Chest drains, nurse management, maintenance and removal, RHC

Equipment: Available for ongoing management or in case of any untoward event

The following equipment should be available in all areas for ongoing management of the underwater seal chest drain, in case of any unplanned event and for removal.

1.1 Safety Packs

There should be a Safety pack (Figure 1 & 2) present at the bedside for each chest drain in-situ. This should always be kept with the patient and should include:

• Clamps (non-serrated)
• Occlusive dressing (E.g. Duoderm®)
• Steri-strips
• Sterile Gauze
• Sterile Scissors
• 70% alcohol & 2% Chlorhexidine swabs (E.g. Clinell® swabs)

1.2 Equipment Stock

The following stock should always be easily accessed and available in each area:

• Clamps (minimum of 1 clamp per drain depending on area)                        
• Suction tubing
• Spare connector – correct size (attached to back of chest drainage system)
• Suitable occlusive dressing e.g. Duoderm ®
• 70% alcohol & 2% Chlorhexidine swabs (E.g. Clinell® swabs)
• Sterile gloves
• Sterile water
• Sterile scissors
• Dressing Pack
• Disposable apron
• Disposable gloves
• Spare Underwater Seal Chest Drain Systems
• Low flow wall suction
• Stethoscope

When caring for the infant or child with a chest drain, it is important to ensure checks are carried out at the beginning of each shift to create a baseline for observation and management. All safety checks must be carried out within the first hour of each shift, and vital signs/patient observations should be carried out regularly. The timing and regularity of these will depend on the clinical area. The following gives a basic guide to the care and management required when caring for an underwater seal chest drain system and any further resources/guidance required can be found in Appendix 5.6 - Additional Resources’

2.1 Start of shift checks

• Ensure emergency kit is available at bedside (Safety Pack and Clamps*)
• Observe chest drain insertion site for any signs of dislodgement or infection and ensure dressing is intact.
• Observe chest drain tubing for any kinks or blockages
• Ensure Low flow suction is present/attached and separate to high flow suction
• Ensure drain is on suction and bellow inflated as per manufacturers guidance (if suction required)
• Ensure drain is anchored to floor and labelled e.g. Pleural, Mediastinal
• Document current drain losses and calculate previous average shift losses as baseline
• Auscultate chest (N.B - this may only be applicable to PICU area)
• Check vital signs

*Ensure Clamps are non-serrated (flat) clamps. The use of serrated can cause damage chest drains & tubing.

2.2 Vital signs & patient observations

The infant or child with a chest drain(s) in situ must have the following observations monitored & documented frequently*:

• Respiratory rate, effort & work of breathing
• Air entries
• Heart rate & pulse
• Oxygen saturations (SpO2)
• Blood pressure
• Temperature
• If a suitable invasive monitoring line is in-situ, then regular arterial or venous blood gases should be done.

*Suggested frequency: Following immediate admission to PICU for post operative patients -

• Every 15 minutes for first hour following insertion
• 1 hourly for 4 hours
• 1-4 hourly as indicated by patient condition

On the ward setting- This should be discussed with medical team caring for the patient. Vital signs should be carried out a minimum of 4 hourly with drain losses and drain site condition documented every hour. Please See Appendix 5.1 for a copy of ‘Ward Specific Documentation’ (This should also be used when discharging a patient from PICU to the ward with a Chest Drain In-situ). Drain losses should be added to the patient fluid balance chart.  

2.3 Chest drain site care

The nurse must ensure the drain site is checked regularly for the following:

• Drain is properly anchored with appropriate suture(s) and secured to child’s chest wall
• Drain site is dry, clean & covered with dry non-adherent dressing
• Drain site dressing should be inspected for signs of leakage or odour
• Area around drains site inspected for signs of air leakage (audible or visible), inflammation, infection or subcutaneous emphysema

2.4 Dressing Changes

Chest Drain Dressings whilst drain in situ* should be changed:

• Every seven days unless otherwise indicated - Changes are a risk for accidental drain removal. Avoid unnecessary changes
• If they are no longer dry and intact, or signs of infection - Infected drain sites require daily changing, or when wet or soiled

*In post-op cardiac patients, chest drains should be dressed separately to sternotomy wounds (if able) to minimise dressing changes. Please follow local policy for frequency of cardiac dressings.  

