Chest Drains: Difference between revisions
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== ”’Basics of Breathing”’ ==
* Breathing is stimulated by the build up of CO2 levels in the bloodstream.
== Description ==
* When the diaphragmdescends there is an increase in intrathoracic space and a decrease in intrathoracic pressure. Intrapulmonary pressure also decreases which draws air into the lungsas the pressure outside of the lungs is greater than the pressure inside. The lungs are elastic and want to recoil with the pleura, this elasticity creates the negative pressure which causes the lungs to inflate.
[[File:Chestdrain.png|thumb|202x202px]]
* Lungs are surrounded by pleura which have a layer of fluid between them. The visceral pleura is attached to the lungs while the parietal pleura is attached to the ribs. Intrapleural pressure is always negative however during inspiration it is more negative (-8cm H2O) whilst during expiration when the diaphragm relaxes it’s less negative (-4cm H2O).
=== ”’What is a Chest Drain?”’ ===
Chest drains, also referred to as chest tubes, under water sealed drainage (UWSD), thoracic catheter, tube thoracostomy, or intercostal drain. They provide a method of removing air & fluid substances from the pleural space. The idea is to create a one-way mechanism that will let air/fluid out of the pleural space and prevent outside air/fluid from entering into the pleural space. This is accomplished by the use of an underwater seal.
[[File:Breathing.jpg|thumb|Mechanism of action for inhalation and exhalation]]
==== ”’Basics of Breathing”’ ====
* Breathing is stimulated by the build up of CO2 levels in the bloodstream.
* When the diaphragm descends there is an increase in intrathoracic space and a decrease in intrathoracic pressure. Intrapulmonary pressure also decreases which draws air into the lungs as the pressure outside of the lungs is greater than the pressure inside. The lungs are elastic and want to recoil with the pleura, this elasticity creates the negative pressure which causes the lungs to inflate.
* Lungs are surrounded by pleura which have a layer of fluid between them. The visceral pleura is attached to the lungs while the parietal pleura is attached to the ribs. Intrapleural pressure is always negative however during inspiration it is more negative (-8cm H2O) whilst during expiration when the diaphragm relaxes it’s less negative (-4cm H2O).
* If this intrapleural pressure is lost e.g. during a stabbing, the loss of negative pressure will cause the lung to collapse and a chest drain will be needed to restore the correct pressures.
* If this intrapleural pressure is lost e.g. during a stabbing, the loss of negative pressure will cause the lung to collapse and a chest drain will be needed to restore the correct pressures.
* A weak diaphragm decreases the available volume making it harder to draw air in and also increases the risk of developing [[pneumonia]]. <ref name=”:2″>Pryor JA, Prasad AS. Physiotherapy for respiratory and cardiac problems: adults and paediatrics. Elsevier Health Sciences; 2008 Mar 6.</ref>
* A weak diaphragm decreases the available volume making it harder to draw air in and also increases the risk of developing [[pneumonia]]. <ref name=”:2″>Pryor JA, Prasad AS. Physiotherapy for respiratory and cardiac problems: adults and paediatrics. Elsevier Health Sciences; 2008 Mar 6.</ref>
==== ”’Principles of underwater seal drainage”’ ====
== ”’Principles of underwater seal drainage”’ ==
* The main aim of the drainage system is to remove fluid/air from pleura & preventing its re-entry into the pleural space.
* The main aim of the drainage system is to remove fluid/air from pleura & preventing its re-entry into the pleural space.
* This is achieved when distal end of the drain tube is submerged 2cm under the surface level of the water in the drainage (or collection) chamber. It in turn creates a hydrostatic resistance of +2cmH20 in the drainage chamber.
* This is achieved when distal end of the drain tube is submerged 2cm under the surface level of the water in the drainage (or collection) chamber. It in turn creates a hydrostatic resistance of +2cmH20 in the drainage chamber.
** Positive pressure during expiration pushes air and fluid out of the pleural space and into the tube and collection bottle.
** Positive pressure during expiration pushes air and fluid out of the pleural space and into the tube and collection bottle.
