Chest Drainage Medical Management Preoperative: Examination of the patient from the patient to the drainage bottle should

take place regularly to inspect all aspects of the patient and the drainage system. A chest x ray is usually done before the chest drainage tube is inserted. Sometimes fluid becomes trapped in isolated spaces in the lung, and it is necessary to do an ultrasound to determine where to locate the drainage tube. Computed tomography scans (CT) are useful in locating small pockets of fluids caused by cancer or tuberculosis. Nursing management Once a chest drain is inserted, it is important for the nursing staff to ensure that the patient and the drain are closely monitored. However, wide variations of practice have been observed, which are based on local policies and individual preferences rather than evidence-based protocols (Avery 2000, Charnock and Evans 2001). The suggestions below have been compiled and highlighted from the literature. 1. Positioning The patient should be placed in a semi-recumbent position with regular position changes in order to encourage drainage and prevent stiffening of the shoulder joints. These might enhance breathing and expectoration, as well as allowing full lung expansion and possibly preventing complications of prolonged immobilization. 2. Drain patency Drainage can be impeded by excessive coiling, dependent loops, kinked or blocked tubes, and which potentially might lead to tension pneumothorax or surgical emphysema. The tubing should be lifted regularly to drain the fluid into the collection bottle if the coilings cannot be avoided. The effects of clamping, milking and striping of chest tubes are controversial and are usually not advised. Replacement of tubing is usually advised if blockage is detected. Lung damage from the sharp pressure changes generated during stripping of tubing might be resulted. Although clamping of drains are still observed and practiced in cases where there are no longer any air leakage and when replacement of tubing or bottle is necessary, this is not recommended in the major international guidelines.

3. Observation Patients vital signs, respiratory rate, oxygen saturation as well as the presence of tidaling and bubbling in chest drainage system should be closely monitored. Any deterioration or distress of the patient should be reported to the doctors immediately. 4. Pain management There are currently no definite guidelines on pain assessment and pain control with regard to chest drainage. The pain could be substantial and might affect coughing, ventilation, sleep as well as re-expansion of the lung. Nurses should be aware of the potential need for prescribed on-demand pain killers or inform clinicians about the possible requirements. 5. Recording and observing drainage The drainage system should be kept below the patients chest level to prevent fluid reentering the pleural space. Volume, color, tidaling, bubbling of drainage fluid and level of suction pressure should be regularly evaluated and recorded on patients chest drain chart. The frequency of recording will vary depending on the condition of the patients and their underlying disease(s). 6. Drain security and wound management Using of tape to secure connections has been controversial with no apparent clear recommandation. Some researchers advocated that taping the connections can avoid potential disconnection but others argued that taped tube may mask disconnections. The use of transparent, water-proof and secure tapings might be necessary in a busy and congested ward environment. The insertion site should be checked everyday to ensure that the wound is dry and clean, with no loosen sutures or visible side hole(s) of chest tube (i.e. slipping out). Presence of or increasing surgical emphysema, pus, or excessive bleeding around insertion sites should also be noted. 7. Potentially dangerous conditions that require urgent attention Large amount of bubbling in the water seal chamber, which might signify a large patient air leak or a leak in a system Sudden or unexpected cessation of bubbling, which may indicate a blockage in the tubing. Large amount of bloody discharge might indicate haemothorax or trauma to underlying organ(s) Increasing dyspnoea, increased heart rate, lowered blood pressure & low oxygen saturation: may signify recurrent pneumothorax (after drain removal) or insufficient

drainage or tube blockage Absence of gentle bubbling in suction control bottle/ chamber may indicate disconnection of the suction pressure or inadequate suction force to counteract the large air leakage.

Postoperative: Normally after the material has been removed from the chest cavity and the situation is resolved, the chest drainage tube is removed. In cases where the reason for the tube was air in the pleural cavity, the tube is clamped and left in place several hours before it is removed to make sure no more air is leaking into the space. If the patient is on mechanical ventilation, the tube is often left in place until a respirator is no longer necessary. Chest drainage therapy is usually done in conjunction with treating the underlying cause of the fluid build-up. The fluid that has been drained is examined for bacterial growth, cancer cells, pus, and bloodto determine the underlying cause of the condition and appropriate treatment.

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