How to manage chest drain in patients?

1. Chest Drain Management
By : Dr. M. Rezaei
Fellowship of Pediatric Pulmonology

2. UWSD
 Also known as Under Water Sealed Drain (UWSD)
 inserted to allow draining of the pleural spaces of air,
blood or fluid, allowing expansion of the lungs and
restoration of negative pressure in the thoracic cavity.
 underwater seal also prevents backflow of air or fluid
into the pleural cavity.

3. Indications for Insertion of a Chest Drain
 Post operatively e.g. cardiac surgery, thoracotomy
 Pneumothorax
 Haemothorax
 Chylothorax
 Pleural effusions

4. Start of shift checks:
Patient assessment
Vital signs
 In ICU:
 Continuous monitoring
 HR, SaO2, BP, RR
 In Ward areas:
 On insertion of chest drain monitor patient observations of HR,
SaO2, BP, RR:
 15 minutely for 1 hour
 1 hourly for 4 hours
 Includes HR, SaO2, BP, RR and temperature
 1-4 hourly as indicated by patient condition

5. Start of shift checks:
Patient assessment
Pain

6. Start of shift checks:
Patient assessment
Drain insertion site
 Observe for signs of infection and inflammation and
document findings
 Check dressing is clean and intact
 Observe sutures remain intact & secure (particularly long
term drains where sutures may erode over time)

7. Start of shift checks:
Patient assessment
UWSD Unit & tubing
 Never lift drain above chest level
 The unit and all tubing should be below patients chest level to
facilitate drainage
 Tubing should have no kinks or obstructions that may inhibit
drainage
 Ensure all connections between chest tubes and drainage unit
are tight and secure
 Tubing should be anchored to the patients skin to prevent
pulling of the drain
 In ICUs tubing should also be secured to patient bed to prevent
accidental removal
 Ensure the unit is securely positioned on its stand or hanging on
the bed
 Ensure the water seal is maintained at 2cm at all times

8. Start of shift checks:
Patient assessment
Drainage:
Volume
 Document hourly the amount of fluid in the drainage chamber
on the Fluid Balance Chart
 Calculate and document total hourly output if multiple drains
 notify medical staff if there is a sudden increase in amount of
drainage
 notify medical staff if a drain with ongoing loss suddenly stops
draining (Blocked drains are a major concern for cardiac surgical
patients due to the risk of cardiac tamponade)
Colour and Consistency
 Monitor the colour/type of the drainage. If there is a change eg.
Haemoserous to bright red or serous to creamy, notify medical
staff.

9. Start of shift checks:
Patient assessment
Oscillation(Swing)
 The water in the water seal chamber will rise and fall
(swing) with respirations. This will diminish as the
pneumothorax resolves.
 Watch for unexpected cessation of swing as this may
indicate the tube is blocked or kinked.
 Cardiac surgical patients may have some of their drains in
the mediastinum in which case there will be no swing in the
water seal chamber.

10. Chest Drain Dressings
Dressings should be changed if:
 no longer dry and intact, or signs of infection e.g. redness,
swelling, exudate
 Infected drain sites require daily changing, or when wet or
soiled
 No evidence for routine dressing change after 3 or 7 days
 This procedure is a risk for accidental drain removal so
avoid unnecessary dressing changes

11. Removal of Chest Drains
Indications
 Absence of an air leak (pneumothorax)
 Drainage diminishes to little or nothing
 No evidence of respiratory compromise
 Chest x-ray showing lung re-expansion

12. Removal of Chest Drains
Procedure
 Perform hand hygiene
 Opening dressing pack and add sterile equipment and 0.9%
saline
 Remove all dressings around the area
 Clamp drain tubing
 If there are multiple drains insitu, clamp all drains before removal.
Once the required drains are removed, unclamp remaining drains
 Clean around catheter insertion site and 1-2cm of the tubing
with 0.9% Saline
 Remove suture securing drain
 Instruct patient exhale and hold if they are old enough to
cooperate; if not, time removal with exhalation as best as
possible.
 If there is no purse string present remove drain and quickly seal
hole with occlusive dressing

13. Removal of Chest Drains
 CXR should be performed post drain removal
 Clinical status is the best indicator of a reaccumulation of air or
fluid. CXR should be performed if patient condition deteriorates
 Monitor vital signs closely (HR, SaO2, RR and BP) on removal
and then every hour for 4 hours post removal, and then as per
clinical condition
 Dressing to remain insitu for 24 hours post removal unless dirty
 Complications post drain removal include pneumothorax,
bleeding and infection of the drain site