** Air bubbles out of tube into the underwater seal.
** Air bubbles out of tube into the underwater seal.
** Fluid drains by gravity, mixing with water and raising the fluid level.[[File:Screen Shot 2017-08-08 at 16.57.55.png|thumb|267x267px|Mechanism of action of chest drain]]
** Fluid drains by gravity, mixing with water and raising the fluid level.[[File:Screen Shot 2017-08-08 at 16.57.55.png|thumb|267x267px|Mechanism of action of chest drain]]
[[File:Draining.png|thumb|Underwater seal chest drainage. A- Single-bottle system. B- Two bottle system. C- three bottle system]]
[[File:Draining.png|thumb|Underwater seal chest drainage. A- Single-bottle system. B- Two bottle system. C- three bottle system]]
=== UWDS Systems ===
== UWDS Systems ==
==== Glass Bottle System: ====
=== Glass Bottle System: ===
===== 1 bottle =====
==== 1 bottle ====
* The simplest form of underwater seal drainage systems. This system can drain both fluid and air. The distal end of the drainage tube must remain under the water surface level. There is always an outlet to the atmosphere to allow air to escape. It is suitable for use with a simple pneumothorax, when the vent is left open to the atmosphere, or following a pneumonectomy when the tubing is clamped and released hourly
* The simplest form of underwater seal drainage systems. This system can drain both fluid and air. The distal end of the drainage tube must remain under the water surface level. There is always an outlet to the atmosphere to allow air to escape. It is suitable for use with a simple pneumothorax, when the vent is left open to the atmosphere, or following a pneumonectomy when the tubing is clamped and released hourly
===== 2 bottle =====
* This system is suitable for the drainage of air and fluid. The first chamber is for collection of fluid and the second is for the collection of air. As the two are separate, fluid drainage does not adversely affect the pressure gradient for evacuation of air from the pleural space. A separate chamber for fluid collection enables monitoring of volume and expelled matter.
* This system is suitable for the drainage of air and fluid. The first chamber is for collection of fluid and the second is for the collection of air. As the two are separate, fluid drainage does not adversely affect the pressure gradient for evacuation of air from the pleural space. A separate chamber for fluid collection enables monitoring of volume and expelled matter.
===== 3 bottle =====
==== 3 bottle ====
* Suction is required when air or fluid needs a greater pressure gradient to move from the pleural space to the collection system. Suction may be applied via a third bottle or a suction chamber.<ref name=”:2″ /><ref>Sugarbaker D, Bueno R, Colson Y, Jaklitsch M, Krasna M, Mentzer S. Adult chest surgery. McGraw Hill Professional; 2014 Jul 22.</ref> <br />
* Suction is required when air or fluid needs a greater pressure gradient to move from the pleural space to the collection system. Suction may be applied via a third bottle or a suction chamber.<ref name=”:2″ /><ref>Sugarbaker D, Bueno R, Colson Y, Jaklitsch M, Krasna M, Mentzer S. Adult chest surgery. McGraw Hill Professional; 2014 Jul 22.</ref> <br />
==== Plastic Bottle System: ====
=== Plastic Bottle System: ===
* Pleur-evac Chest Drainage System
* Pleur-evac Chest Drainage System
* Thora-Seal Chest Drainage Unit
* Thora-Seal Chest Drainage Unit
== Indications for Chest Drain insertion ==
== Indications for Chest Drain insertion ==
Chest drains are inserted as an invasive procedure to; Remove fluid/air from the pleural space/mediastinum, and/or Re-expand the lungs and restore negative intrapleural pressure and respiratory function.<ref name=”:0″>Charnock Y, Evans D. Nursing management of chest drains: a systematic review. Australian Critical Care. 2001 Nov 1;14(4):156-60.</ref>
Chest drains are inserted as an invasive procedure to; Remove fluid/air from the pleural space/mediastinum, and/or Re-expand the lungs and restore negative intrapleural pressure and respiratory function.<ref name=”:0″>Charnock Y, Evans D. Nursing management of chest drains: a systematic review. Australian Critical Care. 2001 Nov 1;14(4):156-60.</ref>
* Pneumothorax
* Pneumothorax
** “Air in the pleural cavity”. This occurs when there is a breach of the lung surface or chest wall which allows air to enter the pleural cavity and consequently cause the lung to collapse.
