Chapter 12: Respiratory care, CPR and blood transfusion
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Source: Adapted from Chadwick et al. ([42]), Havelock et al. ([103]), Mohammed ([164]), Porcel ([221]), Woodrow ([290]).
Chest drain: insertion
Evidence‐based approaches
Management of excess fluid or air within the pleural space is dependent on the size and complexity of the effusion or pneumothorax, the patient's symptoms and the presence of any underlying disease (Tschopp et al. [275]). Fine needle aspiration using a needle and syringe is recommended by the British Thoracic Society for primary spontaneous pneumothoraces or small free‐flowing effusions (Davies et al. [55], Hassan and Shaarawy [102], MacDuff et al. [138]) and this would be carried out by an appropriately trained clinician. Chest drain insertion is recommended for patients with secondary spontaneous pneumothoraces, failed fine needle aspiration for primary spontaneous pneumothoraces, malignant effusions, or complicated accumulations of fluid that are causing the patient to be symptomatic (Davies et al. [55], MacDuff et al. [138], Mahmood and Wahidi [141]); this would again be carried out by an appropriately trained clinician with the assistance of a nurse. While both are common procedures, they are not without risk. Chest drain insertion should be carried out in a clean area using a strict aseptic technique and with adequate monitoring available (Adlakha et al. [5], Havelock et al. [103]). The sections below relate to chest drain insertion; needle aspiration would only be carried out by a doctor or highly trained nurse and is beyond the scope of this manual.
Rationale
Ventilation and the normal mechanics of breathing become compromised as the abnormal collection of fluid or air compresses the lung, or as the negative pressure within the chest cavity is altered, causing partial or complete collapse of the affected lung (Tschopp et al. [275]). Needle aspiration and chest drain insertion are methods used to remove the collection of air, serous fluid, pus, lymph or blood from the pleural space, restoring the negative pressure within the chest cavity and allowing the lung to re‐expand (Noorani and Abu‐Omar [201]).
Indications
Chest drain insertion is indicated in the following circumstances (Noorani and Abu‐Omar [201], Porcel [220], Yousuf and Rahman [292]):
- pneumothorax
- pleural effusion
- empyema
- traumatic haemopneumothorax
- chylothorax
- post‐operatively following thoracotomy, oesophagectomy or cardiac surgery
- bronchopleural fistula.
Contraindications
No contraindications exist for a patient with a tension pneumothorax (MacDuff et al. [138]). The risks and benefits should be weighed up for all other patients, and expert advice and guidance sought if required. The procedure should be carried out by a healthcare professional with extensive and relevant ultrasound skills (Havelock et al. [103]). Depending on the nature of the problem (e.g. a loculated pleural effusion), it may be preferential for the procedure to be carried out by an experienced radiologist.
Absolute contraindications
Chest drain insertion is absolutely contraindicated if the patient does not consent to the procedure and they are not at risk of imminent cardiac arrest.
Relative contraindications
Chest drain insertion has the following relative contraindications (Havelock et al. [103], Porcel [221], Ravi and McKnight [225]):
- abnormal blood clotting screen or low platelet count; it is good practice to correct any coagulopathy or thrombocytopenia prior to chest drain insertion; ideally, international normalized ratio (INR) should be less than or equal to 1.5 and platelets above 50 × 109/L
- differential diagnosis between pneumothorax and bullous lung disease needs to be investigated
- any previous surgery involving the thoracic cavity on the side of the proposed intervention
- diaphragmatic hernia
- localized skin infection, or cutaneous metastatic cancerous deposits at the site of the drain insertion.
Principles of care
The following principles should be adhered to (Havelock et al. [103], Porcel [221], Woodrow [290]):
- Maintain sterility of the chest drainage system and avoid introduction of bacteria into the pleural space.
- Maintain a negative intrapleural pressure by keeping the system patent and airtight.
- Keep the system upright and below chest level, and prevent water and/or pleural fluid re‐entering the pleural space.
- Drain the fluid slowly and prevent pain and/or re‐expansion pulmonary oedema.
- Monitor the patient's observations/NEWS and pain score, and escalate any change or concerns regarding the patient's condition.
- Monitor the drain for swinging, bubbling, and the amount and type of fluid drained.
- Remove the drain as soon as it has reached the predefined therapeutic goal, or when it has become non‐functioning.