Equipment Required:

• Dressing pack
• Appeal
• Normasol or Prontosan
• Occlusive Dressing (e.g DuoDerm^TM)
• High Absorbing Fibrous Dressing (e.g. Urgoclean ^TM)

Procedure:

1. Prepare Sterile Dressing Pack as per ANTT guidance.
2. Perform hand hygiene and then don gloves, apron and appropriate PPE for procedure
3. Remove old dressing
   • change gloves in-between this and next step.
4. Clean the drain site using the appropriate solution.
   • Use standard ANTT and clean site using Normasol Topical 0.9% Sodium Chloride solution
   • If the wound is showing signs of being infected, contaminated or soiled, obtain a swab sample then use Prontosan Solution or Gel as per local guidance.

5. Once the site is dry apply High Absorbing Fibrous Dressing around site and under drain (Figure 3.)
6. Finally apply Occlusive Dressing over drain & Site (Figure 4.)
7. Remove gloves and perform hand hygiene

*Please note – not all drains will be dressed as above. This may change depending on the clinician putting in the drain. Above guidance is for PICU and may differ dependant on area/type of drain inserted.

2.5 Chest drain system care

The nurse must check the underwater seal chest drain system frequently to ensure it is working correctly and to avoid potential problems: 

Drainage System Checks:

• If suction required - Check suction tubing connected to low flow suction & suction control stopcock switched on - Bellows must be expanded to Δ mark or beyond for a –20 cmH2 O or higher regulator setting. (Figure. 5 - E)
• Ensure there is water in the water seal chamber and is maintained at 2cm level. (Figure. 5 – B)
• Monitor the water seal chamber of the chest drain system for signs of air leak (bubbling) and report any changes to nurse-in-charge and medical staff. (Figure. 5 – C)
• If chest drain is in pleural cavity, observe and record any fluctuations in water seal level of Chest drainage system with respiratory effort/ventilation – ‘tidalling’
• Check fluid Collection Chamber frequently and document losses including volume, type and colour of losses e.g. fresh blood, serous, cloudy. (Figure. 5 - D)
• Document drain losses in fluid balance chart **
• If fluid replacement therapy is required due to increased drain losses, this needs to be prescribed and documented on the patient’s fluid balance chart
• The Chest Drain System must be changed when the fluid collection chamber becomes 3/4 full to avoid fluid build-up - See Section 2.6 for ‘Chest Drain System Change’

** Drain losses should be assessed and documented every 15 minutes for first hour of insertion, 30 minutes for next 4 hours then hourly thereafter 

If the following is observed, inform medical staff:

• A sudden increase in amount of drainage
  • Greater than 5mls/kg in 1 hour
  • Greater than 3mls/kg consistently for 3 hours
• Significantly reduced output over an extended length of time
• Drain with ongoing loss suddenly stops draining

Blocked drains are a major concern for cardiac surgical patients due to the risk of cardiac tamponade

Drainage System Positioning:

• Keep chest drain system and tubing below the level of the patient's chest
• Inspect chest drain system & drain connections regularly (suggested hourly) and keep tubing free from bedsides/cot-sides
• Ensure tubing & drain(s) are secure but not ‘pulling’. Try not to secure tubing to child’s bed, linen or loose clothing ( 6)
• Aim to lay tubing horizontally across bed before dropping it vertically into drainage system to facilitate drainage – avoid dependent ‘loops’ or kinking of tubing. (Figure. 7)
• Ensure chest drainage unit is secured upright on floor beside or at the end of the bed/cot.
• Always label chest drain(s) and drainage systems clearly. E.g. Left (L) pleural 1 or Right (R) mediastinal 2.

