CHEST TUBE: CARE AND MANAGEMENT

DOCUMENT TYPE: PROCEDURE

Site ApplicabilityApplicable site-wide at BC Children’s Hospital (BCCH), excluding Sunny Hill Health Centre (SHHC).

Practice Level/Competencies

Physicians may insert, remove and manage care of a chest tube A physician’s order is required: For chest tube insertion To specify the level of suction required (cm of H2O) Use of gravity drainage For clamping the chest tube. Exception: in the case of an emergency where the tubing

becomes disconnected When instillation of TPA and Normal Saline is required. See policy: “Protocol For The

Management Of Pleural Effusions In Previously Healthy Pediatric Patients” For removal of the chest tube For chest tube replacement

Registered Nurses in acute care at BCCH have foundational skills to care for and monitor patients with chest tubes.

Nurse Practitioners with advanced practice skills are able to remove chest tubes.

Equipment & Supplies PPE Chest Tube Emergency Equipment

o Dry sterile occlusive dressing (such as Tegaderm™, Tegaderm Absorbent™)o Non-grooved occluding clamps per chest tube x 2o Chlorhexidine 2% and 70% Alcohol pads x 2 (Povidone-Iodine swab sticks may be used if

patient allergic to chlorhexidine) Universal securement device (Stat-Lok™ or Grip-Lok™) Securement of chest tube to chest drainage system (Banding gun and zap straps) Sterile disposable closed chest tube drainage system (Atrium™) Wall suction regulator x 2 (one for drainage system and one for emergency equipment) Suction tubing

o Three way stop cock and 12 inch extension tubing (required for pigtail drain only; extension tubing only available from Procedures)

Cardiorespiratory and pulse oximetry monitoring device Stethoscope Waterproof tape Specimen collection: appropriate specimen container, alcohol swab, Luer-lock syringe

ProcedureThe purpose of a chest drainage device is to help to remove excess air and/or fluid in a closed, one-way fashion. This reduces collection of air and/or fluid in the thoracic cavity and optimizes expansion of the lung and respiratory function. Indications for a chest tube include: pneumothorax, hemothorax, chylothorax, pleural effusion, and/or post cardiac surgery or thoracotomy.

The purpose of this practice support document is to facilitate the safe management of chest drainage systems for patients at BCCH.

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STEPS RATIONALE1. PERFORM hand hygiene and OBSERVE appropriate

isolation precautions. DON PPE as needed.To reduce transmission of microorganisms.

2. PERFORM a thorough ASSESSMENTCONDUCT a full set of vital signs, per “Nursing Assessment Of Pediatric Patients And Related Documentation: Inpatient Units” policy, (Heart Rate, Respiratory Rate, Blood Pressure, Oxygen Saturations, and Temperature) every 4 hours, unless otherwise ordered, as needed, and whenever adjusting any connection sites or suction. MAINTAIN continuous oxygen saturation monitoring, per “Oximetry (Spo2) Monitoring” Policy, unless otherwise ordered.

CONDUCT a full neurological and head to toe assessment at beginning of shift and as needed.

ASSESS cardiorespiratory function including respiratory rate, rhythm, effort, breath sounds, air entry, and oxygen saturations at a minimum of every of 4 hours.

PERFORM pain assessment at minimum of every 4 hours and ADMINISTER analgesics as ordered.

NOTIFY physician if increase in respiratory distress, decreased or absent breath sounds, muffled heart sounds, subcutaneous emphysema, tracheal shift, vital sign changes outside of normal, pain management issues, or there are any other abnormal findings.

To monitor patient trends and respond appropriately. Escalate as necessary per PEWS Escalation Aid.

Obtaining patient’s baseline is essential to monitoring and care.

To monitor efficacy of chest tube and ensure no complications are developing.

Relieving the patient’s pain promotes comfort which facilitates deep breathing, coughing, and range of motion exercises. Ensure there is a plan for pain control in place.

3. ENSURE emergency equipment and supplies are checked and readily available:

appropriate and functioning suction equipment including:o adult or pediatric size oral Yankauer suction

catheters as requiredo suction regulator, canister, and tubing set up

correctly appropriate and functioning oxygen equipment

including:o appropriate size oxygen mask, tubingo oxygen regulator

cardiorespiratory and pulse oximetry monitoring deviceo on appropriate mode with alarm limits on and

set based on child’s age and condition chest tube emergency equipment

o Dry sterile occlusive dressing (such as Tegaderm™, Tegaderm Absorbent™)

o Non-grooved occluding clamps per chest tube x 2

o Chlorhexidine 2% and 70% Alcohol pads x 2 (Povidone-Iodine swab sticks may be used if patient allergic to chlorhexidine)

Immediate interventions can be provided in case of deterioration in patient’s condition.Note: Emergency suction is in addition to the wall suction regulator for each test tube.