Clinical governance
Pleural aspiration and chest drain insertion should only be inserted by healthcare professionals who have had relevant training and are deemed competent, or who have adequate supervision by an experienced clinician (Havelock et al. [103]). The use of ultrasound guidance is advocated when performing pleural aspiration or inserting a chest drain to prevent injury to adjacent organs. Practitioners must be competent in the use of the ultrasound equipment (Adlakha et al. [5], Havelock et al. [103]). It is also advisable that there should be a clinical lead identified for the training of all staff involved in chest drain insertion.
Clinical policies regarding chest drain insertion and management should be implemented and followed by both medical and nursing staff. Incidents regarding chest drain insertion and management should be reported to risk management teams, and processes should be reviewed regularly.
Consent
Prior to commencing chest tube insertion, the procedure should be explained fully to the patient and written consent gained and recorded in accordance with national guidelines (Havelock et al. [103]). The General Medical Council guidelines for consent state that it is the responsibility of the doctor carrying out a procedure, or an appropriately trained individual with sufficient knowledge of the procedure, to explain its nature and the risks associated with it. The exception to this is during an emergency when chest drain insertion is indicated to prevent further clinical deterioration and cardiac arrest. In this scenario, verbal consent should be gained if possible and documented (GMC [90]). Associated risks include visceral injury, pneumothorax, pain, haemorrhage, infection, drain blockage, drain dislodgment and procedure failure (Havelock et al. [103], Yousuf and Rahman [292]).
Competencies
All staff caring for patients undergoing chest drain insertion and those managing a patient with an exisiting chest drain should have undertaken the relevant local training and be deemed competent. The basis of these competencies should include the following (Mallet et al. [143]):
- knowledge of the indications for chest drain insertion
- knowledge of the potential complications regarding insertion and having a chest drain in situ
- knowledge of how to manage any potential complications
- familiarity with the equipment and the ability to set it up for insertion, change the chest drain bottle while in situ, and remove the drain effectively and safely.
Pre‐procedural considerations
Equipment
Drain size
In the past, the use of a large‐bore chest drain (>14 Fr) (Figure 12.22) was recommended to prevent blockage of the drain by viscous malignant or infected fluid. Although there is currently no consensus on the optimal chest drain size, the British Thoracic Society advocates the use of small, flexible catheters (10–14 Fr) for the drainage of most simple effusions and pneumothoraces, and recommends that they are inserted using the Seldinger technique (Mahmood and Wahidi [141], Porcel [221]). Small‐bore drains may be straight, angled or coiled at the end (pigtail; Figure 12.23). Pigtail drains have the advantage of a thread that, when pulled, creates the pigtail effect to hold the drain firmly in place. Small‐bore drains can easily be flushed to prevent blockage, have fewer complication rates, and are generally more comfortable and tolerable for patients (Mahmood and Wahidi [141]).
Figure 12.22 Large‐bore chest drain.
Figure 12.23 (a) Pigtail drain with (b) magnification of the end.
Large‐bore chest drains (≥20 Fr) may be inserted for ongoing air leaks, pneumothoraces caused by mechanical ventilation, haemothoraces and post‐operative drainage of the chest cavity (Porcel [220]). Drains larger than 24 Fr should be inserted using a blunt dissection technique. Trocars should no longer be used as they are associated with high complication rates and leave patients with an unsightly scar (Havelock et al. [103]).
Drainage systems
There is a wide variety of drainage systems available to drain effusions or pneumothoraces; however, the single‐bottle, underwater‐seal drainage system can be used for the majority of situations (Figure 12.24). The underwater seal occurs when the screw‐top lid is removed and sterile water is poured into the chest drain bottle up to the fluid line. The long length of tubing supplied in the pack is attached to the distal end of the chest drain, and the other end is inserted into the screw‐top port and immersed 2–3 cm below the level of the water (Havelock et al. [103]).
Figure 12.24 Underwater chest drainage system.
There is a second port, which acts as a venting aid and is either exposed to air or attached to a suction unit. Venting prevents the build‐up of pressure in the chest drainage system and aids evacuation of air or fluid from the lungs. The underwater seal maintains the negative intrapleural pressure and acts as a one‐way valve, preventing the backflow of air into the pleural space (George and Papagiannopoulos [88]).