2.6 Nursing considerations

• The nurse should assess the child’s level of pain or discomfort regularly and administer analgesia as prescribed
• Reposition the child regularly as tolerated ensuring drain and tubing secure throughout – this should be a two-nurse procedure.
• It is important to check the chest tube connections for signs of air leaks, such as “hissing” sounds or bubbling in the water seal.
• Remember to check the condition of the tube itself for signs of clotting in the tube.
• Avoid excessive chest tube handling and manipulation. ‘Milking’ or ‘stripping’ is no longer recommended practice and should only be carried out in exceptional circumstances by senior medical/surgical staff.
• Avoid routine clamping of chest drain tube unless specifically instructed by senior physician - Significant risk of tension pneumothorax development if clamped
• When two or more indwelling chest tubes are attached to a single chest drain via a “Y” connector set up, it is important to ensure that all indwelling catheters are properly tailored and attached so they do not kink (Figure 8).
• If Drains are required to be “Split” i.e. to monitor drain losses separate, this should be carried out as early as possible, and all drain losses documented accurately prior to splitting - see Appendix 5.4 for ‘Drain Separating Procedure’
• When there is no air leak, the water level in the water seal chamber should rise and fall with the patient's respirations, reflecting normal pressure changes in the pleural cavity during respiration. During spontaneous respirations, the water level should rise during inhalation and fall during exhalation.
• If the patient is receiving positive pressure ventilation, the oscillation will be just the opposite. Oscillations may be absent if the lung is fully expanded, and suction has drawn the lung up against the holes in the chest tubes.
• A patient with mediastinal chest tubes (and a ‘closed’ chest) should have no bubbling or fluctuations in the water seal chamber. As one of the risks of accumulation of fluid, blood or clots around the heart is cardiac tamponade, it is particularly important for nurses caring for patients with mediastinal chest tubes to be watchful for signs of cardiac tamponade with special attention paid to the volume and consistency of drainage in the collection chamber.

2.7 Chest Drain System Change

Each chest drain chamber needs to be replaced when it is ¾ full or when the Chest drain System sterility has been compromised e.g. accidental disconnection  

Equipment Required:

• New Underwater Seal Drainage System
• Dressing pack
• Clamps
• PPE

Procedure:

1. Perform hand hygiene.
2. Use personal protective equipment to protect from possible body fluid exposure.
3. Using an Aseptic Non-Touch Technique, remove the unit from packaging and prepare the new system - See Appendix 5.3 for ‘Set-up Guide'.
4. Ensure patients drain is clamped to prevent air being sucked back into chest using either patient tube clamp or separate clamps (Figure 9.)
5. Disconnect old chamber by holding down the clip on the in-line patient tube connector to pull the tubing away from the chamber. (Figure 10.)
6. Insert the tubing into the new chamber until you hear it click.
7. Unclamp the chest drain
8. Ensure drain is secured to floor and back on suction if required.
9. Place old chamber into orange clinical waste bag and large Clinical Waste Bin - as per hospital infection control policy.
10. Perform hand hygiene and ensure Clinical Waste Bin disposed of as per local policy.

When carrying out start of shift and ongoing management checks, if there are any concerns or indications of risk/future problems, please consider the following troubleshooting guides. This list is not exhaustive therefore if your concerns are not listed below, please use the links to manufacturers handbook and full troubleshooting guides provided in Appendix 5.5 ‘Additional Resources’.

3.1 Signs of Infection

Chest Drain Site

• The Chest drain site should be assessed hourly to recognise signs of skin deterioration or infection – monitor exudate type and amount, odour, redness and swelling.
• If infection suspected, using ANTT remove the dressing and obtain a wound swab and send to microbiology for culture & sensitivity
• Apply an appropriate dressing to chest drain site according to hospital wound chart or contact Tissue Viability Nurse for wound assessment
• Document wound management plan, by completing wound chart and re-assess regularly.

