Chest Tubes and Under Water Seal Drains

Question 1

Draw a diagram of the gross anatomy of the lung

Answer 1

• The pleural space lies between the 2 pleural membranes of the lung
  1) Visceral pleura: membrane lining lung surface
  2) Parietal pleura: membrane lining chest wall
• Pleural fluid produced by pleural membrane fills this space preventing friction and damage to lungs

Question 2

What is a pneumothorax

Answer 2

Breach in pleural space where air collects and causes lung to collapse

Question 3

What is the purpose of an ICC

Answer 3

• Pneumothorax

- Pleural effusion

Question 4

What are considered small and large ICCs

Answer 4

• Small: = 16F
  
  • -> Inserted by Seldinger technique (catheter over wire)
• Large: =/> 20F
  
  • -> Inserted by blunt dissection

Both must be anchored appropriately and attached to UWSD

Question 5

Where is an ICC usually inserted?

Answer 5

• 4th-5th ICS at MAL on affected side in triangle of safety

–> most comfortable and safest position

Question 6

List complications of ICC

Answer 6

• tube misplacement
• haemorrhage
• nerve/organ damage
• infection
• pneumothorax
• necrosis around tube site
• subcutaneous emphysema

Question 7

What requirements are in place to minimise the likelihood of ICC complications?

Answer 7

• hourly ICC observations

- CXR post insertion to confirm tube placement, daily to assess clinical status, pre removal and 1-4 hours post removal

Question 8

Outline nursing responsibilities for care of patients with ICC and UWSD

Answer 8

• UWSD observations and general care
• ICC bottle change and wound dressings
• removal of ICC

Question 9

Outline observations for ICC/UWSD

Answer 9

• Patient:
  > Signs of respiratory compromise
  > Pain score / appropriate analgesia

- Chest tube:
 > Insertion site (nil signs of infection)
 > Tubing (intact, nil kinks)
 > Osciltation
 > Connections (visible and secure)

• Drainage:
  > Amount (rate/volume)
  > Colour
  > Composition

Question 10

Outline limits to drainage of fluid from ICC

Answer 10

• Maximum 1.5L in first hour after insertion
• Maximum 500mL/hour post first hour
• Rapid evacuation can result in re-expansion of pulmonary oedema

Question 11

Describe oscillation/swing/tidalling

Answer 11

• Changes in UWSD fluid level corresponding to respirations
  > Inspiration: intrapleural pressure decreases, transmitted into UWSD causing fluid column to rise
  > Expiration: intrapleural pressure increases causing fluid column to move down
• Normal value approx 2- 4 cm
• Swing won’t be present if tube is blocked or suction is off

Question 12

Describe bubbling

Answer 12

• Intermittent bubbling corresponding to respirations with pneumothorax: pleural space draining air
• Continuous bubbling: suspect leak
• Bubbling present in absence of pneumothorax: ask patient to cough

Question 13

Describe suction

Answer 13

• Must be low pressure
• High pressure suction can evacuate lung tissue causing:
  > discomfort
  > tissue damage
  > haematoma
  > death

Question 14

Describe care for UWSD unit

Answer 14

• Maintained in upright position
• Change bottle every 72 hours and pRN
• Set up as per instructions
• Cover under water rod with 2-4 cm of water
• Dressing: inspected and changed at least daily, swab if signs of infection

Question 15

When should a UWSD be clamped

Answer 15

• Only if ordered by MO and there is adequate staff to patient ratio
• Educate patient of symptoms of respiratory compromise / chest tightness/ CP/ SOB (signs of recurrence of pneumothorax or developing tension pneumothorax)

Question 16

How can nursing staff promote drainage and lung expansion

Answer 16

• 30 degree angle on bed
• Semi-Fowler’s position
• Encourage deep breathing and coughing
• Repositioning every 2 hours minimum
• Encourage early ambulation

Question 17

Indications for ICC removal

Answer 17

• Pneumothorax: air leak has ceased for 24 hours in presence of patent system (evidenced by swing) and lung is fully reinflated (evidenced by CXR)
• Pleural fluid: usually when drainage is <200mL/s in 24 hours