14. Complications and Troubleshooting
Pneumothorax
 Signs and symptoms include: Decreased SaO2, increased
WOB, diminished breath sounds, decreased chest
movement, complaints of chest pain, tachycardia or
bradycardia, hypotension
 Notify medical staff
 Request urgent CXR
 Ensure drain system is intact with no leaks, or blockages
such as kinks or clamps
 Prepare for insertion/ repositioning of chest drain

15. Complications and Troubleshooting
Bleeding at the drain site
 Don gloves
 Apply pressure to insertion site
 Place occlusive dressing over site
 Notify medical staff
 Check Coagulation results
 Check drain chamber to ensure no excessive blood loss

16. Complications and Troubleshooting
Infection of insertion site
 Notify medical staff
 Swab wound site
 Consider blood cultures

17. Complications and Troubleshooting
Accidental disconnection of system
 Clamp the drain tubing. Clean ends of drain and reconnect.
Ensure all connections are cable tied. If a new drainage
system is needed cover the exposed patient end of the
drain with sterile dressing while new drain is setup. Ensure
clamp removed when problem resolved
 Check vital signs
 Alert medical staff
Accidental drain removal
 Apply pressure to the exit site and seal with steri-strips.
Place an occlusive dressing over the top
 Check vital signs
 Alert medical staff.

18. Prevent air & fluid from
returning to the pleural space
 Most basic concept
 Straw attached to chest
tube from patient is
placed under 2cm of
fluid (water seal)
 Just like a straw in a
drink, air can push
through the straw, but
air can’t be drawn back
up the straw
Tube open
to
atmosphere
vents air
Tube from
patient

19. Prevent air & fluid from
returning to the pleural space
 This system works if only air is leaving the chest
 If fluid is draining, it will add to the fluid in the water
seal, and increase the depth
 As the depth increases, it becomes harder for the air to
push through a higher level of water, and could result in
air staying in the chest

20. UWSD
 For drainage, a second bottle
was added
 The first bottle collects the
drainage
 The second bottle is the
water seal
 With an extra bottle for
drainage, the water seal will
then remain at 2cm
Tube from
patient
Tube open
to
atmosphere
vents air
Fluid
drainage
2cm
fluid

21. UWSD
 The two-bottle system is the key for chest drainage
 A place for drainage to collect
 A one-way valve that prevents air or fluid from returning to
the chest

22. UWSD
 Many years ago, it was believed that suction was always required to
pull air and fluid out of the pleural space and pull the lung up
against the parietal pleura
 However, recent research has shown that suction may actually
prolong air leaks from the lung by pulling air through the opening
that would otherwise close on its own
 If suction is required, a third bottle is added

23. UWSD
2cm fluid water
seal
Collection
bottle
Suction
control
Tube from
patient
Fluid
drainage
Tube open
to
atmosphere
vents air
Straw under
20 cmH2O
Tube
to
vacuu
m
source

24. UWSD
 The straw submerged in the suction control bottle (typically to
20cmH2O) limits the amount of negative pressure that can be
applied to the pleural space – in this case -20cmH2O
 The submerged straw is open at the top
 As the vacuum source is increased, once bubbling begins in this
bottle, it means atmospheric pressure is being drawn in to limit the
suction level

25. UWSD
The depth of the
water in the suction
bottle determines the
amount of negative
pressure that can be
transmitted to the
chest, NOT the
reading on the
vacuum regulator

26. From bottles to a box
 The bottle system worked, but it was bulky at the bedside and
with 16 pieces and 17 connections, it was difficult to set up
correctly while maintaining sterility of all of the parts
 In 1967, a one-piece, disposable plastic box was introduced
 The box did everything the bottles did – and more

27. From bottles to a box
Collection
chamber
Water
seal
chamber
Suction
control
chambe
r
from
patient
Suction
control
bottle
Water
seal
bottle
Collection
bottle
From
patient
To suction

28. From box to bedside

29. At the bedside
Keep drain below the chest
for gravity drainage
This will cause a pressure
gradient with relatively
higher pressure in the
chest
Fluid, like air, moves from
an area of higher pressure
to an area of lower
pressure
Same principle as raising
an IV bottle to increase
flow rate

30. Setting up the drain
 Follow the manufacturer’s instructions for adding water to the 2cm
level in the water seal chamber, and to the 20cm level in the suction
control chamber (unless a different level is ordered)
 Connect 6' patient tube to thoracic catheter
 Connect the drain to vacuum, and slowly increase vacuum until
gentle bubbling appears in the suction control chamber

31. Setting up suction
 You don’t need to boil spaghetti!
 Vigorous bubbling is loud and disturbing to most
patients
 Will also cause rapid evaporation in the chamber, which will lower
suction level
 Too much bubbling is not needed clinically in 98% of patients –
more is not better
 If too much, turn down vacuum source until bubbles go away,
then slowly increase until they reappear, then stop