Other multi‐chamber or digital drainage systems may also be used. The three‐chamber system consists of a collection chamber, a water‐seal chamber and a suction chamber, all of which are interconnected. Suction can be applied to assist in the management of an ongoing air leak. Digital systems are able to monitor for air leaks and can maintain and adjust the negative pressure accordingly without the use of external suction (Porcel [220]). Manufacturers’ instructions should be followed to guide set‐up and aid maintenance of the system.
A dry drainage system that incorporates a one‐way Heimlich valve can also be used to facilitate early discharge home in ambulatory patients (Woodrow [290]). The ambulatory bag (Figure 12.25) must be primed prior to use to ensure that the Heimlich valve is working. This can be done by flushing air through the valve using a 50 mL syringe and inspecting for slight bag inflation.
Figure 12.25 Ambulatory chest drain bag with Heimlich valve.
Pharmacological support
Surrounding tissue and nerve fibres are damaged during chest drain insertion, which may cause the patient significant pain throughout and after the procedure. Supportive treatment in the form of oxygen and analgesia should therefore be given before and after drain insertion, and prior to drain removal. Unless contraindicated, opioid analgesia should be prescribed and administered to ensure the patient is able to tolerate the drain and subsequent drainage of fluid, and also to allow them to breathe deeply and cough effectively (Noorani and Abu‐Omar [201], Woodrow [290]).
Specific patient preparation
The patient's baseline observations and NEWS must be recorded prior to the procedure. A chest X‐ray should be performed and reviewed by the practitioner to confirm the site of the pneumothorax or effusion to be drained. CT (computed tomography) imaging may also be required for uncertain or complex cases (Davies et al. [55], Hooper et al. [111]). The exception to this is for patients who have signs and symptoms of a tension pneumothorax when immediate needle decompression or chest drain insertion is required (MacDuff et al. [138]). The British Thoracic Society strongly advocates the use of ultrasound guidance during chest drain placement (Havelock et al. [103]).
To minimize the risk of bleeding, patients should temporarily stop their usual anticoagulation therapy, and drain insertion should be delayed until their INR is below 1.5 (Havelock et al. [103], Porcel [221]). Platelet and coagulation abnormalities should be corrected as per local policy or as advised by a haematologist.
Chest drains are usually inserted in an area known as the ‘triangle of safety’ (Figure 12.26). This is the triangle outlined by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major, a line superior to the horizontal level of the nipple, and an apex below the axilla. Drains may be placed outside this area under ultrasound or radiology guidance (Mahmood and Wahidi [141]). Depending on the area for insertion, patients may be placed in a supine, 45° position with the arm on the affected side abducted, externally rotated and placed behind their head (Figure 12.27a). Alternatively, patients may sit upright on the side of the bed leaning over an adjacent table, with arms resting on a pillow in front of them (Figure 12.27b), or lie on their side (Figure 12.27c) (Adlakha et al. [5]).
Figure 12.26 Triangle of safety.
Source: Laws et al. ([130]). Reproduced with permission of BMJ Publishing Group, Ltd.
Figure 12.27 Alternative positions for chest drain insertion. (a) Supine on the bed with the arm on the affected side placed behind the head away from the chest wall or abducted to 90°. (b) Resting over an adjacent table supported by a pillow in front. (c) On the side with the lung to be drained uppermost.
Education
Nurses caring for patients with chest drains must be familiar with their management and keep up to date with current guidelines, local policies and protocols (Havelock et al. [103], Noorani and Abu‐Omar [201]).
Procedure guideline 12.4
Chest drain: assisting insertion
Post‐procedural considerations
Immediate care
The nurse should monitor the patient's observations and NEWS immediately after insertion to check for any signs of respiratory or cardiovascular compromise. The patient should also be observed for changes in their breathing pattern or increasing shortness of breath (Woodrow [290]). Any change in condition or deterioration in the patient's observations or NEWS warrants immediate escalation and review by a senior member of staff (RCP [230]). This may include the practitioner who inserted the chest drain or members of the clinical team. Radiological imaging (chest X‐ray) should be performed to determine where the drain is placed and the status of the pneumothorax or effusion (Porcel [221]). The drain should be monitored for the features outlined in Table 12.11, and the monitoring should be documented on the relevant chart.
