In chest drainage system a chest tube is a flexible plastic tube, is inserted through the chest wall into the pleural space or mediastinum through the doctor
Chest surgeries causes a pneumothorax on the operated side. During a thoracotomy the parietal pleura is incised and the pleural space is entered. Atmospheric air enters the pleural space, changing the normally negative pressure is that pleural space to a positive pressure. As a result, the lung recoils to its unexpanded size and remains collapsed.
Chest tubes are usually inserted in an operating room during chest surgerr. However, in some emergencies, a chest tube may be inserted in a treatment room or at the bedside.
Two catheters are usually placed in the chest following resectional surgery (except pneumonectomy).
One catheter ( the upper or anterior tube) is placed anteriorly through the second intercostals space to permit the escape of airising in the pleural space.
The second catheter,( the lower or posterior tube) is placed posteriorly between the sixth to ninth intercostals spaces in the midaxillary line to drain serosanguineous fluid accumulating in the lower portion of the pleural space. The lower tube may have a large diameter than the upper tube, to enhance fluid drainage. The catheres are secured to the client’s skin with sutures.
The two chest tubes may be joined to each other with a plastic Y-junction and then attached to one closed-chest drainage system.
Why Closed Drain System is Require
- Promote evacuation of air and serosanguineous fluid from the plural space
- Prevent the reflux of atmospheric air into the pleural space
- Help re-expand the remaining lung tissue by re-establishing normal negative pressure in the pleural space.
- Prevent mediastinal shift and pneumothorax by equalizing pressures on the two sides of the thoracic cavity.
- A drainage device must..
- Be allow air and fluid to leave the chest;
- Contain a one-way valve to prevent air & fluid returning into the chest;
Design is like, the device is below the level of the chest tube so it maintain gravity drainage
Types of Closed-Chest Drainage system
- Wet Suction Control System
- Dry Suction Control System
Wet Suction Control System
The suction control chamber always located on the left side of system. In this system, the suction control chamber is filled with sterile fluid to desired height and the tubing is connected to a suction source, which is to be adjusted to produce gentle bubbling in the suction control chamber.
To increase the airflow through system it is necessary to increase suction at the suction source. Excessive source suction causes loud bubbling (disturb client and caregivers), and also hastens evaporation of water from the suction control chamber. These results decreases water level which cause lower amount of suction applied to the client.
Wet suction control systems have three main compartments…
The Collection Chamber
The collection chamber collects drainage and allows monitoring of the volume, rate and nature of drainage from the pleural space. A pressure is recommended for suction is −20 cm H2O. For infant indicated lower level pressure and adult, with friable lung tissue or as per doctor recommended.
The Water-Seal Chamber
The water-seal chamber is used as a one-way valve so that air or fluids can drain from the client’s chest but not return.
The Suction-Control Chamber
The suction-control chamber uses suction to promote drainage from the pleural space ( at a greater rate than achieved by gravity alone) and assist in re-expanding the lung.
Dry Suction Control System
Dry suction unit is controlled by a self-compensating regulator. For suction setting, the dial is rotated and suction could be set at −10, −15, −20, −30, or −40 cm of water. The common unit is usually pre-set at −20 cm of water when it is used. Suction source must be capable of delivering a minimum of 16 liters per minute (LPM) air flow.
Client situations may require higher suction pressures of −30 or −40 cm H2O. It include: a large air leak from the lung surface, empyema or viscous pleural effusion, a reduction in pulmonary compliance, or anticipated difficulty in expansion of the pulmonary tissue to fill the hemi-thorax.
Dry suction control systems have two main compartment. Regulating the level of suction is not performed through a column of water, but controlled with a self-compensating regulator using a spring or dial mechanism.
The collection chamber and water-seal chamber of a dry system are the same as for the wet system.
Advantages of Dry System
Dry control system includes…
- Ease in setup
- No noise of bubbling water in the suction-control chamber
- No evaporation of water over time
- Provision of high and more precise levels of suction.
Disadvantages of Dry System
- Dry suction system does not provide the same level of client assessment information as a conventional water seal;
- The clinician does not see changes in the water level reflecting pressure changes in the chest.
- For air leak detection, a separate air leak monitor to be filled with water.
- A vacuum indicator of drain provides visual evidence of negative pressure (vacuum) inside the collection chamber.
Other Types of Chest Tube Drainage
- One Bottle Chest Drainage System
- Two Bottle Chest Drainage System
- Three Bottle Chest Drainage System
Things to Observe in Chest Drainage
- Always keep the system closed and below chest level.
- Make sure all connections are taped and the chest tube is secured to the chest wall;
- Ensure the suction control chamber would be filled with sterile water to the 20 cm level or as doctors order.
- If using suction, make sure the suction unit’s pressure level causes slow but get steady bubbling in the suction control chamber;
- Always chack the fluctuation (tidaling) of the fluid level in the water-seal chamber; it may cause, the system may not be patent or working properly, or the lung of the client may have re-expanded;
- Monitor constant or intermittent bubbling in the water-seal chamber, which indicates leaks in the chest drainage system. Try to correct external leak if you don’t then immediately inform the healthcare worker and correct it.
