patients to chest infections, venous stasis that may result in deep vein thrombosis, and potential pulmonary embolism. Near the end of the 20th century, the use of smaller bore drains (10-14 FG) and single plastic collection chambers (Figure 1) became standard practice (Roskelly and Smith 2011). Complete time out activity 2 Smaller intrapleural chest drains have proved as effective as larger devices for most pneumothoraces (Davies et al 2010, Fysh et al 2010, Galbois et al 2012), although larger diameter drains may be required to drain haemothoraces (Light et al 2011). Where conditions such as COPD cause recurrent pleural effusions, small ‘pig-tailed’ drains and collection bags with a one-way ‘flutter’ valve (Figure 2) allow mobilisation and therefore discharge home with, if necessary, a chest drain in place (MacDuff et al 2010). More recently, dry collection chambers with one-way valves have been introduced to replace underwater seal systems (Figure 3). There are many sophisticated custom-made collection chambers available commercially, and nurses should familiarise themselves with manufacturers’ instructions for products used. Complete time out activity 3
Observations In addition to general observations of vital signs in patients with intrapleural chest drains, respiratory function should be monitored closely, specifically in terms of rate, depth, symmetry of breathing, skin colour and responsiveness, using the AVPU (Alert, Voice, Pain, Unresponsive) scale. There are a number of observations specifically related to the care of patients with chest drains that nurses should monitor and record. These have been abbreviated as: 4S (Swinging). 4B (Bubbling). 4D (Draining). If mechanical suction is used, these chest drains should not swing, but SBD can also stand for: 4Suction. 4Bubbling. 4Draining.
Swinging
Provided suction is not used, fluid in the drainage tube should swing with the patient’s respiratory pattern, even if the pneumothorax has resolved, as negative pressure created during inspiration causes the fluid to rise slightly back towards the patient. Cessation of swinging therefore suggests blockage, which needs to be resolved urgently to prevent a tension pneumothorax developing.
FIGURE 1 Underwater seal collection chamber
FIGURE 2 Example of a portable collection bag
2 Discuss with your medical colleagues what size of intrapleural chest drains they usually use and the reasons for their choice. 3 Identify the manufacturer and model of the intrapleural chest drain used in your organisation. Read through the manufacturer’s instructions and note the aspects you consider will be useful for your practice.
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Learning zone respiratory nursing If air only is being drained and a dry drainage system (Figure 3) is used, then there will be no fluid in the tube to swing. If swinging is seen when suction is being used, then the vacuum should be checked. For example, it may have been turned off inadvertently or become disconnected. If turned on and connected, then the suction pressure should be increased.
Suction
Technically, gravity drainage applies suction to enable any siphon system to work. Historically, additional mechanical suction was thought to increase drainage by removing fluid that had already drained into the first collection chamber, thereby reducing resistance to further drainage. However, there is no evidence for or against the use of additional suction (Havelock et al 2010). A Cochrane review is investigating whether suction is beneficial; so far only the protocol for this review has been published (van Miert et al 2012). Adding mechanical suction is usually achieved through wall unit suction. High negative pressure from the wall unit should be avoided, as this pressure could be relayed to the intrapleural space, and perpetuate the leak, causing or prolonging hypoxia (MacDuff et al 2010). Therefore, a thoracic (also called ‘low’) suction unit rather than a high suction unit should be used – a unit that exerts only low, rather than high, negative pressures. In underwater seal drainage systems, the height of the water in the chamber determines
the negative pressure in the intrapleural space, hence suction is measured in centimetres of water. It is therefore important to ensure that the water level is that recommended by the manufacturer, whether or not additional suction is used. Some collection chambers, such as the dry system illustrated in Figure 3, include a suction regulator. If using additional suction, the BTS guideline recommends 10-20cmH2O (Havelock et al 2010), which is approximately 1-2 kilopascals (kPa) (1cmH2O = 0.0981kPa; 1kPa = 10.197cmH2O). The unit of measurement used by equipment should be checked before use, as many mechanical suction units in the UK use the Syste`me international d’unités (SI) unit of kPa. Suction pressure should be checked at least once each shift, the pressure recorded, and the pressure changed if different from that required.
