Introduction

Chest drain can be used to drain abnormal collections of fluid or air from the pleural cavity. It is mostly used to treat pneumothorax and pleural effusions. Although chest drains have been used for over a century, there is surprisingly little research-based evidence. Most literature is largely anecdotal and often based on expert opinions or retrospective series. In the following discussion, a review of the current nursing care and management of chest drains would be made. Types of chest drainage system Several drainage systems are available and it is important that the nurse is aware of the function of each one. The most common employed one is the one-bottle system, but traditionally there are two- and three-bottle systems, which are now less commonly used. Instead some manufacturers have produced plastic multi-chamber units. Some knowledge on the design of such systems will enhance the understanding and management of such units. One-bottle system The simplest way to set up a single bottle with a tube submerged to a depth of 2cm under water which creates a water seal is illustrated in figure 1a. One tube leads out of the bottle through the plug at the top, allowing air to open

into the atmosphere. However, excessive accumulation of fluid inside the bottle might impose resistance and hence the optimal functioning of the unit. The system can also be connected directly to the low regulator suction if negative pressure is required to improve drainage afterwards. (Figure 1b)

Two-bottle system One form of this system involves separate drainage/collection and water seal units, with air from the pleural space conducted through the tubing that connects the two bottles and bubbles through the water seal bottle and exits to the atmosphere, as illustrated in figure 2a. By adding a bottle container before the water-seal bottle, rising resistance from excessive concomitant pleural fluid drainage can be avoided. Another form involves a water-seal bottle connected to a second suction-regulating bottle to gauze the pressure created via external suction (Figure 2b). However, the maximum negative pressure available is usually limited to 10-12 cm H2O due to the limited height of the water column in the commonly available bottles.

Three- bottle system A three bottle system contains a collection chamber, an under water seal & a suction regulating device to maintain constant negative pressure as illustrated in figure 3. The level of fluid in the suction control bottle determines the amount of suction provided to promote drainage from the pleural space. As illustrated, the three bottle system is bulky and therefore hence is seldomly used. The commercially available plastic multi-chamber systems incorporate the three bottle system into one unit with three chambers as illustrated in figure 4

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 re-entering 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. Conclusion Nursing management of chest drains is important. A comprehensive understanding of the operations of the chest drain systems and areas requiring special attention would be important to reduce the complications arising from chest tube drainage.

Suctioning The upper airway warms, cleans and moistens the air we breathe. The trach tube bypasses these mechanisms, so that the air moving through the tube is cooler, dryer and not as clean. In response to these changes, the body produces more mucus. Suctioning clears mucus from thetracheostomy tube and is essential for proper breathing. Also, secretions left in the tube could become contaminated and a chest infection could develop. Avoid suctioning too frequently as this could lead to more secretion buildup.

Removing mucus from trach tube without suctioning 1. Bend forward and cough. Catch the mucus from the tube, not from the nose and mouth. 2. Squirt sterile normal saline solutions (approximately 5cc) into the trach tube to help clear the mucus and cough again. 3. Remove the inner tube (cannula). 4. Suction. 5. Call 911 if breathing is still not normal after doing all of the above steps. 6. Remove the entire trach tube and try to place the spare tube. 7. Continue trying to cough, instill saline, and suction until breathing is normal or help arrives. When to suction Suctioning is important to prevent a mucus plug from blocking the tube and stopping the patient's breathing. Suctioning should be considered

Any time the patient feels or hears mucus rattling in the tube or airway In the morning when the patient first wakes up When there is an increased respiratory rate (working hard to breathe) Before meals Before going outdoors Before going to sleep

The secretions should be white or clear. If they start to change color, (e.g. yellow, brown or green) this may be a sign of infection. If the changed color persists for more than three days or if it is difficult to keep the tracheostomy tube intact, call your surgeon's office. If there is blood in the secretions (it may look more pink than red), you should initially increase humidity and

suction more gently. A Swedish or artificial nose (HME), which is a cap that can be attached to the tracheostomy tube, may help to maintain humidity. The cap contains a filter to prevent particles from entering the airway and maintains the patient's own humidity. Putting the patient in the bathroom with the door closed and shower on will increase the humidity immediately. If the patient coughs up or has bright red blood mucus suctioned, or if the patient develops a fever, call your surgeon's office immediately. How to suction Equipment Clean suction catheter (Make sure you have the correct size) Distilled or sterile water Normal saline Suction machine in working order Suction connection tubing Jar to soak inner cannula (if applicable) Tracheostomy brushes (to clean tracheostomy tube) Extra tracheostomy tube 1. Wash your hands. 2. Turn on the suction machine and connect the suction connection tubing to the machine. 3. Use a clean suction catheter when suctioning the patient. Whenever the suction catheter is to be reused, place the catheter in a container of distilled/sterile water and apply suction for approximately 30 seconds to clear secretions from the inside. Next, rinse the catheter with running water for a few minutes then soak in a solution of one part vinegar and one part distilled/sterile water for 15 minutes. Stir the solution frequently. Rinse the catheters in cool water and air-dry. Allow the catheters to dry in a clear container. Do not reuse catheters if they become stiff or cracked. 4. Connect the catheter to the suction connection tubing. 5. Lay the patient flat on his/her back with a small towel/blanket rolled under the shoulders. Some patients may prefer a sitting position which can also be tried. 6. Wet the catheter with sterile/distilled water for lubrication and to test the suction machine and circuit. 7. Remove the inner cannula from the tracheostomy tube (if applicable). The patient may not have an inner cannula. If that is the case, skip this step and go to number 8. a. There are different types of inner cannulas, so caregivers will need to learn the specific manner to remove their patient's. Usually rotating

the inner cannula in a specific direction will remove it. b. Be careful not to accidentally remove the entire tracheostomy tube while removing the inner cannula. Often by securing one hand on the tracheostomy tube?s flange (neck plate) one can/ will prevent?accidental removal. c. Place the inner cannula in a jar for soaking (if it is disposable, then throw it out). 8. Carefully insert the catheter into the tracheostomy tube. Allow the catheter to follow the natural curvature of the tracheostomy tube. The distance to the location of catheter becomes easier to determine with experience. The least traumatic technique is to pre-measure the length of the tracheostomy tube then introduce the catheter only to that length. For example if the patient?s tracheostomy tube is 4 cm long, place the catheter 4 cm into the tracheostomy tube. Often, there will be instances when this technique of suctioning (called tip suctioning) will not clear the patient?s secretions. For those situations, the catheter may need to be inserted several mm beyond the end of the tracheostomy tube (called deep suctioning). With experience, caregivers will be able to judge the distance to insert the tracheostomy tube without measuring. 9. Place your thumb over the suction vent (side of the catheter) intermittently while you remove the catheter. Do not leave the catheter in the tracheostomy tube for more than 5-10 seconds since the patient will not be able to breathe well with the catheter in place. 10. Allow the patient to recover from the suctioning and to catch his/her breath. Wait for at least 10 seconds. 11. Suction a small amount of distilled/sterile water with the suction catheter to clear any residual debris/secretions. 12. Insert the inner cannula from extra tracheostomy tube (if applicable). 13. Turn off suction machine and discard catheter (clean according to step 3 if to be reused). 14. Clean inner cannula (if applicable).