Managing chest drains on medical wards

Question 1

When are intercostal chest drains used

Answer 1

pneumothorax

• tension pneumothorax
• persistent or recurrent after pleural aspiration
• large secondary pneumothorax in patients greater than 50 years

Pleural effusion

• malignant effusion with or without pleurodesis
• large parapneumonic effusion
• empyema

Traumatic haemopneumothorax

Post surgery

• thoracotomy
• oesophagectomy
• cardiac surgery

Question 2

when are chest drains used in the community

Answer 2

• indwelling pleural catheters are increasingly being used to treat patients with malignant pleural disease who are unable to undergo conventional drainage and pleurodesis
• drained up to three times a week by trained community nurses
• well tolerated but associated with a high risk of infection

Question 3

Why do you use thoracic ultrasonography when inserting a chest drain

Answer 3

• reduces the risk of a pneumothorax

- reduce complication rates

Question 4

What do you do when the chest drain is inserted

Answer 4

• immediately request a chest radiograph for all patients to ensure adequate drain position and assess for complications

Question 5

Where is the ideal placement for a chest drain in a pneumothorax and pleural effusion

Answer 5

• Pneumothorax—Apical placement

- Pleural effusion—Basal placement

Question 6

what are the complications that can happen when a chest drain

Answer 6

• pneumothorax
• drain kinked or inserted too deep
• drain subcutaneous or not inserted to a sufficient depth
• subcutaneous emphysema
• haemothorax

Question 7

what do you do with a drain that is inserted too deep

Answer 7

• Withdraw drain to the required length, re-suture and repeat the chest radiograph

Question 8

what do you do with a drain subcutaneous or not inserted to a sufficient depth

Answer 8

Remove and discard chest drain. Repeat chest drain insertion with new kit. Do not insert current drain further as this risks contaminating the pleural space

Question 9

where should the drainage bottle be positioned

Answer 9

Attach the drainage bottle to an underwater seal and instruct the patient to ensure the bottle remains below the level of his or her waist at all times to avoid retrograde flow of drain contents into the pleural space

Question 10

what pain medication should the patient be on with a chest drain

Answer 10

Offer pre-emptive analgesia before drain insertion. Ensure all patients have adequate analgesia prescribed after drain insertion, as pain often increases as local anaesthetic wears off. Warn patients of this and encourage pre-emptive analgesia. Prescribe “as required” opiate analgesia (such as codeine phosphate plus liquid morphine sulphate, dosed according to patient requirements) and offer regular opiates should pain continue.

Question 11

what dressing should a chest drain

Answer 11

• standard dressings often suffice with adequate gauze used as padding under the drain site
• use a clear dressing so that the insertion site is visible without removing the dressing
• monitor the drain site daily for dressing soiling and signs of infection
• skin allergies to dressings are not uncommon

Question 12

What is the drain plan for a pneumothorax

Answer 12

• Chest x ray immediately after insertion
• Do not clamp drain
• Monitor chest drain for swinging or bubbling
• Medical review once per day
• Once bubbling has stopped, repeat chest x ray to assess lung re-expansion
• If blockage occurs, flush with 10 mL 0.9% saline three times daily
• Contact doctor if patient develops shortness of breath, chest pain, or
severe cough

Question 13

What are the drain plans for pleural effusion

Answer 13

• Chest x ray immediately after insertion
• Drain 1.5 L of fluid and clamp drain for 2 hours*
• Re-open and drain a further 1.5 L
• Clamp for a further 2 hours, then free drainage
• Record drain output every 1-4 hours depending on flow
• Medical review once per day
• If blockage occurs, flush with 10 mL 0.9% saline three times daily
• Once draining <100 mL in 24 hours, repeat ultrasonography or chest x
ray and consider drain removal
• Contact doctor if patient develops shortness of breath, chest pain, or severe cough

Question 14

what does it mean if the chest drain is swinging

Answer 14

• normal

- the water column in the drainage bottle or tubing will move during the respiratory cycle this is called swinging

Question 15

what should the chest drain look like if it is placed for the removal of air

Answer 15

• drain will initially bubble spontaneously as the increased intrathroacic pressure caused by the pneumothorax forces air out of the pleural space
• as the pressure reduces the bubbling will only occur on coughing
• and as the pneumothorax resolves the bubbling will stop altogether and the drain will only swing

Question 16

What should the chest drain look like if it is placed for the removal of fluid

Answer 16

• drain will initially drain the effusion quickly due to the increased intrathoracic pressure caused by the pleural effusion
  = drainage tube will often begin to fill the drainage bottle
• as the pressure reduces the flow will reduce and a swing will be visible
• a swinging drain does not indicate that the whole effusion has been drained just that the initial pressure has reduced

Question 17

when draining how much fluid should be drained in one go

Answer 17

No more than 1.5 L should be drained in one go.