Chest Drain Fluid

• Chest drain losses should be assessed regularly as per suggested frequency.
• Observe fluid for any changes in appearance and document colour of fluid loss (Blood, Haemoserous, Serous, Chyle, Pus or Air if no fluid loss expected)
• Consider taking sample of drain loss to assess for chylothorax (See Sample Collection Procedure below)

3.2 Sample Collection Procedure

• Use an ANTT approach throughout
• Wash hands, don apron and gloves before procedure
• Sample must be taken from the drainage system tubing, not the collecting chamber
• Clean sample port with Clinell® swab.
• Attach Luer-lock syringe (E.g. 5ml) to sample port (Figure 11.)
• Manipulate chest drain system tubing to manoeuvre exudate towards sampling port* (Figure 12.)
• Aspirate sample into syringe.
• Insert aspirated chest drain exudate into universal container (vacuum white cap)
• Send to microbiology for culture & sensitivity and / or investigations requested by medical staff
• Continue to monitor child for signs of systemic sepsis

* All chest drain systems are NEEDLE-FREE.

**Chest drains tubing blockage, Accidental Removal, Accidental Dislodgement/Damage. See Appendix 5.2 for Chest drain trouble shooting flowchart.

4.1 Considerations

The decision to electively remove any chest drain(s) is a clinical one.

It should be ascertained that the chest drain is no longer required. That is, the original need for chest drain insertion has been resolved, such as evidence of adequate lung re- expansion or minimal serous fluid loss.

Written documentation by medical staff or ANP for drain removal specifying drain/drains to be removed for the correct patient.

If an x-ray is available pre drain removal this should be checked by Medical Personnel. If multiple drains in-situ, then medical personnel should ensure the correct drain for removal is identified and labelled before nursing staff remove drain.

The nurse should check the child’s vital signs, particularly their respiratory status. These should be stable before considering removal of chest drains and monitored closely throughout.

The patient’s blood results should be checked, in particular haematology and coagulation status should be available, before chest drain removal, as a low platelet count would result in excessive bleeding.

Other clinical evidence of bleeding in the child, such as oozing at invasive line or wound sites, should be noted as this may indicate clotting problems and should be highlighted to medical staff prior to ensure informed decision on removal is made.

If the child is receiving any anticoagulant or thrombolytic therapy, then they are at greater risk of bleeding if the chest drain(s) is removed. Protocols for pausing therapy briefly for procedures such as chest drain removal, should be adhered to. See anticoagulation guidance.

4.2 Indications

• Absence of air leak (pneumothorax)
• Drain losses are diminished to little or nothing
• Respiratory stable
• Chest x-ray confirming re-expansion of the lung

4.3 Pre-Procedure & patient considerations

• Patient should be fasted pre procedure as per medical personnel instructions - see local guidance (are specific)
  *Fasting Guidance for Procedures on PICU Patients in PICU or Theatre 
• Explain procedure to child and family
• Provide appropriate analgesia and sedation for the patient. Oral midazolam liquid can be prescribed by medical staff to be give pre procedure, please refer to BNFC under conscious procedure section for guidance and doses. If patient has NCA/PCA Morphine in situ background should be paused and boluses used for pain management, consult with Pain Team and/or Medical Staff. If no NCA/PCA then give appropriate prescribed analgesia.
• If pacing wires and drain to be removed, remove pacing wires first (see anticoagulation guidance)
• If patient is receiving anticoagulant medication refer to local guidance if applicable (link)
• Ensure there are enough staff to assist and carry out procedure, (Minimum of 2 competent nurses).

4.4  Equipment

• Clean trolley
• Gloves – sterile & non-sterile
• Disposable apron                 
• Disposable visor mask/goggles
• Sterile Dressing pack: inc. drape, gallipot, gauze.
• Chest drain site & wound site cleaning solution: 0.9% sodium chloride (Prontosan may also be used)
• Stitch cutter       
• Steri strips
• Occlusive dressing for chest drain wound site: E.g. Duoderm®     
• Chest drain clamps (minimum x2 per drain))
• Clinical waste bags (x2) & large sharps bin

*Dressing for mediastinal wound site and chest drain site if removing mediastinal drains post-cardiac surgery (Duoderm® & UrogoClean)