** “Air in the pleural cavity”. This occurs when there is a breach of the lung surface or chest wall which allows air to enter the pleural cavity and consequently cause the lung to collapse.
* Pleural Effusion
* Pleural Effusion
** a collection of fluid abnormally present in the pleural space, usually resulting from excess fluid production and/or decreased lymphatic absorption.
** a collection of fluid abnormally present in the pleural space, usually resulting from excess fluid production and/or decreased lymphatic absorption.
* Haemothorax
* Haemothorax
* Empyema
* Empyema
** is a collection or gathering of pus within a naturally existing anatomical cavity. For example, pleural empyema is empyema of the pleural cavity. It must be differentiated from an abscess, which is a collection of pus in a newly formed cavity.
** is a collection or gathering of pus within a naturally existing anatomical cavity. For example, pleural empyema is empyema of the pleural cavity. It must be differentiated from an abscess, which is a collection of pus in a newly formed cavity.
* Post Cardiac or thoracic surgery <ref>Symbas PN. Chest drainage tubes. Surgical Clinics of North America. 1989 Feb 28;69(1):41-6.</ref>
* Post Cardiac or thoracic surgery
{{#ev:youtube|f6bngHjMLA0|400}}<ref>Pleural Effusion</ref>
{{#ev:youtube|f6bngHjMLA0|400}}<ref>Pleural Effusion</ref>
== Complications of Chest Drains ==
== Complications of Chest Drains ==
* Pain – chest wall/ neck / shoulder
* Pain – chest wall/ neck / shoulder
* Blocked drains
* Blocked drains
* Pleural sepsis
* Pleural sepsis
* Subcutaneous emphysema<ref name=”:1″>Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax. 2003 May;58(Suppl 2):ii53.</ref>
* Subcutaneous emphysema<ref name=”:1″>Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax. 2003 May;58(Suppl 2):ii53.</ref>
== Insertion of a Chest Drain ==
== Insertion of a Chest Drain ==
Local anesthetic and intravenous analgesia are mandatory, as the placement is a painful procedure. The use of sedation should always be discussed with a senior emergency doctor, as it can potentially worsen the patient’s clinical condition.<ref name=”:1″ />Establish patient on continuous cardiac monitoring and pulse oximetry.
Local anesthetic and intravenous analgesia are mandatory, as the placement is a painful procedure. The use of sedation should always be discussed with a senior emergency doctor, as it can potentially worsen the patient’s clinical condition.<ref name=”:1″ />Establish patient on continuous cardiac monitoring and pulse oximetry.
Procedure as per ‘The BTS Guidelines for the insertion of a chest drain, 2003′<ref name=”:1″ />
Procedure as per ‘The BTS Guidelines for the insertion of a chest drain, 2003′<ref name=”:1″ />
* Anchor the drain and suture the wound. Tape in place with tegaderm sandwich and anchor the tube to the patient’s side. – Connect to the UWSD.
* Anchor the drain and suture the wound. Tape in place with tegaderm sandwich and anchor the tube to the patient’s side. – Connect to the UWSD.
* Watch for “swinging” of water in tube connection.<ref name=”:1″ /><br>
* Watch for “swinging” of water in tube connection.<ref name=”:1″ /><br>
{{#ev:youtube|qR3VcueqBgc}}<ref>Sparky Sparcy. Chest Tube ATLS. Available from: https://www.youtube.com/watch?v=qR3VcueqBgc [last accessed 09/08/17]</ref>
{{#ev:youtube|qR3VcueqBgc}}<ref>Sparky Sparcy. Chest Tube ATLS. Available from: https://www.youtube.com/watch?v=qR3VcueqBgc last accessed //</ref>
== Assessment of a Chest Drain ==
== Assessment of a Chest Drain ==
** Anterior
** Anterior
** Basal
** Basal
** Right or Left side etc
** Right or Left side etc
* Pain
* Pain
* Swing/Oscillation –
* Swing/Oscillation –
* If you knock over the chest drain: put it back upright, check the levels and inform the nurse on duty so she can perform the necessary tests to make sure it’s still working properly.