In case where tubing breaks, completely occlude chest tube with clamp to prevent air from entering the pleural space.

In case where chest tube falls out, place occlusive dressing over site immediately.

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4. PERFORM a site to source check hourly

a. MONITOR the insertion site for signs of infection, bleeding, subcutaneous emphysema and skin integrity. ENSURE dressing is dry and intact, reinforce and change as needed. See “Chest Tube: Dressing Change”.

b. ENSURE chest tube is well secured to the patient with Grip-Lok universal securement device. AVOID pinning tubing to bedding.

c. ASSESS chest tube and connected tubing for air leaks, kinks, dependent loops and patency. ENSURE all connection sites are secure (use banding gun – if banding impossible, use waterproof tape). ENSURE the blue manufacturer’s clamp is open.

d. ENSURE appropriate suction is set on dry suction regulator as per prescriber’s order. Dry suction regulator can be adjusted from -10 cm H2O to -40 cm H2O. To change the setting, adjust rotary dial located on side of collection chamber.

e. ASSESS water seal compartment. ENSURE level of water in water seal chamber is at the 2 cm fill line and that it is moving to indicate it is working correctly. No bubbling with minimal float ball oscillation at bottom of the water seal will indicate no air leak is present. This system is intended to be a quiet non-bubbling system. NOTIFY physician if this is a new finding.If the water seal chamber has less than required, it is the healthcare professional’s responsibility to add sterile water via suction port located on top of drain until fluid reaches the 2 cm fill line.

f. OBSERVE the graduated water seal column for changes in patient pressure as evidenced by the float ball and level of water, known as tidaling.

To assess for any changes or complications (such as infection) with chest tube and ensure it is operating appropriately.

These are signs of the inflammatory response that will be present with infection. Subcutaneous emphysema around the site may indicate and incorrect position of the tube.

To avoid accidental movement or removal of chest tube. Avoid use of waterproof tape as this may cause skin breakdown.

Dependent loops containing fluid can completely block drainage within 30 minutes and dramatically increase pleural pressure which may damage lung tissue or cause a tension pneumothorax. This will also prevent clots from forming.

The least amount of suction to maintain full expansion of the lung is appropriate as too high of suction may delay pleural healing. When lowering regulator setting, temporarily depress the vent located on top of the drain to reduce excess vacuum pressure.

The water seal acts as a one way valve and prevents air and/or fluid from going back into the pleural space. For a child breathing spontaneously, the water level in the water seal chamber should rise with inspiration and fall with expiration.When air bubbles are observed going from right to left, this indicates an air leak (patient or chest tube system). Intermittent bubbling that corresponds with respirations indicates an air leak in the pleural space and will resolve as the lung re-expands. If continuous, check chest tube system connections. A prolonged air leak may contribute to the development of a tension pneumothorax. See “Chest Tube: Troubleshooting” for further instructions.

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During prolonged periods of extreme negative pressure, the water seal and float ball may be drawn into the graduated water seal column. If this occurs, depress the manual vent located at the top of the drainage system. Do not use manual vent to lower water seal column when suction is not operating or when the patient is on gravity drainage.

g. ENSURE the positive pressure release valve located on top of drain is not obstructed.

h. ASSESS chest tube drainage amount, colour and consistency and RECORD hourly cumulative totals on BCCH Daily Flowsheet. DOCUMENT any changes in drainage.

NOTIFY physician with sudden increase or decrease in drainage, changes in colour and consistency of drainage (notify immediately if frank bloody drainage), signs of infection, and any other relevant changes in patient condition. CONSIDER fluid replacement for excessive drainage (>5 mL/kg/hr) and the need for a sample when colour changes occur.

i. ENSURE wall suction is on. Suction bellows will expand to the ▲ mark or beyond when suction is connected and operating at a regulator setting of -20 cmH2O or higher. If the bellows is expanded but less than the ▲ mark, increase the wall suction to -80 mmHg or higher. For regulator settings less than -20 cmH2O, any visible bellows expansion in bellows window will confirm suction operation. If STRAIGHT OR GRAVITY DRAINAGE is ordered, do not have suction on and leave suction port uncapped and free of obstruction.

Bubbling/Air Leak Algorithm

Tidaling Algorithm

This valve releases accumulated positive pressure.