4.5 Procedure - Chest drain removal

1. Assemble equipment and take to bedside once analgesia/sedation has taken effective
2. Identify staff to help and identify specific roles - see appendix 5.5 for roles
3. Ensure patient is in optimal position lying in bed 30 degree head tilt and drains are easily accessible.
4. Perform hand hygiene
5. Open dressing pack and other equipment to clean trolley
6. Don appropriate PPE for procedure
7. If drain is connected to suction, then stop suction and clamp drain
8. Clamp chest drain(s) being removed (Figure 13) and all other drains connected to, or sharing the same chest drainage unit. If only one drain is removed and other on the same connection/drainage unit are still in situ, the drainage tubing to the removed drain must remain clamped following removal.
9. Removal all dressing from the area and examine site. Identify drain anchor sutures (if any/cardiac patients) and the purse string and expose the ends, unwind in preparation for assistant to tie.
10. Remove disposable gloves, preform hand hygiene and don sterile gloves
11. Clean around the catheter insertion site with appropriate skin cleaning solution
12. Together with assistant, identify anchor suture and purse string
13. Ensure the assistant and patient are ready
14. Prepare purse string for tying once drain has been removed
15. Cut anchor suture and ensure drain mobile and ready for removal
16. Remove drain:
    • nurse using one hand to ‘brace’ either side of the chest drain site, should start to remove chest drain smoothly and briskly with other hand.
    • If the child is old enough to understand (and not on mechanical ventilation) they may be asked at this stage to take a breath and hold it as the drain is removed (a few practice breaths may be tried first). Once the drain is out they should be encouraged to breathe normally.
    • If the child is receiving inhalational anaesthetic for chest drain removal, please communicate with doctor administering anaesthetic when chest drain about to be removed.
      Note: If at any point the drain does not come out easily or if there is an excess of tissue/omentum, then stop procedure, apply occlusive dressing and inform medical staff immediately.

17. As drain is removed the assistant should tie the wound suture firmly and securely to close drain site, ensuring the suture is not pulled too tight
18. As soon as drain is removed and wound site closed, pressure should be applied with a Prontosan swab over the site briefly, then remove and quickly inspect the site. If closure of site does not look complete, then steri-strips should be applied.
19. If removing two drains (E.g. mediastinal) then repeat the above procedure (remember to keep clamps on until all drains to come out have been removed).
20. Once drain(s) removed, the site(s) should then be checked, cleaned again, steristrips applied (if required) and covered with a suitable occlusive dressing (E.g. Duoderml® +/- Urgoclean).
21. In certain circumstances children with more than one drain on the same drainage system may require removal of only one of these drains.

• • In these cases follow above procedure, keep chest drain clamps on all drains, change connectors (if applicable) and do not remove clamps until remaining drains are connected back to the underwater seal unit.
  • Once underwater seal established on remaining drains, remove clamps and recommence suction (if required).

22. Ensure child comfortable and positioned upright after procedure.
23. Note and document child’s vital signs, colour, air entries, oxygen saturation, respiratory rate and effort post drain removal.
24. Arrange for chest x-ray post drain removal if requested by medical staff** Observe patient closely following removal for signs of pneumothorax/deterioration and alert medical staff immediately.
25. Remove chest drain clamps and keep for re-sterilisation. Dispose of removed chest drains, drainage system, dressing pack and aprons and gloves into clinical waste bags (orange) x2, then place in large clinical waste bin.

**Follow Removal flow chart for specific roles see appendix 5.5

4.6 Further Information and precautions

Sometimes omentum may come out with the chest drain being removed. If this does happen, pause procedures, clean site and apply dressing and inform medical staff immediately.

Occasionally the chest drain wound site may not have a wound closing suture (E.g. drain inserted as emergency by transport team prior to admission). In this instance, when removing drain ensure application of sufficient steristrips, occlusive dressing and document.

Post drain removal x-ray will only be considered on Consultant’s request. Follow POCUS (Point of Care Ultrasonography) in the first instance if the patient is showing clinical signs of pneumothorax.

Dressing post drain removal must be closely monitored and changed every 48hours until dry and skin healthy and healing. If signs of infection or oozing present the dressing may require to be changed more frequently, and a swab taken of the area. If stay sutures in place these should be remove on day 5 post drain removal.  

Daily chest drain monitoring chart (pdf)

View flowchart as pdf

This Set-up guide can be used when setting up a new ‘Atrium Oasis Dry Suction Water Seal Chest Drain Chamber’ for either the initial setup or when setting up a new chamber for replacing a full chamber.

