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CHEST TUBES

PURPOSE The purpose of this practice support document is to describe procedures related to the care of a patient with chest tube(s) including assisting with insertion, care and monitoring guidelines, how to change the chest drainage system, how to remove a chest tube, how to change the dressing and troubleshooting guidelines.

PROCEDURES CHEST TUBE INSERTION 1. ASSEMBLE equipment:

a. pediatric chest drainage insertion tray b. sterile gown, sterile gloves, masks c. chest tube(s) (trocar catheter) d. local anaesthetic e. chlorhexidine gluconate 2-4% solution f. suction regulator (for continuous suction only) g. sterile disposable chest drainage unit h. sterile water (500 ml bottle) i. 1 inch water proof tape j. two non-grooved occluding clamps per chest tube k. suction tubing l. petroleum dressing (Jelonet®) or Vaseline m. gauze and occlusive transparent dressing

2. ENSURE emergency suction and oxygen equipment are at bedside and properly functioning.

3. ENSURE the following supplies are at bedside at all times in case of accidental removal, disconnection or air leak:

a. petroleum dressing (Jelonet®) b. gauze dressing of appropriate size c. sterile occlusive transparent dressing of appropriate size d. bottle of sterile water - 500 mL e. two non-grooved occluding clamps per chest tube

4. ENSURE adequate cardiorespiratory monitoring.

5. MASK, WASH hands and DON clean gloves.

6. PREPARE equipment using aseptic technique:

7. ATTACH suction regulator to vacuum inlet.

8. CONNECT suction tubing to the suction regulator and to the short latex tubing of the disposable chest drainage system.

9. ENSURE informed consent has been obtained by physician performing the chest tube insertion.

10. IDENTIFY patient and ENSURE patient and family understand procedure and questions are answered.

WATER SEAL a. Fill underwater seal chamber with sterile

water to 2 cm line as directed on drainage system package instructions

b. Fill suction control chamber with sterile water to ordered suction pressure (-10 to -20 cm H20) and replace vent plug

DRY SUCTION a. Fill underwater seal chamber with sterile

water to 2 cm line as directed on drainage system package instructions

b. Set dry suction regulator on front of drainage system to ordered suction pressure (-10 to -40 cm H20). The suction regulator is pre-set to -20 cm H20.

CC.09.01 BC Children’s Hospital Child & Youth Health Policy and Procedure Manual Effective Date: Apr-08-2007 Page 1 of 10

CHEST TUBES

11. ENSURE patient has received pre-medication and that a plan for pain management is in place.

12. POSITION patient supine with head of bed at 30-50˚ with affected side slightly up as shown. The sitting position is an alternative for those patients who are unable to lay flat because of respiratory distress.

13. ASSIST physician in preparing local anesthetic for insertion of chest tube.

14. ASSIST with insertion as required.

15. REMOVE cap from end of connection tubing and using sterile technique, ATTACH to end of chest tube. The patient’s side of tubing is connected to collection chamber (to right when looking at the front of the system).

16. ASSIST with suturing the chest tube in place.

17. SECURE chest tube to chest wall as shown.

18. ESTABLISH suction as ordered. The suction side of tubing is connected to suction side of unit (on the

left when looking at front of the system.

For WATER SEAL Units,

o TURN ON suction regulator until constant, gentle bubbling occurs in the suction control chamber

For Dry Suction Units: o TURN ON suction source vacuum until the suction monitor bellows expand to the mark or beyond for a

-20cm H2O or higher regulator setting (usually between 40-80 mmHg). The regulator control dial, located on the side of the drain, can be adjusted to any suction setting between -10cm H2O and -40cm H2O.


CHEST TUBES

o Dial down to lower the suction setting and dial up to increase.When the suction control regulator is set at -20cmH2O or higher, the bellows must be expanded to the mark or beyond when suction is operating. If the bellows is observed to be expanded, but less than the mark, the suction source vacuum pressure must be increased.

o For a regulator setting less than -20cmH2O suction, any observed bellows expansion across the monitor window will confirm suction operation. The bellows need not be expanded to the mark for pressures less than -20cmH2O, just visibly expanded to confirm suction operation.