Chest tube drainage changes may indicate change in management (i.e. change to low fat diet due to chylous drainage, need for flushing or tPA [see Protocol for the Management of Pleural Effusions in Previously Healthy Pediatric Patients], need for imaging, emergency care, or removal of chest tube etc.)

Amount of wall suction needed will vary patient to patient due to other factors (such as amount and consistency of fluid) and must be set individually and checked routinely per patient. This should be reviewed daily by the medical team and the decision documented.

Leaving suction port free of obstruction allows air to exit and minimizes chance of tension pneumothorax.

5. CHANGE the drainage collection chamber when: anticipated to be full within 2-3 hours. Do not wait

for the chamber to be full. chest drainage system sterility has been

compromised such as in accidental disconnection

Changing the drainage collection chamber before it is full will prevent pressure build up and decrease the chance of a tension pneumothorax.

If the drainage collection chamber sterility is

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of the drain. chest drainage system tips over and fluid spills

into multiple columns

PERFORM hand hygiene and DON PPE.

PREPARE a new drainage collection chamber.a. FILL water seal to 2 cm line with 45 mL sterile water.

b. CLEANSE the area around the in-line connector with Chlorhexidine 2% and Alcohol 70% pad for 30 seconds and allowing drying for 60 seconds.

c. DOUBLE CLAMP chest tube above in-line connector using 2 non-grooved clamps for a short period of time.

NOTE: If there is any respiratory distress unclamp immediately.

d. TURN suction off.e. DISCONNECT the tubing at the in-line connector and

CONNECT the new drainage system. Give a slight tug on either side of the connection to ensure it is secure.

f. REMOVE double clamps.g. RE-ESTABLISH suction as ordered. If gravity

drainage is ordered, do not connect suction tubing to the suction port and ensure the suction port is free of obstruction.

h. OBSERVE drainage into new closed collection system.

i. PERFORM site to source check of chest tube drainage system as outlined in step 4.

j. DISCARD old collection chamber in biomedical waste in soiled utility room.

compromised, this will increase the risk of infection for the patient.This will ensure accurate monitoring of chest tube drainage.

To reduce transmission of microorganisms.

This creates a water seal (see Step 4e).

To prevent infection.

To prevent air from entering the pleural space.

To establish new connection.The locking in-line patient tube connector provides for system replacement and disconnection.Do not separate in-line connector prior to clamping off patient tube clamp.

To allow for suction.To provide negative pressure for lung re-expansion and removal of gas and/or fluids from pleural space.

To ensure proper chest tube functioning.6. ENSURE chest drainage system is kept below the

patient’s chest level. COIL excess tubing on bedside – do not allow tubing to hang below the bed and coil on the floor. To avoid accidental knock over, open the floor stand for secure placement on the floor or hang the system bedside with the hangers provided. AVOID taping to the floor.

To prevent fluid or gas re-entering the pleural space.Prevent dependent loops and pressure changes, and accidental occlusion of tubing.Avoiding taping to the floor promotes ambulation and prevents accidental removal.

7. DO NOT CLAMP tubing during patient transfers or ambulation. ONLY CLAMP tubing for a short period of time when changing drains, checking for air leaks, accidental disconnection, when moving collection

Clamping the chest tube prevents air or fluid from leaving the pleural space, increasing risk of respiratory distress or a tension pneumothorax.

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chamber above chest height, or when ordered in preparation for discontinuation. UNCLAMP immediately if respiratory distress occurs.

8. DO NOT ROUTINELY STRIP or MILK the tubing.NOTE: Gentle MANIPULATION of the tube may be

necessary if there are visible clots in the tubing. This is accomplished by squeezing hand over hand along the tubing and releasing the tubing between squeezes.

To avoid excessive pressure that could cause damage to lung tissue or a tension pneumothorax.

9. COLLECT specimens as ordered using aseptic non-touch technique (ANTT):

a. SWAB needleless cap with chlorhexidine 2% and alcohol 70% pad for 30 seconds and allow to dry for 60 seconds.

b. ATTACH syringe directly onto needleless cap and WITHDRAW required amount as per eLab handbook.

c. PLACE aspirate into specimen container. LABEL container and send to lab with appropriate requisition.

d. ENSURE amount of fluid removed is documented on BCCH Daily Flowsheet.

To assess lab values and treat appropriately (i.e. PRBC if hemoglobin low or change in antibiotics due to C&S results).

10. OBTAIN chest imaging as prescribed.NOTE: Patients with chest tubes must be accompanied to

tests by RN and monitored as prescribed.

To detect malpositioning of chest tube and aid in determining when able to remove chest tube. When able, obtain both lateral and medial CXR images.

