Nursing Management of Chest Drains

Nursing Management of Chest Drains Module 9 M.Lynch

Rationale for insertion • To overcome the accumulation of air or fluid in the pleural cavity that might impair ventilation. • Pleural membranes have a vital role in ensuring the lungs are expanded. • Therefore any disruption to the integrity of these membranes or changes within the pleural space,will compromise ventilation

The pleura • The external surface of the lungs are coveredby a thin, smooth serous membrane called the VISCERAL PLEURA. • A similar membrane lines the thoracic cavity, this contains nerve receptors to detect pain called the PARIETAL PLEURA

Con. • The VISERAL and PARIETAL pleura Are in close contact,between them is a Potential space the PLEURAL SPACE or PLEURAL CAVITY this space contains a thin layer of fluid which acts as a lubricant,this allows the pleural membrane to slide easily against each other during respiration.

Con. • If air, or more than a few mls . Of fluid of any kind enters the pleural space the lung will partially or fully collapse (Bourke and Brewis 1998, Bray et al 1999, McMahon-parkes 1997).

Chest Drains • It therefore follows that any injury or disease process that can cause accumulation of air or fluid in the pleural space will impair ventilation. • Air ,blood,fluid,bile,pus,chyle or gastric content can all collect in the pleural space.

Pneumothorax • This is the presence of air and is in the pleural space and can be classified as : • SPONTANEOUS typically occur in previously young,slender men. Caused by the rupture of a cyst or bleb in the lungs. • These are also associated with nearly all underlying lung diseases.COPD, Asthma,Inflammatory disease(Compeau and Johnston 199a)

traumatic • Wounds to the chest with or without penetration into the lung, for • example knife wounds, or fractured ribs

Iatrogenic • These occur as a consequence of care in hospital for example piercing the pleura during central line insertion,or during lung biopsy,or surgery to adjacent regions. • Also as a complication of positive pressure endotracheal ventilation

tension • This occurs if the opening from the lung to the pleural space acts as a one way valve,therefore air can not re-enter the lung leading to an ever increasing build up of air in the pleural space. • The lung on the affected side collapses, the medastinum shifts to the opposite side and venous return and cardiac output are impaired ?leading to ????

Con: • This is a life-threatening situation requiring prompt recognition and treatment (Bourkeand Brewis 1998.McMahon-Parkes 1997)

Heamothorax • Usually caused by a chest injury.Bleeding may occur from the heart,lungs,vessels or chest wall and the blood will enter the pleural space and compress the lung

Pleural effusion • Acollection of fluid in the pleural space usually from one of the following; Left Ventricular Failure, • Hypoalbuminaemia or liver failure. • Pleural metastases. • Obstruction of lymphatic drainage

Empyeama • Multiplication of bacteria in the pleural effusion secondary to an infection or TB can cause empyeama which is pus in the pleural space

Chest drain insertion • If the patients clinical condition allows, Informed Consent should be obtained prior to the insertion of the drain. • Lignocaine is used as a local anaesthetic. However Gray 2000 recommends Opioid Analgesia to be given alongside.

Con. • Medical staff will assess the patients CXR to locate air or fluid and determine the exact site for drain insertion. • For most conditions the optimum site for chest drain placement is usually the 3rd,4th 5th or 6th intercostal space in the midaxillary line.

Con. • This is sterile procedure for which (excluding life threatening emergencies) the doctor will scrub up and the patients skin will be cleansed and draped to minimise infection risks.

The Role of the Nurse • To prepare the sterile equipment and chest drainage system. • To assist the doctor with the procedure. • To position the patient in a suitable and comfortable position. • To observe the patients heamodynamic state.

Con. • To offer comfort and support to the patient throughout the procedure. • To ensure the 2 clamps are secure post insertion • And attached the drain tubing to the chest drain bottle. • Observe the drainage or the oscillation of the drain

Con. • Prior to the dressing being applied over the insertion site, it is very important that the doctor has inserted a PURSE-STRING suture around the incision to close the track and aid in drain removal. • The drainage bottle must to dated • And a zero mark indicated on the bottle to allow for accurate estimation of fluid/blood drained.

Con. • In some cases more than one drain will be inserted if both air and fluids are to be removed from the PLEURAL space. • These will be referred to as APICAL and BASAL drains. These are labelled as such.

Nursing management • Several drainage systems are available, the most common being the one-bottle system,which is generally adequate to drain an uncomplicated pneumothorax,heamothorax or pleural effusion. • The tube from the patient is attached to a tube in the collecting bottle that must be under the water in that bottle by at lest 2cm

Con. • Low pressure suction may be applied to enhance drainage (Avery 2000) • Too little suction may prevent lung expansion and increase the risk of infection, atelectasis and tension pneumothorax (Tang et al 1999)

con • Too high suction should be avoided as this can lead to lung tissue damage and perpetuate air leaks (McMahon-Parkes 1997) • Munnell 1997 found the most common amounts of pressure used are 5kpa or 20cmH20

Con. • It is the responsibility of the nursing and medical staff to monitor the patient and the drain closely • There are wide variations of practice based on local protocols as to the management of Underwater seal drains

Patient Care • Position the patient as the clinical condition allows, ideally nursed in a semi-upright position well supported with pillows and regular changes of position to facilitate drainage and prevent stiffness of the shoulder joints (McMahon-Parkes 1997)

con • Observations : continuous heamodynamic monitoring, and close observations of the respiratory status,included breath sounds,equal expansion of the chest,effort and depth of respirations, O2 saturations., and monitoring ARTERIAL BLOOD GASES>

Con. • The drainage set-up must be closely monitored for SWINGING and/or BUBBLING. • PAIN MANAGEMENT.Gray (2000) acknowledges that pain is a problem for patients with chest drains, she suggests this is managed with NSAIs

con • The drainage bottle MUST BE KEPT BELOW THE PATIENTS CHEST. To prevent fluid re-entering the chest. • Drainage should be evaluated and recorded on the patients fluid chart • If drainage suddenly increase the medical staff must be informed

Drain Security and Dressings • Avery (2000) advises that the connection be secured with an impermeable adhesive tape which allows observation of the connection • However there area variety of practices • Applied to secure this connection

Drainage tubing and clamping/milking/stripping • Looped,coiled or clotted impeded drainage can lead toa TENSION PNEUMOTHORAX or SURGICAL EMPHYSEMA. • AVERY(2000) recommends replacing the tubing if a blockage occurs, if the tube is milked by hand or with a roller this can result in lung damage(WELCH 1993)

CLAMPING • Drains should only be clamped when changing the bottles or following disconnection (Compeau and Johnston 1999,Mallett and Dougherty 2000,Munnell 1997) • TWO lockable flat bladed clamps MUST be at the bedside for this use, • And removed as soon as possible to prevent a TENSION PEUMOTHORAX

Changing the drainage unit. • If the unit is full or damaged then it will be changed. • Local protocols will dictate this,Godden and Hiley 1998 state that there is little research into this • Generally these are changed when drainage collected impedes flow

Nursing Management of Chest Drains