19. PLACE closed chest drainage system below chest level in an upright position. To help avoid accidental knock-over, place the unit on the floor or hang it on the bedside with the hangers provided.

20. SECURE connections using “zap straps” as shown.

21. APPLY an occlusive petroleum dressing or Vaseline around the insertion site and COVER with a dry gauze

and SECURE with an occlusive transparent dressing.

22. ENSURE chest X-ray is obtained.

23. OBSERVE insertion site and initial drainage into the closed collection system.

24. DISPOSE of equipment and WASH hands.

25. DOCUMENT in appropriate record(s): o Date, time, length of procedure o Name of physician performing procedure o Patient assessment pre/post insertion (breath sounds, signs of oxygenation, ventilation, pain) o Amount, colour, consistency of drainage o Amount negative pressure suction o Site assessment o Dressing type o Comfort assessment and any specific interventions o Patient/family education o Unexpected outcomes and related treatment

CARE AND MONITORING GUIDELINES 1. MONITOR respiratory, cardiovascular and neurologic status before, during and hourly after the procedure

or as ordered and as required by patient condition.

2. MONITOR the insertion site for signs of infection, bleeding and air leaks hourly.

3. EVALUATE chest tube drainage amount, colour and consistency and RECORD hourly cumulative totals by marking drainage set with date and time of each recording.


CHEST TUBES

4. ASSESS chest tube system for air leaks, kinks and dependent loops hourly. ENSURE level of water in water seal chamber is at the 2 cm mark. VERIFY suction operation via the Suction Monitor Bellows ensuring expansion at or beyond mark.

5. ENSURE chest drainage system is kept below the patient’s chest level to prevent fluid re-entering the pleural space.

6. ASSESS dressing and reinforce or change as needed. ENSURE tubing is well secured to chest wall.

7. ASSESS pain status and pain management plan every hour while awake.

8. ENCOURAGE deep breathing, coughing and use of incentive spirometer every hour while awake.

9. AMBULATE patient as soon as able, with a physician’s order.

10. DO NOT CLAMP tubing during patient transfers or ambulation.

11. DO NOT ROUTINELY STRIP or MILK the tubing as this exerts excessive pressure and could cause damage to the lung tissue.

NOTE: MANIPULATION of the tube may be necessary if there are visible clots in the tubing. A gentle “massaging” technique is accomplished by squeezing hand over hand along the tubing and releasing the tubing between squeezes.

12. COLLECT specimens as ordered: a. SWAB needleless cap with chlorhexidine gluconate/alcohol swab (CHG/alcohol) for 30 seconds

and allow to dry for 1 minute b. ATTACH syringe directly onto needleless cap and WITHDRAW required amount c. PLACE aspirate into specimen container. LABEL container and send to lab with appropriate

requisition. d. DISPOSE of equipment appropriately.

NOTE: if unable to aspirate drainage via needleless cap, samples may also be taken directly from the patient tube connector by inserting a 20 gauge needle or smaller with syringe. Swab resealable tube with CHG/alcohol prior to inserting syringe needle at a shallow angle and aspirate drainage.

13. DOCUMENT 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 (mark drainage set with date and time of

hourly recording) Comfort assessment and any specific interventions Patient/family education Unexpected outcomes and related management

CHANGING THE CHEST DRAINAGE SYSTEM Change the drainage collection chamber when you anticipate it will be full in 2-3 hours - do not wait for it to be completely full.

Replacing the entire system may be necessary if there is damage to the tubing or Y'd tubings need to be separated. Consult with 3M clinical leadership team, PICU RN or surgeon if entire system requires replacing.

1. PREPARE new chest drainage system as in NC 007: Chest Tubes: Insertion – Assist.

2. IDENTIFY patient and EXPLAIN procedure.


CHEST TUBES

3. WASH hands and DON clean gloves.

4. CLEANSE the area around the in-line connector with chlorhexidine/alcohol swab.

5. DOUBLE CLAMP chest tube above in-line connector using 2 non-grooved clamps.

6. TURN suction off.

7. 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’s secure.