11. ENCOURAGE deep breathing and coughing every hour while awake. ENGAGE Child Life and Physiotherapy to develop an age appropriate patient specific plan of care.

To promote secretion drainage and expand the lungs.Engaging Child Life and Physiotherapy enhances and promotes patient coping abilities.

12. AMBULATE patient as soon as able. Prior to ambulation, determine if suction is to be maintained by portable suction or at straight drainage. A prescriber’s order is necessary.

To promote circulation, fluid drainage and decrease recovery time.

13. PROVIDE patient and family education and support as needed. TEACH caregiver’s how to safely care for the chest tube and drainage chamber, including:

Call for help immediately if patient has increased work of breathing or are otherwise concerned.

Call for help immediately using ‘Staff Assist’ if chest tube falls out or disconnects.

Notify nursing if chest tube chamber tips over. Do not leave room without nursing and

emergency equipment.DOCUMENT teaching in Nursing Notes.

To decrease anxiety and promote a culture of family centered care.Parents must be able to respond and call for help immediately in the case that the drain is accidentally removed or the tubing becomes disconnected.

DocumentationDOCUMENT in appropriate record(s): Date, time Patient assessment (breath sounds, signs of oxygenation, ventilation, pain) Amount negative pressure suction Site and dressing assessment Amount, colour, consistency of drainage (amount to be recorded on I&Os hourly – see Appendix A) Comfort assessment and any specific interventions Patient/family education Unexpected outcomes and related management

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HYPERLINK "http://www.atriummed.com/EN/chest_drainage/Documents/OasisWallChart-010395-Letter-Size.pdf" Atrium Oasis Wall ChartA Personal Guide to Managing Chest DrainageRelated BCCH Documents:

Blake Chest Tube Maintenance and RemovalChest Tube: Dressing ChangeChest Tube: InsertionChest Tube: RemovalChest Tube: Troubleshooting Unexpected OutcomesClinical Skill Validation: Chest TubesPEWS Escalation AidPre and Post-Operative CareProcedural Sedation: Non-Critical Care AreasProtocol for the Management of Pleural Effusions in Previously Healthy Pediatric Patients

ReferencesAmerican Association of Critical Care Nurses. (2007). Procedure Manual for Pediatric Acute and Critical Care. St. Louis:

Elsevier.

Atrium Med. (n.d). Oasis Dry Suction Water Seal Drain. Retrieved from http://www.atriummed.com/EN/chest_drainage/oasis.asp

Carol, P. (2013). Evidence-Based Care of Patients with Chest Tubes. American Association of Critical-Care Nurses National Teaching Institute. Boston, MA.

Crawford, D., (2011). Care and management if a child with a chest drain. Nursing Children and Young

Curley, MAQ and Thompson, JE. (2001). Oxygenation and Ventilation in Critical Care Nursing of Infants and Children 2nd edition. Curley, MAQ and Moloney-Harmon, PA (ed). Saunders: Philadelphia.

Durai, R., Hoque, H., & Davies, T. (2010). Managing a chest tube and drainage system. AORN Journal, 91(2), 275-283. doi:10.1016/j.aorn.2009.09.026

Elsevier. (2018). Chest Tube Care (Pediatric). Retrieved from http://point-of-care.elsevierperformancemanager.com/#/skills/743/quick-sheet?skillId=CCP_036

Gan, K. L. J., & Tan, M. (2015). Evidence-based management of patients with chest tube drainage system to reduce complications in cardiothoracic vascular surgery wards. International Journal of Evidence-Based Healthcare, 13(2), 58.

Gogakos, A., Barbetakis, N., Lazaridis, G., Papaiwannou, A., Karavergou, A., Lampaki, S., Baka, S., Mpoukovinas, I., Karavasilis, V., Kioumis, I., Pitsiou, G., Katsikogiannis, N., Tsakiridis, K., Rapti, A., Trakada, G., Zissimopoulos, A., Tsirgogianni, K., Zarogoulidis, K., … Zarogoulidis, P. (2015). Heimlich valve and pneumothorax. Annals of translational medicine, 3(4), 54.

Great Ormond Street Hospital for Children. (2016). Chest drain management. Retrieved from https://www.gosh.nhs.uk/health-professionals/clinical-guidelines/chest-drain-management#Rationale

Jeffries, M. (2017). Research for Practice. Evidence to Support the Use of Occlusive Dry Sterile Dressings for Chest Tubes. MEDSURG Nursing, 26(3), 171–174.