Bubbling
Systems draining air will bubble. However, if only fluid is drained, bubbling will not occur. If a drain ceases to bubble, then air is no longer draining, either because the tube is blocked or the pneumothorax has resolved. Any drain that has stopped bubbling should be reported urgently to medical staff. Gallon (1998) recommends that if a drain stops bubbling, the patient should be asked to take a deep breath and cough, as this may dislodge any blockage. Presence, absence, or any change with bubbling should be documented (Havelock et al 2010) and reported.
Draining
FIGURE 3 Example of a dry collection chamber
Volume drained should be measured and recorded at least once daily (Havelock et al 2010). Collection chambers should not be emptied or changed just to measure drainage – most can be written on, but if this is not possible then paper tape can be applied to the chamber instead. It is recommended to mark, date and time the fluid level at the start of each shift, and also whenever any significant volumes of drainage occur. The colour and type of drainage should be recorded in the nursing notes and on a dedicated chest drain observation chart. Volume drained should also be included on the fluid balance chart. If only air is being drained, fluid levels should not change visibly.
Oxygen
Patients with a pneumothorax may be hypoxic and require supplementary oxygen. 52Downloaded june 5 :: vol 27rcnpublishing.com no 40 :: 2013 by ${individualUser.displayName} on Feb 10, 2015. © NURSING STANDARD / RCN from For personal use only. No other PUBLISHING uses without permission. Copyright © 2015 RCN Publishing Ltd. All rights reserved.
O’Driscoll et al (2008) and MacDuff et al (2010) acknowledged that the evidence is weak that high concentration oxygen (for example, 100% oxygen) increases absorption of air from the pleural cavity. There is also evidence that high concentration oxygen may be toxic (Cabello et al 2010). If supplementary oxygen is used, it should always be prescribed (O’Driscoll et al 2008). Nurses should monitor pulse oximetry to ensure prescribed target oxygen saturations are achieved.
Nursing care and management Wound care
Like any wound, the intrapleural chest drain insertion site is a potential source for infection. The dressing should therefore be inspected at least daily (Havelock et al 2010). Jones (2011) recommends covering the insertion site with a dry dressing; dry dressings should preferably have a pre-cut incision and hole, such as dressings manufactured for cannulae or tracheostomy tubes, and should be hypoallergenic. Depending on the type of dressing used, an adhesive (preferably transparent) covering may be necessary (Jones 2011). Any dressing or heavy strapping that may restrict breathing should be avoided (Roskelly and Smith 2011). Dressings used should be recorded in the nursing care plan. Provided they are clean and intact, dressings should only be changed if there is a specific indication, or at the frequency recommended by the manufacturer of the dressing. The dressing should be removed to inspect the wound if dressings are soiled or not intact, there is new pyrexia or other signs of infection, there is odour from the site and/or there is audible bubbling or sucking beneath the dressing. If infection is suspected, the wound should be swabbed. If skin shows signs of reaction to any dressing, this should be recorded and a different dressing used. Appearance of the wound site should be recorded during each shift in the nursing notes. Complete time out activity 4
Clamping
Clamping an intrapleural chest drain prevents drainage and can create a tension pneumothorax. Clamping should therefore be avoided whenever possible. The only indications for clamping are listed in Box 1. Rapid initial drainage of pleural effusions may cause pulmonary oedema (Roskelly
and Smith 2011). Havelock et al (2010) suggest maximum initial drainage should not exceed 1,500mL in the first hour, although Roskelly and Smith (2011) suggest limiting initial drainage to 500mL, with subsequent clamping time of a further hour. If initial drainage is large, medical help should be summoned urgently. Changing the collection chamber or unit necessitates clamping the chest drain, only for the duration of the changeover. Disconnection of the drain from the collection chamber may allow the pneumothorax to enlarge, so the drain from the patient’s chest should be clamped urgently. A new collection chamber should be attached quickly, and the chest drain unclamped. Moving the collection chamber over the patient’s bed may cause gravity drainage into the pleural space. If possible, chambers