8. REMOVE clamps. 9. RE-ESTABLISH suction as ordered.

10. OBSERVE drainage into new closed collection system.

11. PERFORM site to source check of chest tube drainage system and ensuring clamps are removed.

12. DISPOSE of equipment and WASH hands.

13. DOCUMENT in appropriate record(s): a. date and time b. amount negative pressure suction c. comfort assessment and any specific interventions d. patient’s response to procedure e. any other pertinent actions or observations

CHEST TUBE REMOVAL A registered nurse who has completed advanced education for Chest Tube and Epicardial Pacer wire removal and has had their competency validated by a cardiac surgeon, clinical nurse educator, or clinical resource nurse who is competent in this procedure may independently remove chest drains in the Pediatric Intensive Care Unit or on the Children’s Heart Unit (Inpatient Unit 3M). In all other cases, chest tube removal will be done by a physician.

A written cardiac surgeon order is required to remove a pleural/pericardial/mediastinal chest tube.

Chest tube removal from the pleural or mediastinal space is performed when the chest tube is no longer necessary or no longer functioning.

Expected outcomes of chest tube removal include: • Child maintains adequate oxygenation and ventilation • No re-accumulation of fluid or air in the pleural or mediastinal space • Insertion site remains free of infection, and • Child receives adequate pain control during procedure

PROCEDURE Rationale 1. DETERMINE that you have the relevant

competencies and CHECK chart for physician order. NOTE: relevant competencies developed through attendance at Chest Tube and Epicardial Pacerwire removal workshop and/or related experience and training.

Chest tube removal is considered an advanced nursing skill and must only be practiced once a nurse has attended the required advanced cardiac science education and whose learning has been validated at the bedside with the appropriate clinical support person.

2. IDENTIFY patient and EXPLAIN procedure to patient and family. ENSURE patient and family understand procedure and questions are answered.

Ensures identification mechanism is present to prevent treatments, medications, and procedures to wrong patient. Reduces child and family’s anxiety. Evaluates and reinforces understanding of previously taught information


CHEST TUBES

3. PERFORM hand hygiene. GATHER needed equipment, supplies and involved health care professionals:

o Analgesics and sedation as per order o Personal protective equipment (PPE) (mask,

gown, goggles, gloves) o Emergency equipment available (manual

ventilation bag, mask and oxygen source) o Clamp for each chest tube o Sterile gauze (4X4) o 0.9% normal saline or 2% Chlorhexidine in

70% alcohol solution swabs for cleaning site o Suture removal kit o Dressing (sterile gauze, petroleum gauze

and occlusive dressing for insertion sites without a purse string suture and meopore dressing for insertion sites with a purse string suture)

o Absorbent pad o Sterile specimen collection container (as

required)

Facilitates completion of tasks in a timely manner.

4. ENSURE adequate cardiopulmonary monitoring. Patient may decompensate during procedure. 5. ASSESS patient need for analgesia and ENSURE

plan for pain management is in place. Removal of chest tubes is a painful procedure; pain and anxiety control help child maintain position.

6. OBTAIN assistance of a second nurse. POSITION child with chest exposed and place an absorbent pad underneath.

Ensures accessibility to insertion site.

7. PREPARE supplies and equipment to complete procedure. OPEN suture removal kit. PREPARE petroleum gauze occlusive dressing.

This is not a sterile procedure although aseptic technique is necessary to prevent infection; petroleum gauze decreases potential of introducing air into pleural space.

8. PERFORM hand hygiene and APPLY PPE (mask, goggles, gown, clean gloves).

Standard/routine precautions; reduces transmission of micro organisms; PPE must be applied when an exposure to a blood or body substances is anticipated.

9. REMOVE dressing over chest tube site. Allows access to chest tube. 10. CLEAN chest tube exit site and around retention

suture with gauze and 0.9% normal saline or 2% Chlorhexidine in 70% alcohol solution swab using aseptic technique.

11. REMOVE the retention suture that secures the chest tube to the skin. If a purse string suture is present, ensure that a loose throw is found in it.

Frees the chest tube from the skin.

12. INSTRUCT age-appropriate non-mechanically ventilated children to take a deep breath and hold.

Creates positive pressure in the pleural space and helps to limit the introduction of air into the pleural space.

