Chapter 12: Respiratory care, CPR and blood transfusion
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Chest drain removal
Evidence‐based approaches
The decision to remove a drain is usually made by a clinician based on the following criteria:
- There is an absence of air bubbles in the underwater‐seal chest‐drain bottle, usually noted when the patient exhales forcibly or coughs. This will coincide with expiration in a patient who is being mechanically ventilated with positive pressure.
- The volume of fluid draining into the chest‐drain bottle is minimal, usually between 100 and 500 mL per day (Chadwick et al. [42]).
- There is no evidence of respiratory compromise or failure.
- There is no coagulation deficit or increased risk of bleeding (check the latest coagulation results prior to removal).
- In many cases, radiological evidence of the absence of air or fluid within the pleural space will be required before removal.
The patient should be offered analgesia at least 30 minutes prior to chest drain removal (Woodrow [290]) before being placed in a comfortable position in bed that allows the nurse to gain access to the drain insertion site. The Valsalva manoeuvre (asking the patient to hold their breath, bear down and breathe against a closed glottis) should be taught and practised before the drain is removed (Mohammed [164]).
Small‐bore pigtail drains should have the holding thread cut or released (depending on the make and manufacturer) so as to uncoil the drain within the pleural space and allow removal. Both large‐bore and small‐bore drains will have an anchor suture, which should be cut prior to removal. Large‐bore chest drains may also have an additional mattress suture to help seal the incision site immediately after the drain is removed.
After removing the anchor suture, the chest drain should be removed with a brisk, firm movement while the patient performs the Valsalva manoeuver on the third expiratory breathe. If a mattress suture is present, a second nurse should tie this closed at the same time as the drain is removed (Havelock et al. [103]). Chest drains inserted for pneumothorax do not need to be clamped during the removal process.
A follow‐up post‐removal chest X‐ray is required to ensure no air has been allowed to enter during the removal process with formation of a subsequent pneumothorax (Woodrow [290]).
Procedure guideline 12.7