should not be raised to, or above, the patient’s chest level, and many commercial chambers have tubing long enough to pass around the ends of beds. If passing the collection chamber over the patient is unavoidable, it should be clamped for as long as it is at, or above, chest level. Patients (and visitors) should be discouraged from touching this equipment, and advised never to lift the collection chamber to, or above, chest level. Following sclerosant or other drug instillation, the intrapleural chest drain should be clamped for one hour (Roberts et al 2010). Instilling drugs into the pleural space should only be performed by medical practitioners or suitably qualified specialist nurses, such as a respiratory nurse specialist. The intrapleural chest drain can be clamped before removal (Gupta 2001), although the necessity of this has been debated. Previously, these drains were often clamped before removal, so that if a pneumothorax recurred, it could be treated by unclamping the drain rather than having to insert a new one. However, there is no evidence that clamping before removal is
4 What intrapleural chest drain dressings are recommended in your trust? Discuss the recommendations with the tissue viability specialist and search the intranet to read local guidelines and policies.
BOX 1 Indications for clamping intrapleural chest drains 4Following rapid initial drainage (>1,500mL in the first hour). 4During collection unit or chamber changeover. 4During disconnection of the drain from the collection chamber. 4While moving the collection chamber over the patient’s bed. 4Following sclerosant or other drug instillation, for a brief period of one hour duration. 4Before removal of the intrapleural chest drain (debatable).
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Learning zone respiratory nursing beneficial, and medical staff who request clamping before removal should clearly document the duration of clamping in the patient’s medical notes (Havelock et al 2010). With the above exceptions, a bubbling intrapleural chest drain should never be clamped (Havelock et al 2010, Roskelly and Smith 2011). In addition, clamps should be removed as soon as possible. Patients with a clamped drain should be supervised closely by nurses familiar with management of chest drains, and the drain should be unclamped if there are any signs of patient deterioration (Havelock et al 2010).
Flushing
Medical literature often discusses flushing intrapleural chest drains to maintain patency (Davies et al 2010). While nurses could reasonably flush tubing away from the patient and towards the collection chamber, provided this is done aseptically, blockage is unlikely to occur in this tubing. Blockage is more likely in the thinner drain, which would necessitate flushing towards the patient’s pleura. This should only be performed by medical staff or suitably qualified specialist nurses.
Changing containers
Chambers should only be changed when full, or there is some other specific indication such as disconnection. Changing chambers requires an aseptic technique. If using an underwater seal drainage system, insert the volume of sterile water indicated by the manufacturer’s instructions. Before removing the old chamber, the drain should be clamped. The new chamber should be connected immediately, and the drain unclamped. The volume drained should be recorded, and the old container should be disposed of according to local infection control guidelines.
Milking
Historically, drainage tubing was often ‘milked’ with custom-made rollers in the belief this helped maintain patency. However, it often created dangerously negative pressures in the patient’s chest (Roskelly and Smith 2011). Therefore, chest drains should never be milked; custom-made rollers have long been removed from practice and no other means of milking should be attempted. If tubes are blocked, thrombolytic therapy may be used by suitably qualified practitioners, or (more often) the tube should be replaced (Roskelly and Smith 2011).
Complications Despite improvements in equipment used, 30% of patients with intrapleural chest drains experience complications (Ball et al 2007). Jones (2011) suggested there are three main types of complication: 4Insertional (for example, pain or tissue damage). 4Positional (for example, inadequate drainage or emphysema). 4Infection. Although these chest drains are not usually inserted by nurses, where and how they are inserted can result in complications that nurses may be able to alleviate, while many subsequent complications can be prevented, or their effects reduced, by skilled nursing care.