13. HOLD gauze and occlusive dressing above chest tube site with one hand and securely hold chest tube with other hand. REMOVE chest tube rapidly at end of inspiration and immediately place folded gauze over the chest tube entry site.

Prevents introduction of air into the pleural space.


CHEST TUBES

14. TIE the purse string suture if present by

simultaneously pulling the ends taut and cinching the edges of the wound closed.

NOTE: Tissue necrosis can occur if sutures are pulled too tightly. Dark, purple or dusky skin at the site may indicate tissue necrosis.

Closes chest tube entry site.

15. APPLY occlusive dressing over chest tube site immediately for insertion sites without a purse string suture. Ensure an airtight seal.

Prevents the introduction of air into the pleural space.

16. DISCARD used supplies and equipment in appropriate receptacle. REMOVE PPE and PERFORM hand hygiene.

Standard/routine precautions; reduces transmission of microorganisms.

17. EVALUATE cardiorespiratory status, MONITOR vital signs (HR, RR and BP) every 15 minutes for 1 hour. OBSERVE for signs and symptoms of pneumothorax for pleural chest tubes or tamponade for mediastinal or pericardial drains.

Clinical symptoms identify patient with complications.

18. OBTAIN a chest x-ray if clinically indicated (respiratory distress, decreased breath sounds) and ensure that the appropriate physician/NP has reviewed CXR.

Clinical symptoms indentify child with pneumothoraces.

19. DOCUMENT on appropriate record(s): o child and family education o pain and anxiety management and effectiveness

of interventions o location and appearance of chest tube/drain

Communication to additional members of the health care team. Assists with meeting Professional Standards for documentation and legal requirements.


CHEST TUBES

removed o assessment of site and presence of bleeding o status of oxygenation and ventilation o results of chest x-ray o unexpected outcomes and related treatment o any other actions or observations

DRESSING CHANGE 1. CHANGE dressing if it is soiled, loose or no longer occlusive.

2. ASSEMBLE equipment: a. 2 drain sponges (7.5 x 7.5 cm) b. 2 gauze sponges according to patient size c. Chlorhexidine swab sticks X 3 (povidone-iodine swab sticks may be used if patient allergic to

chlorhexidine) d. Chlorhexidine swabs x 2 e. Transparent dressing (eg. Tegaderm®) f. Securement device (eg. Statlock®) or waterproof tape g. Non-sterile gloves h. Sterile gloves

3. WASH hands and DON non-sterile gloves.

4. REMOVE old dressing and securement device/tape and INSPECT chest tube site and surrounding skin for: o Redness, discoloration of the skin o Type, amount and color of drainage o Air leaks o Bleeding o Condition of sutures.

5. REMOVE gloves and WASH hands.

6. OPEN packages and DON sterile gloves.

7. CLEANSE the first 2" of the chest tube with the chlorhexidine swabs, starting where it exits the skin.

8. CLEANSE the first 2" of the chest tube with the chlorhexidine swabs, starting where it exits the skin.

9. APPLY the split drain gauze dressing around the chest tube so that the openings do not lie directly over one another.

10. LAY two gauze dressings over the drain dressings covering the chest tube (optional).

11. APPLY transparent dressing to create an occlusive dressing.

12. LABEL dressing with date and time dressing changed.

13. SECURE chest tube to chest wall using waterproof tape or securement device (eg. Statlock®)

14. DOCUMENT in appropriate record(s): o Procedure and time o Assessment of site and surrounding skin o Patient's response to procedure o any other pertinent actions or observations.

Unexpected Outcomes and Related Management Accidental Disconnection CC.09.01 BC Children’s Hospital Child & Youth Health Policy and Procedure Manual Effective Date: Apr-08-2007

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CHEST TUBES

1. CLAMP chest tube close to the chest wall briefly (less than 1 minute) using 2 non-grooved occluding clamps and maintain tube below level of chest tube insertion sit

2. CLEAN both exposed ends with chlorhexidine/alcohol swabs and allow to dry. 3. RECONNECT to chest tube drainage system and RETAPE connections. 4. UNCLAMP chest tube. 5. If unable to reconnect drainage system or drainage system is broken, UNCLAMP chest tube and KEEP

end of chest tube in 500 mL bottle of sterile water to maintain water seal. KEEP bottle below level of chest tube insertion site at all times. REPLACE drainage system as soon as possible following steps i-iv.

