ATI Skills Module: Care of a Client with a Closed Chest Drainage System

Overview of Closed Chest Drainage Systems

  • Purpose and Function:

    • Providers insert chest tubes to restore a collapsed lung or to drain fluid from the pleural cavity.
    • Tubing is connected to a sealed drainage system or a one-way valve.
    • The system allows the removal of air and fluid from the chest cavity while preventing air from entering, which avoids the development of a tension pneumothorax.

  • System Configurations:

    • Single Chamber: Used for collecting smaller amounts of drainage while maintaining a water seal. Fluid in the chamber ascends during inhalation and descends during exhalation.
    • Two Chambers: Used for larger amounts of drainage or more accurate measurements. Fluid flows into a collection chamber while air flows into a separate water seal chamber.
    • Three Chambers: Essential when using a controlled suction source to draw air or fluid out of the pleural space.

Components of a Three-Chamber Closed Chest Drainage System

  • Collection Chamber:

    • The chest tube connects directly to this port.
    • All secretions flow into this chamber.
    • It is calibrated for accurate measurement and typically features a writing surface for documenting the date, time, and fluid amount.

  • Water Seal Chamber (Middle Chamber):

    • Function: Acts as a one-way valve, allowing air to exit the pleural space during exhalation while preventing it from entering during inspiration.
    • Setup: Follow manufacturer directions to fill with sterile water or recommended fluid, typically to the 2 cm2\,\text{cm} line.
    • Maintenance: The system must remain upright. The fluid must be maintained at the recommended level because of evaporation.
    • Tidaling: This refers to the water level rising with inhalation and returning to baseline with exhalation.
      • In positive pressure ventilation, the reverse occurs: the level falls with inhalation and rises with exhalation.
      • If tidaling/oscillation stops, it indicates a patent chest tube has potentially become obstructed, the lung has re-expanded, or a dependent loop exists.
    • Bubbling:
      • Occasional bubbling is normal during forceful expiration or coughing.
      • Continuous bubbling indicates an air leak.
    • Air Leak Meter: Newer designs include numbered columns; higher numbers with bubbling indicate a greater air leak.
    • Manometer: Measures negative pressure in the pleural cavity. The water level in the small arm rises as intrapleural pressure becomes more negative.
    • Pressure Release: Some systems have a button to release high negative pressure. This should only be used when necessary to avoid causing a pneumothorax.

  • Suction Control Chamber (Wet vs. Dry):

    • Wet Suction Control:
      • Regulates suction by the height of water in the chamber (usually located on the left).
      • Typically filled to the −20 cm-20\,\text{cm} mark for adults (standard suction pressure of −20 cm H2O-20\,\text{cm}\,H_2O).
      • Lower levels may be required for infants, children, or those with fragile lung tissue.
      • Requires connection to a suction source; the source is adjusted until gentle bubbling occurs.
      • The water level, not the wall suction setting, determines the suction transmitted to the pleural cavity.
    • Dry Suction Control:
      • Uses a self-compensating regulator rather than a water column.
      • Operates quietly due to the absence of continuous bubbling.
      • Can deliver higher suction pressures, with dial settings ranging from −10-10, −15-15, −20-20, −30-30, to −40 cm H2O-40\,\text{cm}\,H_2O.
      • Used for massive air leaks, empyema, viscous pleural effusion, or reduced pulmonary compliance.
      • Suction is adjusted until a float ball appears in the suction control indicator window.

Mobile and Specialized Drainage Devices

  • Autotransfusion Port: Used for clients with large hemothorax or major thoracic surgery to collect autologous blood for reinfusion.

  • Heimlich Valve:

    • A one-way flutter valve that allows air to escape but prevents its reentry.
    • Accommodates small or partial pneumothorax and does not collect fluid.
    • The arrow on the housing must always point away from the client.
    • Movement in the inner valve during exhalation indicates proper airflow.
    • The blue end connects to the chest tube; the transparent end may have a sterile dressing or attach to a vented collection bag.

  • Pneumostat Chest Drain:

    • A one-way valve that attaches directly to the chest tube to collect fluid (up to 30 mL30\,\text{mL}).
    • Includes an air leak well; bubbling after adding 1 mL1\,\text{mL} of water confirms an air leak.
    • To empty: attach a syringe to the needleless luer port and pull back on the plunger.

Physiology and Indications for Chest Drainage

  • The Pleural Space: A small cavity between the visceral and parietal pleura containing serous lubricating fluid.

  • Respiration Mechanics:

    • Inspiration: External intercostals and diaphragm contract, creating negative intrapleural pressure and lung expansion.
    • Expiration: Passive deflation occurs due to elastic recoil, diaphragm relaxation, and alveolar surface tension.

  • Fluid Accumulation (Counterpressure):

    • Hemothorax: Collection of blood due to trauma.
    • Chylothorax: Leakage of lymph fluid from the thoracic duct.
    • Pleural Effusion: Accumulation of transudates/exudates from heart failure, liver cirrhosis, or malignancy.
    • Empyema: High-protein exudative effusion from infection.

  • Pneumothorax: Loss of negative pressure due to air collection, leading to lung collapse.

