Vascular - Underwater Seal Drains

Question 1

Purpose of Chest Tubes

Answer 1

• to remove air / fluid from the pleural space & restore normal intrapleural pressure
• there are 2 layers of plura, 1 that lines the lungs & 1 that lines ribs, should be a small amount of liquid between layers to allow sliding

Question 2

Underwater Seal Drainage

Answer 2

• drainage system using a water seal that allows drainage of substances from the pleural cavity, water creates a seal that allows for re-establishing negative pressure
• air can bubble up, escape into collection chamber, sucks water up, but water is too heavy to go back up into the chest, creating a seal
• functions by drainage, water seal & suction
• drains placed:
  
  • if air - in the apex
  • if fluid - in the base
  • if both - catheter in both apex & base

Question 3

Conditions Requiring Chest Tubes

Answer 3

• air - pneumothorax
  
  • occurs when there is an opening on the surface of the lung or in the airways, in the chest wall
  • open - opening in the chest wall, allows atmospheric air to enter the pleural space - penetrating injuries
  • closed - chest wall is intact, rupture of the lung allows air in - emphasema - eaten through lung, hypertension - popped lung
  • tension pneumothorax - air enters pleural space & has no way to leave, occurs when closed pneumothorax creates positive pressure that continues to build & pushes heart & great vessels into unaffected side of the chest - mediastinal shift can lead to cardiovascular collapse as vena cava & right side of heart cannot accept venous return
• blood - hemothorax
• exudate - pleural effusion
  
  • transudate - clear fluid from fluid shifts due to CHF, malnutrition, renal & liver failure
  • exudate - cloudy fluid with cells & proteins, malignancy, tuberculosis, pneumonia

Question 4

Pleural Drainage

Answer 4

• first compartment - collection chamber
  
  • receives fluid / air from chest cavity, fluid stays here, air vents to second compartment
• second compartment - water seal chamber
  
  • contains 2cm of water, acts as one way valve, incoming air enters, bubbles through & exits into suction chamber
• third compartment - suction control chamber
  
  • applies controlled suction to the chest drainage system

Question 5

Insertion

Answer 5

• 4th or 5th intercostal space in mid axillary line, or 2nd intercostal space in the midclavicular line
• patient preperation
  • baseline haemodynamic & respiratory obs
  • pulse oximetry must be used throughout procedure
  • position dependent on insertion site
  • explanation, reassurance, analgesia, need to stay still

Question 6

Post Insertion

Answer 6

• immediate observation of air / fluid drainage
• chest tube secured (sutured)
• airtight sandwich dressing
• immediate CXR
• documentation - time & location of tube, respiratory status & volume of chest drainage

Question 7

Managing Chest Drainage

Answer 7

• patient assessment - at least 4 hourly
• dressing - airtight
• chest tube & chest drainage system tubing - have clamps, in case of accidental disconnection of tube from intercostal catheter
• chest drainage system
• assessment & managing emergencies - drain is always lower than the level of the chest

Question 8

Patient Assessment

Answer 8

• general comfort & anxiety level
• pain management
• respiratory rate, work of breathing, o2 saturations
• skin colour, peripheral perfusion
• neurological state
• hemodynamic state
• at least ONCE per shift
• catheter security, dressing tight & intact, signs of inflammation / ooze checked for

Question 9

Dressings

Answer 9

• need to support the tube - don’t want to pull on / drag tube
• provide a barrier against infection
• provide an airtight seal
• not add to discomfort
• not hamper mobility
• can remain intact for up to 7 days, if signs of inflammation or oozing, dressing changed daily or PRN

Question 10

Ongoing Assessments

Answer 10

• checking for volume, colour, consistency
• presence of an air leak - characterised by bubbles in the water seal chamber when patient exhales / coughs - indicates pneumothorax, loose connection, ongoing leak
• absence of an air leak - resolution of pneumothorax, obstruction between chest tube & drainage system
• swinging - characterised by fluid column in water seal chamber tubing moving towards the patient on inspiration and away on expiration
• absence of swinging - resolution of pneumothorax, obstruction

Question 11

Removal

Answer 11

• removed on medical orders:
  
  • drainage has diminished to nil<100mls within 24hrs
  • drain has stopped bubbling indicating leak has resolved
  • lung is inflated on xray
  • patient tolerates if chest drain clamped

Question 12

Removal - Procedure

Answer 12

• tube is removed at end of inspiration - take deep breath in (keeps pressure in lungs up), pull out in one long smooth continuous technique (after cutting suture), put occlusive dressing over before patient breathes out
• aseptic technique, cut only suture securing the tubing

Question 13

Post Removal Care

Answer 13

• vitals, breath sounds, respiratory status
• x-ray ASAP
• monitor for respiratory compromise / deterioration & report
• observe dressing, remove dressing in 48hrs, redress with occlusive dressing if remains to ooze
• remove purse string suture as per medical instructions