Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [198], C).
2. 2.Show
   Cleanse hands with soap and water or an alcohol‐based handrub.
   To minimize the risk of infection (NHS England and NHSI [179], C).
3. 3.Show
   Encourage the patient to practice the Valsalva manoeuvre before the chest drain is removed. The Valsalva manoeuvre requires the patient to hold their breath, bear down and breathe against a closed glottis at the end of expiration.
   To ensure the patient understands and is able to perform the Valsalva manoeuvre prior to drain removal. E

   To increase the intrathoracic pressure, reducing the possibility of air re‐entering the pleural space during drain removal (Cerfolio et al. [41], C).
4. 4.Show
   Administer analgesia at least half an hour before the procedure.
   To minimize any pain during the procedure (Woodrow [290], C).
5. 5.Show
   Discontinue suction if in use and disconnect the suction tubing from the suction port.
   To reduce the number of tubes and amount of equipment in the surrounding area. E
6. 6.Show
   Cleanse hands with soap and water or an alcohol‐based handrub.
   Hands need to be cleansed before and after each patient contact to minimize the risk of infection (NHS England and NHSI [179], C).
7. 7.Show
   Prepare a trolley for the procedure. Open the sterile procedure pack onto the top of a clean trolley using aseptic technique, then open the stitch cutter, gallipot and occlusive dressing onto the sterile field. Pour the cleaning solution into the gallipot.
   To ensure all equipment required is prepared prior to starting the procedure. E
8. 8.Show
   Assist the patient into a position that facilitates drain removal while ensuring patient comfort.
   To aid patient comfort and ensure easy removal of the chest drain (Woodrow [290], C).
9. 9.Show
   Place a protective pad underneath the patient.
   To absorb any leakage from the drain during removal. E

Procedure

1. 10.Show
   Cleanse hands with an alcohol‐based handrub and apply apron and gloves.
   Hands need to be cleansed before and after each patient contact to minimize the risk of infection (NHS England and NHSI [179], C).
2. 11.Show
   Remove the dressing from around the drain site. Examine what size of drain has been used and which sutures are present: either a large‐bore drain with a mattress suture and anchor suture (requires two nurses) or a fine‐bore drain with only an anchor suture (requires one nurse).
   To prepare for drain removal and determine how many nurses are required to perform the procedure. E

Large‐bore drain

1. 12.Show
   To remove a large‐bore drain, two nurses are required: one to remove the drain and the other to seal the site. The first nurse loosens the mattress suture, exposing the ends to be tied on removal of the drain.
   To prepare the drain and ensure it is ready for removal. E
2. 13.Show
   The second nurse cuts the anchor suture and ensures the drain is mobile and ready to be removed.
   To prepare the drain and ensure it is ready for removal. E
3. 14.Show
   The second nurse asks the patient to take two deep breaths and then perform the Valsalva manoeuvre at the end of expiration on the third breath. While the patient performs the Valsalva manoeuvre, the second nurse pulls out the drain steadily and smoothly.
   Performing the Valsalva manoeuvre at the end of expiration increases intrathoracic pressure, preventing air flowing into the intrathoracic cavity and the formation of a new pneumothorax (Cerfolio et al. [41], C).
4. 15.Show
   The first nurse pulls and ties the mattress suture while the drain is simultaneously removed.
   To close and seal the drain site, preventing the entry of air and formation of a pneumothorax (Havelock et al. [103], C).
5. 16.Show
   Ask the patient to breathe normally after the drain is removed.
   To assess if there is any air escaping from suture/drain site. E

Fine‐bore drain

1. 17.Show
   One nurse is required to remove a fine‐bore drain. The anchor suture should be cut and the drain prepared ready for removal.

   If a pigtail drain is in place, the nurse will need to follow the manufacturer's instructions to unlock the device, usually by either cutting or unlocking the thread.
   Following the manufacturer's instructions ensures correct removal and reduces the risk of pain, trauma and the formation of a pneumothorax secondary to incorrect removal technique. E
2. 18.Show
   The nurse should remove the drain in a smooth but brisk fashion while the patient performs the Valsalva manoeuvre (see above) on the third expiratory breath.
   Performing the Valsalva manoeuvre at the end of expiration increases intrathoracic pressure and prevents air flowing into the intrathoracic cavity and the formation of a new pneumothorax (Cerfolio et al. [41], C).
3. 19.Show
   The drain site should immediately be covered with sterile gauze until an occlusive dressing can be applied.
   To close and seal the drain site, preventing the entry of air and formation of a pneumothorax (Havelock et al. [103], C).
4. 20.Show
   Ask the patient to breathe normally after the drain is removed.
   To assess if there is any air escaping from suture/drain site. E

Post‐procedure

1. 21.Show
   Clean around the site with 0.9% sodium chloride and apply an occlusive dressing.
   To clean the site and prevent air entry by forming an airtight seal. E
2. 22.Show
   Dispose of waste appropriately, remove gloves and clean hands.
   To ensure safety and reduce the risk of infection (NICE [193], C).
3. 23.Show
   Assist the patient into a comfortable position.
   To ensure patient comfort and aid respiration. E
4. 24.Show
   Monitor the patient's respiratory status and observations/NEWS. Escalate any concerns or deterioration immediately.
   To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP [230], C; Woodrow [290], E).
5. 25.Show
   Document removal of the drain on the chest drain chart and in the nursing documentation.
   To maintain accurate patient records (NMC [198], C).
6. 26.Show
   Escort the patient for a chest X‐ray following drain removal.
   To check that a pneumothorax has not reformed or been introduced during removal (Porcel [220], C).
7. 27.Show
   Monitor the wound site and change the dressing as required.
   To monitor for signs of infection (Havelock et al. [103], C).