Question 18

what does it mean if the patient is coughing and suddenly short of breath

Answer 18

• re-expansion of pulmonary oedema
• due to overly rapid drainage of pleural effusion
• chest radiograph may show evidence of alveolar shadowing - drain must be clamped immediately and symptoms will normally resolve

Question 19

What does it mean if the drain has stopped bubbling or swinging and the patient is short of breath

Answer 19

• drain is either blocked so cannot reflect the transpleural pressures
• drain is displaced

Question 20

What can cause a blockage in the chest drain

Answer 20

• fibrin clots
• blood clots
• drainage holes occluded by the chest wall

Question 21

What do you do when you have a blocked chest drain

Answer 21

• Inspect the drain to ensure it is not kinked or displaced and perform simple drain flushes with 10 mL of 0.9% saline, both into the chest and into the drainage system.
• if this is performed and the blockage does not resolve then consider imaging to assess drain position and need for re-insertion

Question 22

What does it mean if the drain is draining blood

Answer 22

• Haemothorax - can mean intercostal arteries are punctured or lacerated

Question 23

What should you do if the chest drain is draining blood

Answer 23

• make sure patient is harm-dynamically stable
• give blood products, reverse coagulopathy
• urgent cross sectional imaging and discussion with IV radiology and cardiothroacic surgeons

Question 24

how do you differentiate blood staining from a true haemothroax

Answer 24

• run a sample of pleural fluid through the blood gas analyser
• the haemoglobin concentration can provide supporting evidence for a haemothorax
• haemothroax is defined has having a haematocrit of greater than 50% of the haematocrit of the peripheral blood

Question 25

What is a haemothorax defined as

Answer 25

Haemothroax is defined has having a haematocrit of greater than 50% of the haematocrit of the peripheral blood

Question 26

What does it mean if the drain has stopped working and the patient is swelling up

Answer 26

• subcutaneous emphysema
• tends to affect the subcutaneous tissue surrounding the drain only
• normally self limiting and resolves spontaneously

Question 27

How do you treat subcutaneous emphysema

Answer 27

• need for subcutaneous drain insertion to treat severe cases
• ensure that the drain remains in the correct position and is secured to an underwater seal
• if subcutaneous emphysema continues to build up despite conforming drain latency further imaging and drainage may be required to prevent ongoing air leak

Question 28

when should a chest drain be removed in a pneumothorax

Answer 28

• once the chest drain has ceased bubbling and either the lung has re-expanded fully or the drain has blocked
• if the drain has stopped bubbling but is still swinging this implies lung re-expansion but if the drain is not swinging or bubbling then drain blockage may have occurred

Question 29

When should you clamp a chest drain in patients with a pneumothorax

Answer 29

• after radiological confirmation of lung re-expansion to ensure there is no ongoing air leak
• then repeat the chest radiograph 4 hours later to ensure no ongoing airlock before drain removal

Question 30

what surgery can be used if a chest drain fails in a pneumothorax

Answer 30

refer to thoracic surgery for a surgical pleurodesis or pleurectomy.

Question 31

when should you remove a chest drain for pleural effusion

Answer 31

• once the daily drain output falls below 100ml

- perform a repeat chest radiograph or thoracic ultrasound scan to assess for resolution of the effusion

Question 32

How do you remove a chest drain

Answer 32

Seldinger drain

• remove all dressings and stitches first to avoid tugging the skin during drain removal
• remove the drain in a smooth but quick manner in expiration and apply an airtight dressing immediately

Pigtail drains

• curvature of the drain is held by an intraluminal suture that has to be cut before removal
• suture can be released by unclipping the external clip and unwinding the suture to reveal two separate pieces of suture
• cut only one of these to release the curvature and remove the drain in a smooth but firm manner