Chapter 12: Respiratory care, CPR and blood transfusion
Skip chapter table of contents and go to main content
Chest drain: changing the bottle
Evidence‐based approaches
The drainage bottle should be changed when it is three‐quarters full, if there is any damage to the container, or if the tubing has been accidentally disconnected from the chest drain (Woodrow [290]). If there are any concerns about atmospheric air entering the system during the bottle or tubing change, ask the patient to gently cough to get rid of any air within the pleural space. The drainage bottle and hazardous waste contents should be disposed of as per local infection control policy (Woodrow [290]).
Procedure guideline 12.6
Chest drain: changing the bottle
| Problem | Cause | Prevention | Action |
|---|---|---|---|
| Lack of drainage |
Kinking, looping or pressure on the tubing may block and impede drainage |
Educate the patient on care of the drain and how to position themselves to prevent occlusion or kinking of the drain tubing.
Secure the tubing to the patient to prevent kinking or looping using an omental tag. |
Check the tubing and unkink or unloop as required.
Reposition the patient. |
| Excess fluid in the pleural space may have fully drained | None necessary. | Perform a chest X‐ray to check if excess fluid has been adequately drained. Remove drain if required. | |
| Drain is not swinging | Drain or tubing blocked by viscous fluid or tissue | Flush drain on a regular basis if fluid is viscous and likely to block the drain or tubing. | Gently flush the chest drain with sterile normal saline 0.9% to unblock. |
| Underwater seal drain not bubbling as expected |
Drain occluded |
Monitor for bubbling post‐insertion.
Ensure the tubing is not kinked or looped, and that the system is patent.
Ensure the drain is open and not clamped. |
Check the tubing and unkink or unloop it as required.
Flush the drain to ensure it is patent and not blocked.
Unclamp the drain if it is found to be clamped. |
| Drain not correctly placed | The practitioner inserting the drain should ensure correct landmarking and effective drain insertion. |
Perform a chest X‐ray to check the position of drain.
Discuss with radiology if the drain requires repositioning, or if removal and reinsertion of the drain is required. | |
| Continuous bubbling in chest drain bottle | Air leak in system |
Check the bottle for bubbling and swinging, and check integrity of the chest drain system regularly.
Ensure all connections are secure. |
Check for any loose connections throughout the chest drain system.
Check the drain insertion site to determine whether the drain has moved.
The eyelets of the drain may be exposed to the atmosphere, allowing air to enter.
Perform a chest X‐ray to check the position of the drain and status of the effusion or pneumothorax.
Prepare for drain removal and reinsertion if required. |
| Ooze from drain site | Bleeding or infection |
Remove the dressing at least once daily, clean and re‐dress, and document any concerns.
Review the need for the drain daily with senior staff, and remove it as soon as possible. |
Remove the dressing, observe the site and take a wound swab.
Clean and re‐dress the site.
Discuss with medical/surgical team whether antimicrobial therapy is indicated.
Remove the drain as soon as it is no longer required (if the lung has reinflated or the effusion has been adequately drained). |
| Fluid leaking from around the drain site | Bypassing of fluid from around the drain site due to blockage of the drain | Flush the chest drain regularly if the fluid is viscous and likely to block the drain. |
Gently flush the chest drain using sterile normal saline 0.9% to unblock it.
If unable to unblock, removal and reinsertion of a new drain may be required. |
| Accidental disconnection of the drainage tubing from the chest drain | Connections not secure | Secure the connection using an H‐shaped dressing (see Figure 12.30). |
Immediately apply a clamp to the drain above the site of disconnection. Re‐establish the connection as soon as possible. The tubing may need to be changed if it was contaminated during disconnection.
As soon as the drain and tubing are connected, remove the clamp and ask the patient to cough gently to aid removal of air.
If a pneumothorax is present and the bottle was bubbling prior to disconnection, the drain can be unclamped and temporarily submerged in a sterile bottle of water until a new system is set up.
Reassure the patient.
Report the incident to the clinical team and ask them to review the patient.
Consider performing a chest X‐ray to assess whether a pneumothorax is present.
Record the incident in the relevant records and nursing documentation. |
| Chest drain falls out | Drain not secure |
Check the drain insertion site regularly.
Ensure the anchoring stitch is still intact.
Apply a clear dressing over the chest drain site and consider the use of an omental tag to secure the tubing onto the patient's surrounding skin. |
Immediately pull the mattress suture closed (if present) and cover it with an occlusive sterile dressing.
Check the patient's observations/NEWS and escalate immediately if the patient is clinically deteriorating or there are any concerns.
Inform the clinical team and ask for an immediate review.
If the patient is stable, perform a chest X‐ray to determine whether a pneumothorax has been caused.
If the patient is clinically deteriorating and has signs and symptoms of a pneumothorax or tension pneumothorax, call the medical emergency team and prepare for urgent drain reinsertion or needle decompression.
Reassure the patient. |
| Patient complains of pain | Drain pulling at site |
Secure the drain to the patient's skin using an omental tag to prevent pulling.
Administer appropriate analgesia on a regular basis. |
Reposition the tube and secure it using an omental tag to prevent the drain pulling.
Administer analgesia as prescribed.
Escalate to the clinical team if prescribed analgesia is not sufficient. |
Post‐procedural considerations
Documentation
Clearly document in the patient's nursing notes the date, type and size of drain inserted, and for what indication. The status of the drain should be documented at least 4‐hourly to determine whether there is evidence of bubbling, swinging or draining of fluid. The type and volume of fluid should also be recorded on a specific chest drain observation chart (Havelock et al. [103]). If low‐pressure thoracic suction is used, regularly check and document the suction pressure used (Woodrow [290]). Bottle changes and drain removals should also be recorded in both the nursing notes and the chest drain observation chart.
Monitor patient observations/NEWS regularly to ensure the patient is stable and there are no signs of clinical deterioration. Observations should be recorded every 5 minutes for the first 15 minutes following drain insertion and then reduced slowly over the next few hours to a minimum frequency of 4‐hourly (Woodrow [290]). The patient's pain score should also be recorded and analgesia given as required (Woodrow [290]).
Education of the patient and relevant others
Educate the patient as to why the chest drain is required and, if possible, teach the patient how to look after the drain. They should be taught to keep the drain below chest level at all times and ensure the bottle is kept upright and does not fall over (Havelock et al. [103], Woodrow [290]). If suction is indicated, the patient can be taught how to disconnect the suction tubing from the suction port on the underwater‐seal chest‐drain bottle, to allow them to mobilize away from the bed space. They should be instructed to reconnect it or call the nurse to assist with reconnection on their return. When resting in bed, the patient should be encouraged to lie in a position that prevents the tubing being occluded or kinked. The patient should also be encouraged to report any change in their breathing while the chest drain is in place.
Complications
Complications of chest drains include (Mao et al. [144], Ravi and McKnight [225]):
- incorrect placement (extrapleural, intrapulmonary or sub‐diaphragmatic)
- drain dislodgement
- puncturing of adjacent organs: lung, stomach, spleen, liver, heart or great vessels
- pulmonary laceration (haemorrhage or fistula)
- pneumothorax
- haemorrhage
- infection
- mechanical obstruction
- surgical emphysema
- re‐expansion pulmonary oedema.