Procedure:

1. Open remove chamber from packaging and open using Aseptic technique.
2. Ensure manual dial is showing the preset level of -20cm^H2O. (This can be changed at the side of the dial if asked by surgeons – remember to re-check bellow when connected to suction if adjusted)
3. Use 45ml water ampule that is provided on the back of the chamber and empty into blue port at top of drain until water reaches 2cm line on water seal chamber.
4. Ensure patient tubing clamp is open on patient tubing and that all connections and tubing is intact.
5. Connect chamber to patient catheter using sterile technique – this is now putting the drain on “gravity drainage”.
6. If required, connect suction tubing to blue port.
7. Attach and turn on low flow suction vacuum to -10 kPa. (Step-by-Step video states -80mmHg but this is our equivalent and same value – this can be seen on dial)
8. If the Suction Dial is set to -20cmH2O the bellow should inflate to the midline dial shown as ▲. This is a visual indicator that there are sufficient suction levels.
9. The water seal chamber should be still, and if bubbling is present, this is an indicator of an air leak. Check all connections are secure and that the chamber has been set up properly to confirm.
10. Secure chamber to the floor when positioning and drainage confirmed.
11. Label each chamber accordingly and document initial drain readings.  

Atrium Oasis Dry Suction Water Seal Chest Drain (getinge.com)

When multiple drains are inserted, it is the physician’s decision if they wish to link multiple drains and attach them to single chambers using a ‘Y’ connector, or if they wish to have each drain attached to its own separate chamber. If multiple drains are attached to a single chamber and are required to be “Split” i.e. to monitor drain losses separate, this should be carried out as early as possible, and all drain losses should be documented accurately prior to splitting.

Equipment:

• Dry Suction Underwater Seal Chest Drain Chamber
• Clamps
• Dressing Pack
• 70% alcohol & 2% Chlorhexidine swabs (E.g. Clinell® swabs)
• Additional Suction Tubing
• Additional Chest Tubing connectors

Procedure:

1. Wash hands and don PPE as per infection control policy
2. Prepare new chest drain chamber(s) required following set-up guide in Appendix 5.3 ‘Set-up Guide’.
3. Open dressing pack and place sterile sheet under drains in case of drain touching patient/linen.
4. Clamp all drains connected to the chest drain chamber requiring splitting.
5. Clean all areas of the chest drain and chest drain system tubing that will be handled using Clinell Swabs for 30 seconds and allow to dry for 30 seconds.
6. Disconnect ‘Y’ Connector using ANTT and remove from chest drain chamber tubing.
7. Attach new chest drain tubing to each chest drain using in-situ connectors, however if tubing does not fit, additional connectors may be required (male-female/male-male) *.
8. Once each chest drain is attached to its own chest drain tubing & system, release the clamps.
9. If suction is required, reconnect suction tubing to each chest drain – ‘Y’ connectors may be required to link two chest drain chambers to one Low Flow suction Unit.
10. Secure each Chest Drain System to the floor and label each system i.e. Pleural/mediastinal.
11. Carry out all safety checks and ensure chest drain system is working as per section ‘Chest drain care & management’

*You may need a second person to assist you with chest drain tubing/suction tubing*

View flowchart as pdf

Underwater seal chest drainage in the highly dependent or critically ill infant or child: nurse role: chest drain insertion (NHSGGC Paediatric Guideline)

Atrium Oasis Dry Suction Water Seal Chest Drain (getinge.com)

Nursing guidelines : Chest drain management (rch.org.au) (Royal Hospital for Children, Melbourne)

Anticoagulation and antiplatelet therapy in paediatric cardiac patients (1180) (NHSGGC Paediatric Guideline)

Temporary epicardial pacing after cardiac surgery (NHSGGC Paediatric Guideline)

Standard Infection Control Precautions (National Infection Prevention and Control Manual) (scot.nhs.uk) (NHSGGC Guideline)

Aseptic Non-Touch Technique Policy (NHSGGC Guideline)