Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and ensure the operator has gained their consent to proceed (if the patient is conscious and able to consent).
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [198], C).
2. 2.Show
   Decontaminate hands.
   To minimize the risk of healthcare‐associated infection (NHS England and NHSI [179], C).
3. 3.Show
   Ensure the patient has intravenous access that is patent.
   For patient safety in the event of an acute deterioration (Yousuf and Rahman [292], C).
4. 4.Show
   Administer analgesia at least half an hour before the procedure.
   To minimize pain during the procedure and to ensure the patient is able to co‐operate (Noorani and Abu‐Omar [201], C).
5. 5.Show
   Clean and prepare a trolley, placing the equipment on the bottom shelf.
   To ensure the trolley is clean and all equipment required is available. E
6. 6.Show
   Prime the underwater seal drainage bottle with sterile water and fill to the fluid line.
   To create negative pressure and prevent the backflow of fluid or air into the pleural space (Woodrow [290], C).
7. 7.Show
   Decontaminate hands with an alcohol‐based handrub again.
   To minimize the risk of infection (NHS England and NHSI [179], C).
8. 8.Show
   Assist the operator by opening up packs/equipment as instructed, maintaining a sterile environment throughout.
   To minimize the risk of infection. E
9. 9.Show
   Assist the operator to scan the chest using real‐time ultrasound.
   To confirm the side of the effusion or pneumothorax (Yousuf and Rahman [292], C).
10. 10.Show
    Position the patient in preparation for the procedure. The patient may be positioned supine on the bed with the arm on the affected side placed behind their head away from the chest wall, or abducted to 90° (see Figures 12.26 and 12.27a). Alternatively, position the patient on their side with the lung to be drained uppermost (see Figure 12.27c). If the patient is able to sit upright, they can be positioned resting over an adjacent table supported by a pillow in front (see Figure 12.27b).
    To facilitate insertion of the chest drain and prevent injury to adjacent organs (Adlakha et al. [5], C).

    To ensure optimal patient comfort. E

Procedure

1. 11.Show
   Assist the practitioner as requested.
   To ensure the procedure is carried out as smoothly and quickly as possible. E
2. 12.Show
   Observe the patient throughout the procedure, paying attention to their respiratory and cardiovascular status. Monitor the patient's respiratory rate and pattern, movement of the chest wall, oxygen saturations, colour, blood pressure and heart rate. Inform the practitioner inserting the drain of any concerns or change in the patient's condition.
   To monitor for signs of acute deterioration and complications associated with the procedure (Woodrow [290], C).
3. 13.Show
   Communicate with the patient during the procedure and explain what is happening at each stage.
   To minimize anxiety (Woodrow [290], C).

During the procedure

1. 14.ShowUsing a sterile procedure throughout, the practitioner prepares the skin using a cleansing solution before infiltrating the surrounding area with local anaesthetic. Using ultrasound guidance, the drain is inserted into the pleural space using a Seldinger technique. Prior to unclamping the drain, the distal end is attached to the drainage system (tubing, bottle and sterile water) and the proximal end is secured to the skin and subcutaneous tissue using an anchor suture. For large‐bore drains, a mattress suture may also be required (see Figure ). The drain site should be cleaned and dressed using a specifically designed adhesive‐dressing‐based fixation system, or covered with gauze and an occlusive dressing. The drain can then be unclamped (Havelock et al. , Woodrow ).

Post‐procedure

1. 15.Show
   Check the drain is well secured at the exit site using an anchor suture and occlusive dry dressing.
   To prevent accidental disconnection or removal of the drain (Havelock et al. [103], C; Jeffries [119], C).
2. 16.Show
   Check the whole drainage system and ensure all connections are secure. Tape the connection between the chest drain and tubing with an H‐shaped dressing (see Figure 12.30).
   To secure the connection and prevent accidental disconnection. E

   To ensure there are no leaks that will prevent re‐expansion of the lung, or accidental introduction of a pneumothorax (Woodrow [290], C).
3. 17.Show
   Assist the patient into a comfortable position in bed, ensuring the drain and tubing are not occluded or kinked.
   To optimize patient comfort and ensure the system is not occluded or kinked, which would prevent drainage (Woodrow [290], C).
4. 18.Show
   Check the patient's observations/NEWS and document.
   To observe for any change or deterioration in the patient's condition (RCP [230], C).
5. 19.Show
   Give further analgesia if required.
   To ensure patient comfort (Woodrow [290], C).
6. 20.Show
   Monitor for bubbling in the chest drain bottle. Report any unexpected bubbling immediately to the practitioner who inserted the drain, or a senior member of staff.
   Bubbling is to be expected with a pneumothorax but should not be present with a pleural effusion (Woodrow [290], C).

   Bubbling may indicate an air leak or introduction of a pneumothorax and should be urgently investigated (Woodrow [290], C).
7. 21.Show
   Record either the presence or absence of bubbling on the chest drain observation chart. Inform medical or surgical staff when the bubbling ceases.
   To keep an accurate record of the status of the chest drain (Woodrow [290], C).

   A chest drain inserted for drainage of a pneumothorax will stop bubbling once all the excess air has been dispensed and the lung has reinflated (Porcel [221], C).
8. 22.Show
   Do not clamp a bubbling chest drain.
   Clamping a bubbling chest drain could cause a life‐threatening tension pneumothorax (Porcel [221], C).
9. 23.Show
   Monitor for swinging of fluid in the tubing and record its presence or absence on the chest drain observation chart.
   To keep an accurate record of the status of the chest drain (Woodrow [290], C).

   The absence of fluid swinging within the tube may indicate a blocked drain (Chadwick et al. [42], C).
10. 24.Show
    Monitor the amount and appearance of any fluid drained and record this on the chest drain observation chart.
    To keep an accurate record of the status of the chest drain, and the amount and type of fluid drained (Woodrow [290], C).
11. 25.Show
    If the drain has been inserted to drain fluid, allow a maximum of 1.5 L of fluid to be drained in the first hour then clamp. It may be advisable to drain smaller volumes, especially if the patient is petite or frail. Stop draining if the patient begins to cough, complains of chest pain or has vasovagal symptoms.
    To prevent re‐expansion pulmonary oedema (Havelock et al. [103], C).
12. 26.Show
    Dispose of waste appropriately.
    To reduce the risk of sharps injury and cross‐infection (NICE [193], C).
13. 27.Show
    Educate the patient on the need to keep the drainage bottle upright and below chest level, and to avoid any pulling of the drain.
    To prevent drained fluid re‐entering the pleural space, or any accidental disconnection or removal of the chest drain (Woodrow [290], C).
14. 28.Show
    Advise the patient to report any concerns or change in breathing.
    To detect any change or deterioration in the patient's condition early. E
15. 29.Show
    Record chest drain status and patient observations/NEWS 5 minutes and 1 hour after drain insertion, then to a minimum of 4‐hourly thereafter. Repeat observations before and after drainage.
    To detect any change or deterioration in the patient's condition and ensure timely escalation to senior staff if required (RCP [230], C).
16. 30.Show
    Escort the patient to radiology for a post‐drain insertion chest X‐ray.
    To rule out any post‐procedural complications and observe the position of the drain (Porcel [221], C).
17. 31.Show
    Cleanse hands with an alcohol‐based handrub.
    To minimize the risk of cross‐infection (NHS England and NHSI [179], C).