Lippincott. (2015). Lippincott Nursing Procedures (Vol. 7th). [N.p.]: Wolters Kluwer Health. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=e680sww&AN=1473216&site=ehost-live

Perry, A.G., Potter, P.A., Ostendorf, W.R. [Eds.] [2018]. Clinical nursing skills & techniques [9th ed.]. St. Louis: Elsevier. Retrieved from http://point-of-care.elsevierperformancemanager.com/#/skills/743/quick-sheet?skillId=CCP_036

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Regina Qu’Appelle Health Services. (2017). Nursing Procedure: Chest Tube. Regina, SK.

SickKids. (2017). General Care of a Chest Tube Policy. Toronto, ON.

SickKids. (2017). Setting Up and Changing a Chest Drainage System. Toronto, ON.

The Royal Children’s Hospital Melbourne. (2016). Clinical Guideline (Nursing): Chest Drain Management. Retrieved from http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/chest_drain_management/

UpToDate. (2018). Placement and management of thoracostomy tubes. https://www.uptodate.com/contents/placement-and-management-of-thoracostomy-tubes?search=chest%20tube&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

DefinitionsPleural Chest Tube: A drainage tube located in the pleural space between the visceral and parietal pleurae. Used to remove air and/or fluid from the pleural space.Mediastinal Chest Tube: A drainage tube in the mediastinal cavity, which includes part of the thoracic cavity that contains a group of structures (the esophagus, trachea, heart, thymus, thoracic duct). Used to evacuate air and/or fluid. Post cardiac surgery, this tube might also drain the pleural space to evacuate any pooling of blood which left might cause cardiac distress or tamponade.

Pericardial chest tube: Drainage tube located in the pericardial sac of the heart.

Argyle chest tube: A clear PVC single lumen catheter that is inserted using a sharp trocar. The catheter has numerical depth marks at 2 cm increments and once inserted and position it is typically sutured in place.

Pigtail chest tube: A flexible single lumen catheter designed to allow the distal end to coil when a string is pulled at the proximal end. It can be used for the purpose of drainage or introducing fluids. The coil end helps to hold the catheter in place and can slow the flow of fluids injected through the catheter. Pigtail catheters are often used in medical imaging studies or for patients with a pleural effusion. Typically they are held in place with a securement device (ie. Stat Lok™ or Grip Lok™) and are not always sutured into place. A pigtail drain often has extension tubing and a three way stop cock.

Blake chest tube: A white radiopaque silicone drain with four channels along the sides with a solid core center. Typically it is sutured in place using a purse-string suture. The Blake is attached to a reservoir bulb with a mechanical one way valve instead of a water seal chamber. Used when patient requires drainage only (not suction to re-expand lung). See “Blake Chest Tube Maintenance and Removal” policy.

Chest Tube Drainage System: A device used to collect air and/or fluid from a chest tube. Atrium: Disposable water seal drainage system that separates the functions of fluid collection, suction control and water seal.

Water Seal: Water in a chamber that serves as a simple one way valve.

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Dry Suction: The dry suction control regulator works by balancing the forces of suction and atmosphere to deliver reliable suction to the patient. The standard default setting is typically -20 cm H2O. However, this can be adjusted using the rotary dial on the side of the Atrium as per doctor order.

Heimlich Chest Drain Valve: A small one-way valve used for chest drainage that empties into a flexible collection device and prevents return of gases and/or fluids into the pleural space. This may be used instead of a water seal drainage system.

Milking: Any compression of the chest tube using a twisting or squeezing motion to remove clots within the tubing.

Stripping: A systematic and continuous compression of a chest tube from the chest wall toward the collection chamber. Note: this should only be done with Blake Chest Tubes.

Tension pneumothorax: The progressive build-up in air within the pleural space. This is a life-threatening emergency that requires immediate decompression. Signs and symptoms include sudden onset of sharp chest pain, shortness of breath, tachycardia, tachypnea, hypotension, diminished breath sounds and increased work of breathing.

Appendix Appendix A: Chest Tube Drainage Documentation

Appendix B: Atrium OASIS Dry Suction Water Seal Chest Drain Wall Chart

Version HistoryDATE DOCUMENT NUMBER and TITLE ACTION TAKEN06-Mar-2019 C-05-12-60108 Chest Tube: Care And Management Approved at: BCCH Best Practice Committee

DisclaimerThis document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document.  This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA. 

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Appendix A: Chest Tube Drainage Documentation

Hourly & Cumulative without Chamber Levels

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Hourly & Cumulative with Chamber Levels

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Appendix B: Atrium OASIS Dry Suction Water Seal Chest Drain Wall Chart

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