* If you knock over the chest drain: put it back upright, check the levels and inform the nurse on duty so she can perform the necessary tests to make sure it’s still working properly.
* Need to carefully plan any movements to avoid disconnection from the drain during activity
* Need to carefully plan any movements to avoid disconnection from the drain during activity
* If there is a suction port attached to the chest drain and you need to mobilise the patient you have to get surgical permission to temporarily disconnect the suction
* If there is a suction port attached to the chest drain and you need to the patient you have to get surgical permission to temporarily disconnect the suction
* Clamping
* Clamping
** It is never appropriate to clamp chest drains for mobilisation / transport of patients.
** It is never appropriate to clamp chest drains for / transport of patients.
** NEVER clamp in tension pneumothorax or if still bubbling.
** NEVER clamp in tension pneumothorax or if still bubbling.
** When would you clamp a drain?
** When would you clamp a drain?
* Main goal is
* Main goal is
** to assist in removal of fluid/air from pleural space
** to assist in removal of fluid/air from pleural space
** promote re-expansion of the underlying lung tissue
** promote re-expansion of the underlying lung tissue
** prevent accumulation of secretions & secondary atelectasis
**
of
* Techniques:
* Techniques:
# Early bedside Mobilization
# Early bedside Mobilization
# [https://www.physio-pedia.com/Breathing_Exercises?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Breathing exercises]: Deep breathing exercises, Segmental breathing Exercises and Forced Expiratory Technique
# [https://www.physio-pedia.com/Breathing_Exercises?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Breathing exercises]: Deep breathing exercises, Segmental breathing Exercises and Forced Expiratory Technique
*Positive pressure NIV techniques are CONTRAINDICATED!
*Positive pressure NIV techniques are CONTRAINDICATED!
=== 1. Early Bedside Mobilization ===
=== 1. Early Bedside Mobilization ===
* Patients can be mobilized with a chest drain.
* Patients can be mobilized with a chest drain.
* If they are on suction, check if it is a portable suction machine, if so, you will require a trolley to mobilize patient safely.
* If they are on suction, check if it is a portable suction machine, if so, you will require a trolley to mobilize patient safely.
* If suction is attached to the wall & cannot be disconnected//consider bedside exercises.
* If suction is attached to the wall & cannot be disconnected//consider bedside exercises.
== Technological Advances in Chest drains ==
== Technological Advances in Chest drains ==
Use of digital thoracic drainage is the latest in chest drains. Technology is being used to measure size of an air leak in a chest tube. It has an advantage of early mobilization in patients with suction along with underwater seal drainage. These devices also provide more accurate charting of air leak & digital flow recording with in built alarm system. Studies have found them to reduced hospital stay & being more cost-efficient for patients. Thus the future holds scope for more clinically efficient & patient friendly UWSD systems.<ref>Zisis C, Tsirgogianni K, Lazaridis G, Lampaki S, Baka S, Mpoukovinas I, Karavasilis V, Kioumis I, Pitsiou G, Katsikogiannis N, Tsakiridis K. Chest drainage systems in use. Annals of Translational Medicine. 2015 Mar;3(3).</ref>
Use of digital thoracic drainage is the latest in chest drains. Technology is being used to measure size of an air leak in a chest tube. It has an advantage of early mobilization in patients with suction along with underwater seal drainage. These devices also provide more accurate charting of air leak & digital flow recording with in built alarm system. Studies have found them to reduced hospital stay & being more cost-efficient for patients. Thus the future holds scope for more clinically efficient & patient friendly UWSD systems.<ref>Zisis C, Tsirgogianni K, Lazaridis G, Lampaki S, Baka S, Mpoukovinas I, Karavasilis V, Kioumis I, Pitsiou G, Katsikogiannis N, Tsakiridis K. Chest drainage systems in use. Annals of Translational Medicine. 2015 Mar;3(3).</ref>
== References ==
== References ==