Insertional complications
Pain is a common complication of intrapleural chest drains, especially large bore drains (MacDuff et al 2010). Restrictions from, and the weight of, the drainage tubing may also cause pain. Unnecessary pain caused 15 of the 58 chest drain-related claims to the NHS Litigation Authority between 1995 and 2006 (National Patient Safety Agency (NPSA) 2008). Complete time out activity 5 To reduce pain, patients may tend to breathe shallowly; shallow breathing means distal parts of the lungs are not used, leaving warm, moist but static air in which bacteria may develop in the lungs. Shallow breathing therefore increases the risks of chest infection (Gray 2000). Patients should be prescribed analgesics to encourage deep breathing and mobility. Nurses should assess patients with intrapleural chest drains frequently to see if they have pain. Effectiveness of analgesics should also be assessed, and if regimens are ineffective, nurses should ensure the prescription is reviewed by a qualified prescriber. Nurses can relieve pain by repositioning patients and supporting intrapleural chest drain tubing. Nurses should anticipate any procedures that are likely to cause pain, for example dressing changes or physiotherapy, by administering prophylactic pain relief. Anticipated care, and its effectiveness, should be recorded in the nursing care plan.
Positional complications
Sitting upright improves drainage and breathing. Patients with intrapleural chest
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drains should be encouraged to mobilise and breathe deeply. Analgesia may be required before vigorous movement. Subcutaneous emphysema, more often called ‘surgical emphysema’ and sometimes ‘tissue emphysema’, can be caused by anything that allows air or gas to enter tissue spaces, such as a misplaced (side hole outside the pleural cavity) or blocked intrapleural chest drain (Briggs 2010). Air rises to the uppermost parts of the body, so typically collects in the chest, neck or face. Although subcutaneous emphysema is usually benign (Kesieme et al 2012), it can cause discomfort, inhibit breathing, and potentially obstruct the airway, causing respiratory arrest (Kesieme et al 2012). Patients with surgical emphysema may report various problems, including sore throats, difficulty in breathing or swallowing, and wheezing. When skin over the affected area is touched, subcutaneous emphysema causes a distinctive crackling feeling. If detected, possible causes for the surgical emphysema should be assessed. If nurses can identify an obvious cause and (reasonably) remedy it, such as replacing a blocked drainage system, they should do so. Otherwise, medical staff should be informed urgently.
Infection complications
In addition to wounds being a potential source for infection, various complications increase the risk of infection. These include reduced mobility and shallow breathing. Five of the 17 deaths related to chest drains between 1995 and 2006 were caused by infections that were not related to insertion (NPSA 2008). Infection control is therefore an important aspect of patient care, and any task involving disconnection of the drainage system or removal of the dressing should be performed aseptically.
Psychological care As with all aspects of patient care, patients should be informed about and consent to their treatment. While medical staff should ensure this for the initial procedure, patients, or their relatives, often ask questions later. If nurses can reasonably provide the information, they should do so; if they cannot, they should ask a doctor to speak with the patient and his or her family. Nurses should ensure they provide information and obtain consent for nursing interventions, such as dressing changes. Patients with a pneumothorax are often breathless and anxious. In addition to supporting
patients with activities of daily living, such as ensuring nutrition and hydration, and assisting with hygiene, nurses should seek to comfort and reassure patients, and be prepared to repeat explanations if patients forget. If patients remain anxious despite reassurance, the administration of anxiolytic drugs may be beneficial.