- Check fluid in the drainage collection chamber, the amount, colour, and consistency of drainage in the drainage tubing.
- Mark the chest drainage level on the outside of the collection chamber (with date, time, and initials) every 8 hours or more frequently if indicated. Report to consultant related to drainage which is excessive, cloudy, or unexpectedly bloody;
- 500ml to 1000ml of drainage may occur in first 24 hours after chest surgery, Between 100 and 300ml of drainage may accumulate during the first 2 hours; after this time the drainage should lessen.
- Teach and encourage the client to perform deep breathing, coughing, and incentive spirometry.
- Assist with repositioning or ambulation. Provide adequate analgesia as per order.
- Assessment of vital signs, breath sounds, SpO2, and insertion site for subcutaneous emphysema.
- At the time of chest tube removal, immediately apply sterile occlusive petroleum gauze dressing over the site to prevent air from entering the pleural space;
- Observe the drainage tubing, which should not be kinked, looped, or interfere with the client’s movement;
- Do not clamp a chest drainage tube, except momentarily when replacing the chest drainage unit, assessment of an air leak, or assessment of the client’s tolerance of chest tube removal, and during chest tube removal;
- Do not manipulate aggressively the chest tube; do not strip or milk it;
- Observe a client who is free from pain, an effective cough can be produced, will generate a much higher pressure than can safely be produced with suction;
- Suppose a patient cannot re-inflate his own lung, high volume, low pressure “thoracic” suction in the range of 15-25 cm of water could help;
- Clients who are on mechanical ventilators cannot produce an effective cough then suction is advisable;
- Trained nursing staff for close observation and identification of external leakage
- The water seal chamber and suction control chamber provide intra-thoracic pressure monitoring. In gravity drainage without suction the level of water in the water seal chamber = intra-thoracic pressure;
- Need to keep in mind is that, Slow, gradual rise in water level over time means more negative pressure in pleural space which signals healing. Goal is to return to −8 cm H2O;
- Application of suction: Level of water in suction control + level of water in water seal chamber = intra-thoracic pressure.
- To decrease resistance, first, tube is connecting drain to drainage bottles
- The capacity of volume of tube must be exceed ½ of client’s maximum inspiratory volume (otherwise water may enter chest)
- volume of water in second bottle should exceed ½ client’s maximum inspiratory volume to prevent indrawing of air during inspiration
- Chest drain should always kept at least 45cm below client bed (prevention of removed fluid or water refluxing into client chest)
- Always clamp chest drain when moving it.
- When suction is turned off, tubing must be unplugged so air can escape into atmosphere (otherwise client may land up a tension pneumothorax)
- Retrograde flow of fluid may occur if the collection chamber is raised above the client level
- Tension pneumothorax
- Glass bottles can break
- Unidirectional flutter valve is used to replace underwater seal drains
- It consists of a tubing assembly and sealed transparent housing with tubing connection
- End attached to the chest drain and a collection bag
Maintenance of Chest Drainage Tubes
- Ensure that the patient’s ICD drainage tubes are kept in a proper position.
- Ensure that the tubing’s do not loop or interfere with the movements of the patient.
- Ensure that the ICD bag is placed below the level of chest. In case of change of position, take care that the bag is not accidentally placed at a height above chest level.
- Keep two artery forceps ready in order to handle any accidental disconnection of the tube.
- Encourage good body alignment. When the patient is in a lateral position, place a rolled towel under the tubing to protect it from the weight of the patient’s body. Encourage the patient to change his position frequently.
- Encourage patient to do the range of motion exercise of the arm and shoulder of affected side.
- “Milk” the tubing in the direction of the drainage bag as needed.
- Ensure that there is fluctuation (Tidaling) of the fluid level.
- Empty out the contents every 24 hours preferably in the morning at 6 a.m. unless the doctor specifies not to empty out.
- Subtract the amount of normal saline instilled before recording the results.
- Refill the normal saline at the level of the marking and add few drops of Betadine in it for easy visibility of the fluid.
- Fluctuations of fluid in the tubing will stop when –The lung has re-expanded.
- The tubing is obstructed by blood clots or fibrin.
- A dependent loop develops.
- Suction motor on wall is not operating properly.
Removal of Inter-Costal Drainage
Collect the following articles at the bedside –
- Sterile Gloves.
- Sterile Gauze.
- Betadine ointment and lotion.
- Scalpel Blade.
- Analgesic drugs, if ordered.
- Dressing tray.
- Explain the procedure to the patient.
- Give analgesia prior to procedure, if ordered.
- Provide privacy.
- Wear unsterile gloves and remove the dressing. Ask the patient to take a deep breath and hold the breath while the tube is being pulled out.
- After tightening the stitches apply Betadine ointment and apply dressing.
- Ask for chest x-ray.
- Replace the articles.
- Document the procedure in nurse’s notes.
- Any untoward reaction noted duration the procedure.