  • Tension Pneumothorax (Medical Emergency):

    • Air enters the pleural space but cannot escape, making pressure positive relative to the atmosphere.
    • Symptoms: Lung collapse, mediastinal shift to the unaffected side, compressed opposite lung, compromised ventilation, impaired venous return.
    • Clinical Indicators: Hypotension, distended neck veins (JVD), and tracheal displacement toward the unaffected side.

  • Cardiac Applications:

    • Mediastinal Chest Tube: Inserted under the sternum after cardiac surgery to drain the pericardial sac.
    • Cardiac Tamponade Prevention: Prevents life-threatening compression of the heart. Indicators include dropping systolic pressure and JVD.

Nursing Management and Maintenance

  • Monitoring and Assessment:

    • Monitor vitals (including O2O_2 saturation), pain level, breath sounds, and respiratory effort.
    • Breath Sounds: Diminished or absent sounds suggest the lung has not re-expanded.
    • Crepitus: Palpate around the dressing for subcutaneous emphysema (air leaking into tissues).
    • Dressing: Change as necessary using surgical asepsis. Mark the dimensions of any current drainage stains to track increases.

  • Drainage Tracking:

    • Monitor character, consistency, and amount.
    • Intervals: Every hour for the first 24 hours24\,\text{hours}, then at least every 8 hours8\,\text{hours}.
    • Mark the outside of the chamber with the date and time.

  • System Safety:

    • Keep the drainage system upright and below the level of the insertion site.
    • Secure all tubing connections with tape or locking ties.
    • Avoid lifting the system above the chest (prevents backflow).
    • Avoid stripping or milking the tubing (prevents damaging high negative pressure).
    • Ensure the air vent is never blocked or wet.

  • Promoting Lung Expansion:

    • Position the client in Fowler’s or High Fowler's.
    • Encourage frequent coughing, deep breathing, and incentive spirometry.
    • Splint the insertion site during coughing to minimize pain.
    • Perform active or passive range of motion exercises for the arm on the affected side.

  • Transport and Ambulation:

    • Keep the device below the chest.
    • Disconnect from the suction source (verify if a prescription is needed).
    • Ensure the system remains vented to the atmosphere to prevent tension pneumothorax.

Managing Complications

  • Tubing Disconnection from Drainage Unit:

    • Instruct client to exhale and cough.
    • Submerge the end of the chest tube in 1 inch1\,\text{inch} of sterile water to create a temporary seal.
    • Cleanse tips and reconnect quickly.

  • System Damage or Full Chamber:

    • Replace the system immediately. Clamp the chest tube only for the brief duration required for the swap.

  • Complete Dislodgement from the Client:

    • Cover the site immediately with sterile gauze.
    • If air is heard leaking, the dressing must not be occlusive (to prevent tension pneumothorax).
    • Stay with the client and monitor vitals while another staff member notifies the provider.

  • Air Leak Troubleshooting:

    • If continuous bubbling occurs, use rubber-tipped or padded clamps briefly near the dressing.
    • If bubbling stops: Leak is at the insertion site or inside the chest.
    • If bubbling continues: Leak is between the clamp and the drainage system.

  • Pleurodesis:

    • Procedure where a chemical agent (e.g., talc) is instilled into the pleural space to create adhesions.
    • Tubes must remain clamped for a set period; monitor closely for tension pneumothorax.

Evidence-Based Practice

  • Dressing Comparison Study:

    • Evaluated gauze/tape (changed daily or every 3 days3\,\text{days}) vs. silicone foam (changed every 3 days3\,\text{days}).
    • Results: Foam/three-day dressings resulted in less pain, better skin integrity, and no increased complications.

  • Active Tube Clearance Study:

    • Compared standard care to active tube clearance catheters to prevent clogging from blood after cardiac surgery.
    • Results: Active clearance catheters reduced retained blood complications by 59%59\% and decreased dysrhythmias by 30%30\%.

General and Clinical Judgment Considerations

  • Tube Placement:

    • Air (Pneumothorax): Second or third intercostal space (anterior thorax) because air rises.
    • Fluid (Effusion/Hemothorax): Lower lateral chest wall, no higher than the fourth intercostal space.

  • Expected Drainage Volumes:

    • Pleural Insertion (Adult): 100−300 mL100-300\,\text{mL} in the first 3 hours3\,\text{hours}; 500−1,000 mL500-1,000\,\text{mL} in the first 24 hours24\,\text{hours}.
    • Mediastinal Tube: 50−200 mL50-200\,\text{mL} immediately post-op; 500 mL500\,\text{mL} in the first 24 hours24\,\text{hours}.
    • Alert Threshold: Report drainage exceeding 70 mL/hr70\,\text{mL/hr} after the initial few hours.

  • Daily Care:

    • Positioning: If side-lying, use rolled towels to prevent occluding the tube.
    • Ambulation: Every 15 minutes15\,\text{minutes}, lift the coiled tubing to promote flow into the chamber.

Documentation Requirements

  • At Insertion: Informed consent, date/time, device type, anatomical location, tube size, reason, vitals before/after, suction level, and dressing status.
  • Maintenance: Schedule of checks, insertion site/skin status, drainage characteristics/output, system functioning, strategies for oxygenation (incentive spirometry, etc.), and pain management interventions.
  • At Removal: Date/time, breath sounds, respiratory status, oxygen saturation before/after, total drainage, wound appearance, and dressing status.