Removal of the chest drain The timing of removal of an intrapleural chest drain is usually a medical decision. Removal can be painful, therefore sufficient pain relief should be administered before the removal procedure, and time should be allowed for the medication to be effective. The small bore (10-14 FG) chest drains now used may not need sutures, and often remain secure with just the dressing. If drains are sutured, mattress sutures are recommended (Havelock et al 2010). These sutures and their removal are described by Rashid et al (1998). Before removal of the intrapleural chest drain, the nurse should advise the patient to take some deep breaths. This helps ensure good oxygenation and may help the patient relax. If wall suction is connected to the intrapleural chest drain, this should be stopped. During removal of the intrapleural chest drain, the patient should either perform the Valsalva manoeuvre or hold his or her breath after exhaling. The Valsalva manoeuvre (forced expiratory effort against a closed airway similar to straining at stool) creates positive intrathoracic pressure. After removal of the intrapleural chest drain, the site should be covered with an occlusive dressing, the drainage volume recorded, and hazardous waste disposed of according to local infection control policies. A chest X-ray is usually requested to check re-expansion of the lungs. Respiratory observations should be recorded at least every four hours for the first 24 hours following removal.
Recording care Ensuring accurate and sufficiently detailed records of care are valuable ways to communicate effective strategies to staff on future shifts, especially with aspects such as management of chest drains that may not be familiar to all members of the healthcare team. The BTS recommends using specific charts for recording chest drain observations (Havelock et al 2010). Complete time out activity 6
5 Did the patient you identified in time out activity 1 experience pain related to the intrapleural chest drain? How was this pain managed, or anticipated and prevented? Was the pain management effective? What analgesics were administered, and what non-pharmacological care was given to relieve the patient’s pain? 6 From information contained in this article and your own experience, devise a care plan for a patient requiring an intrapleural chest drain.
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Learning zone respiratory nursing Conclusion
7 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 60
Intrapleural chest drains are a useful means of removing air or abnormal fluid from the pleural cavity, and can be a life-saving intervention. However, these chest drains and drainage collection systems expose patients to various risks and complications, which can prove life-threatening. Nursing care of the patient with an intrapleural chest drain requires skill and
knowledge to promote patient safety and comfort and reduce risks. Observations are central to maintaining a safe environment, while skilled nursing care can prevent many complications, with infection and pain control being particularly important aspects of nursing. Intrapleural chest drains should be managed on wards familiar with these chest drains and their management (Havelock et al 2010) NS Complete time out activity 7
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guideline 2010. Thorax. 65, Suppl 2, i61-i76. Jones SKB (2011) Chest Tube Dressings: A Comparison of Different Methods. gradworks.umi. com/34/89/3489450.html (Last accessed: May 1 2013.) Kesieme EB, Dongo A, Ezemba N, Irekpita E, Jebbin N, Kesieme C (2012) Tube thoracostomy: complications and its management. Pulmonary Medicine. doi: 10.1155/2012/256878. Light RW (2011) Pleural controversy: optimal chest tube size for drainage. Respirology. 16, 2, 244-248. MacDuff A, Arnold A, Harvey J, British Thoracic Society Pleural Disease Guideline Group (2010) Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 65, Suppl 2, ii18-ii31. Marieb EN, Hoehn K (2012) Human Anatomy & Physiology. Ninth edition. Pearson, Boston MA. National Patient Safety Agency (2008) Risks of Chest Drain Insertion. Rapid Response Report 03. NPSA, London.
O’Driscoll BR, Howard LS, Davison AG; British Thoracic Society (2008) BTS guideline for emergency oxygen use in adult patients. Thorax. 63, Suppl 6, vi1-vi68. Rashid MA, Wikström T, Örtenwall P (1998) A simple technique for anchoring chest tubes. European Respiratory Journal. 12, 4, 958-959. Resuscitation Council (2011) Advanced Life Support. Sixth edition. Resuscitation Council, London. Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group (2010) Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax. 65, Suppl 2, ii32-ii40. Roskelly L, Smith AP (2011) Respiratory care. In Dougherty L, Lister S (Eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Eighth edition. Wiley-Blackwell, Oxford, 534-614. van Miert C, Dwan K, Hill R, Hoenig MR, Gruen RL, Semple MG (2012) Suction versus no suction for chest drain management. Cochrane Database of Systematic Reviews. Issue 7, CD009939.
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