6. NOTIFY physician of accidental disconnect and possible contamination of system. Accidental Removal 1. OCCLUDE chest wound immediately until occlusive dressing can be applied and OBTAIN help of second

RN. 2. NOTIFY physician STAT. 3. APPLY petroleum gauze to site, cover with sterile gauze and apply occlusive dressing to achieve airtight

seal. 4. ASSESS patient for respiratory distress. 5. POSITION patient, with the affected side down. 6. PREPARE for STAT portable chest X-ray. 7. PREPARE for reinsertion of chest tube. Excessive Air Leak 1. If water seal chamber begins bubbling continuously, SUSPECT an air leak. ASSESS system from insertion

site to chest drainage unit (CDU) to locate source. If having difficulty locating source, CLAMP tubing momentarily at various points along its length starting at the patient end and work your way towards the CDU. Bubbling will stop when you clamp between the air leak and the water seal. If still unable to locate air leak, the CDU may be cracked and needs to be replaced.

For leak at insertion site: i. NOTIFY physician ii. REMOVE dressing, ASSESS site for loose suture and REAPPLY occlusive dressing (suture may

need to be reinforced by physician). iii. CHANGE drainage system if dressing does not correct leak.

Tension Pneumothorax 1. NOTIFY physician for sings of respiratory distress, increased restlessness, or deterioration in level of

consciousness. 2. ADMINISTER oxygen as needed. 3. MONITOR cardiorespiratory status every 5 minutes. 4. CHECK all connections for air leaks, occluded or kinked tubes, or clamps left in place on chest

tube/drainage tubing. 5. COMPRESS drainage tube intermittently along entire length to attempt to dislodge any blockage (ie clots). 6. PREPARE for needle thoracostomy or new chest tube insertion. 7. OBTAIN arterial blood gases and STAT portable chest X-Ray as ordered.

REFERENCES Atrium education website: http://www.atriummed.com/Products/Chest_drains/education.asp

Allibone, L. (2003). Nursing management of chest drains. Nursing Standard. 17(22):45-56.

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

Baumann, M. (2003). What drainage system is ideal? And other chest tube management questions. Current Opinion in Pulmonary Medicine. 9(4):276–281.

Bruce, E, Howard, RF and Franck, LS. (2006). Chest drain revoval pain and its management: a literature review. Journal of Clinical Nursing. 15(2):145-154.


http://www.atriummed.com/Products/Chest_drains/education.asp

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Calhoun Thompson, S, Wells, S, & Maxwell, M. (1997). Chest tube removal after cardiac surgery. Critical Care Nurse. 17(4):34–38.

Charnock, Y and Evans, D. (2001). Nursing Management of Chest Drains: a systematic review. Australian Critical Care. 14(4):156-160.

Coughlin, AM and Parchinsky, C. (2006). Go with the Flow of Chest Tube Therapy. Nursing. 36(3):36-41.

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.

Lazzara, D. (2002). Eliminate the air of mystery from Chest Tubes. Nursing. 32(6): 36-43.

McCornick, J. (2002). The use of routine chest x-ray after chest tube removal in postoperative cardiac patients. Annals of Thoracic Surgery. 74(6):2161–2164.

Oasis Dry Suction Chest Drain: Instructions for Use. Atrium Medical Corporation. 2004.

Ocean Water Seal Chest Drain: Instructions for Use. Atrium Medical Corporation. 2004.

Pettinicchi, TA. (1998). Trouble Chest Tubes. Nursing. 28(3):58-59.

Roman, M and Mercado, D. (2006). Review of Chest Tube Use. Medsurg Nursing. 15(1): 41-43.

Tang, ATM, Velisssaris, TJ and Weeden, DF. (2002). An Evidence-based Approach to Drainage of the Pleural Cavity: Evaluation of Best Practice. Journal of Evaluation in Clinical Practice. 8(3):333-340.


PROTOCOL FOR MANAGEMENT OF CHEST TUBES APPENDIX A: FLOWSHEET DOCUMENTATION

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