Table 12.11 Chest drain observations
| Observation | Detail |
|---|---|
| Bubbling |
Indicates air is still present in the pleural space. Bubbling should decrease and eventually stop as the pneumothorax resolves and the lung reinflates. If bubbling continues, an air leak may be present. Causes of air leaks include:
Note: a bubbling chest drain should never be clamped (even during intra‐hospital transfer to the radiology department, for example). |
| Swinging | Indicates the drain is patent and sitting within the pleural space. If swinging is absent, this may indicate that the drain is blocked, kinked or sitting up against the pleural wall. |
| Draining | Drainage will not occur if the drain is inserted for a pneumothorax. If the drain stops draining a pleural effusion, it may either require removal or indicate that the drain is blocked and requires flushing. |
As described in Table 12.11, ongoing bubbling indicates the presence of an air leak, which should be investigated immediately (Woodrow [290]). The drain and tube should be inspected thoroughly down to the level of the underwater seal to eliminate any external problems such as loose tubing connections, poor seal around the drain insertion site or tube migration outside the chest wall. If no loose connections are found, a chest X‐ray or CT scan will be required to determine the position of the chest drain and rule out a pleural tear (Havelock et al. [103], Porcel [221]). Depending on the cause of the leak, the chest drain may need to be removed and another reinserted. An ongoing air leak may also warrant low‐pressure thoracic suction (see Procedure guideline 12.5: Chest drainage: suction). See Problem‐solving table 12.4 for further guidance on the prevention and recommended actions for problems associated with a chest drain.
Securing the drain
Purse‐string sutures are no longer advised due to the skin trauma and unsightly scar that they cause. A mattress suture (Figure 12.28) is preferred as it offers a more natural closure once the drain is removed and ultimately less scaring. It is recommended that all drains, regardless of size, should have an anchor suture inserted to prevent them pulling and falling out (Havelock et al. [103], Porcel [221]). The drain may also be secured to the surrounding skin with a specifically designed adhesive fixation dressing or an omental tag (Figure 12.29) (Havelock et al. [103]).
Figure 12.28 Mattress suture.
Figure 12.29 Omental tag.
The drains and connections should be checked to ensure that they are secure and the drain tubing is not kinked or looped. An ‘H’ dressing (Figure 12.30) should be applied to re‐enforce the connection between the drain and the tubing while allowing the connection to be visualized at regular intervals.
Figure 12.30 H‐shaped securing tape.
Dressing the insertion site
If a specifically designed adhesive fixation dressing is not available, a simple dry dressing (low‐linting gauze) may be applied around the drain and secured with adhesive tape or an occlusive dressing. Strapping should be avoided as it can restrict chest movement. The dressing should be kept dry and clean, and changed daily or as required. The skin around the drain site should be inspected daily to ensure it is clean, dry, and free from maceration and infection (Havelock et al. [103], Jeffries [119]).
Ongoing care
Clamping of chest drains
Pneumothorax
A bubbling chest drain should never be clamped, as clamping will prevent air leaving the pleural space, which has the potential to cause a tension pneumothorax (Woodrow [290]). The drain should remain unclamped even when patients are mobilizing or being transported to other departments within the hospital. The only time a bubbling chest drain should be momentarily clamped is in the event of accidental disconnection, if there is damage to the drainage bottle or to locate a leak in the drainage system (Mohammed [164], Woodrow [290]).
Pleural effusion
Drainage of a pleural effusion should be controlled by clamping the chest drain intermittently. Davies et al. ([55]) recommend draining off a maximum of 1500 mL in the first hour after insertion, then 1500 mL every 2 hours thereafter. Draining large volumes may cause re‐expansion pulmonary oedema as the lung rapidly re‐expands. It may therefore be advisable to drain off smaller volumes (500 to 1000 mL), especially if the patient is petite or frail. Drainage can either be slowed down or clamped temporarily if the patient experiences pain, starts coughing, experiences vasovagal symptoms or has a drop in blood pressure. Coughing usually subsides within 15 minutes, analgesia can be administered to help with pain, and an IV fluid bolus can be given if the patient becomes haemodynamically unstable. The chest drain should be unclamped in the event of an acute clinical deterioration (Havelock et al. [103]) and expert help sought immediately.
Stripping and milking of chest drains
Stripping and milking of chest tubes to keep tubing patent increases the negative pressure in the intrathoracic cavity to −100 to −400 cmH2O. Such an increase in negative pressure may harm lung tissue; therefore, milking or stripping of chest tubes on a routine basis should be avoided (Mohammed [164]). If a chest drain becomes blocked, the tubing should be flushed or replaced.
