Breathe easy: how to care for patients with chest drains
How do you feel when you have a chest drain patient to care for?
In many cases, we don’t do these often. I remember being so worried about nursing these patients as a student nurse. I worked at a small branch of a 6-practice group, and we very rarely placed these - they were mostly placed and cared for at our main hospital.
I would pop over there on student rotation weeks, or work there at nights and weekends - and then all of a sudden, boom! I had a chest drain patient to care for, but wasn’t so familiar with these devices. It always made for a more stressful shift.
(I’ll also give you an insight into how old I feel right now… we had re-usable, autoclavable metal gate clamps that were placed on our drains! No lovely fancy single-use kit like we have now. Oh how times have changed…)
So, if chest drains aren’t something you do super often, or if you want a refresher on how these are placed and maintained, and how we nurse these patients, that’s what I’m sharing with you in this post.
By the end of it you’ll know how these are placed, why they’re used, how to drain them, and how to nurse patients with indwelling drains.
I’ve also got a free chest drain recording form for you to download and use in your practice - to help you with caring for these patients! Download it below.
What are chest drains?
Chest drains, aka chest tubes, thoracic drains or thoracostomy tubes, are indwelling catheters placed into the pleural space to drain air or fluid.
Pleural space disease
Let’s look at a little anatomy (just for a minute!). Our thoracic cavity contains the intrathoracic trachea and our lungs, as well as our mediastinum (the organs and structures between the lungs, including the oesophagus, heart, aorta and vena cava). The cavity is lined by membranes known as the pleura, as are the outside of the lungs.
There is a small space between these membranes, containing a small amount of fluid. This allows the lungs to move against the thoracic wall without friction during breathing.
Pleural space disease occurs when air, fluid or tissue accumulates within this space. When this occurs, the lungs are not able to expand fully, resulting in hypoventilation and dyspnoea. There are a variety of pleural space diseases we see, including:
Pneumothorax: air in the thoracic cavity
Pyothorax: purulent fluid/exudate in the thoracic cavity
Haemothorax: blood in the thoracic cavity
Chylothorax: chyle in the thoracic cavity
Pleural effusion: a non-specific term for fluid within the thoracic cavity.
When this occurs, the fluid or air needs to be drained in order to allow the lungs to expand and ventilation to return to normal. This may be performed via thoracocentesis, but when this air or fluid continues to accumulate, chest drains are placed to allow repeated drainage.
Note: There is an exception to this - patients with haemothorax often only have enough blood removed from the chest to ease ventilation, rather than remove all of the fluid. The reason for this is because the body will often reabsorb this, and removing it can cause significant anaemia.
So, we place these drains to remove the fluid or air that accumulates too quickly to manage our patients with intermittent thoracocentesis alone. We can also use chest drains to administer medications. Examples of this include local anaesthetic agents to provide analgesia, and chemotherapy agents.
We can also administer blood via a chest drain in a procedure known as pleurodesis. An autologous blood patch pleurodesis may be used in pneumothorax patients to seal the air leak. It is hypothesised that the administration of the patient’s own blood into their chest drain can induce irritation and inflammation of the pleura, causing a clot to form and seal the leak!
How are chest drains placed?
There are two main methods of placing chest drains: the trochar method and the Seldinger or wire-guided method. Trochar drains are wide-bore, stiff catheters introduced via a sharp trochar or stylet. They are quick and easy to place, but can be less comfortable for our patients. For that reason, we generally use the Seldinger method.
Seldinger chest drains are narrow bore (usually 12-16F), fenestrated chest drains. The fenestrations are usually up to wither 4-8” in length, depending on the patient and the type of content being drained. To place them, you will need:
A chest drain kit containing an introducer catheter, guidewire, needle-free port and chest drain catheter with attached gate clamps
A minor kit including forceps, needle-holders and a scalpel handle
A blade
A fenestrated drape
Sterile swabs
A 3-way tap
Syringes of appropriate size depending on the volume to be drained
Plain and EDTA tubes to submit fluid samples
A bowl to collect excess fluid
Alcohol disinfecting caps for the chest drain needle-free port(s)
Bandage material (I like to use a primapore, then wrap the tube in swabs, and secure against the body using a stockinette or surgifix dressing)
Clippers and surgical scrub
Sterile isopropyl alcohol and chlorhexidine applicator/spray
Anaesthesia monitoring equipment and consumables
Placement technique
After the skin is prepared and the site draped, a small stab incision is made between the 7-9th intercostal spaces
An over-the-needle introducer catheter is introduced through the incision and into the pleural space
The stylet is removed and the guidewire advanced through the catheter, into the pleural space
The catheter is removed, leaving the guidewire in place
The chest drain is advanced over the guidewire and into the pleural space
The guidewire is removed and the catheter sutured in place, ensuring gate clamps are closed and a needle-free port is attached
A radiograph is taken to confirm correct placement
Air or fluid is removed from the drain, keeping fluid samples back for cytology and culture as required.
How do we drain them?
The exact frequency of drainage depends on the individual patient, and the rate that their air or fluid is accumulating. It can range from every 6-8 hours, to continually via a specialised drainage device known as a Thoraseal/Pleuravac (which I’m chatting more about in this week’s newsletter, so make sure you’re signed up for that to learn more!)
When removing air or fluid via a chest drain, there are a few key things we need to think about. These include:
Aseptic technique
Gloves should be worn whenever the drain is handled or when fluid is evacuated
Minimising negative pressure
Excessive volumes of negative pressure can cause trauma to the pleural membranes. We therefore need to make sure we don’t put more than 2-3ml of negative pressure on our syringes when draining the chest. Drain slowly and gradually and monitor your patient throughout.
Careful use of gate clamps
Particular attention should be paid to the gate clamps on the drains. These must be kept closed any time that the drain is not being aspirated, especially when changing syringes or disconnecting/reconnecting 3-way-taps or needle-free ports.
If a gate clamp is inadvertently left open, iatrogenic pneumothorax can result - so double-check these are always closed when anything is attached or disconnected from the drain.
Recording volumes of fluid and air obtained
Keep count of the volume of fluid, and the volume of air, removed from each drain and record this on your patient’s hospital record. Note the appearance of the fluid, too - I also quite like keeping a small sample from my pyothorax patients at each drainage, labelled with the date/time, so we can compare improvement in the fluid consistency/cellularity etc as the patient’s treatment progresses.
There are also a few other things we can measure on the fluid obtained, including total protein level, cellularity and triglyceride levels.
I’ve also created a recording form for you to use when managing your chest drains - this allows you to record the volumes of fluid and air removed from each side, as well as the character of the fluid! Download your copy below!
How do we nurse these patients?
In addition to general nursing care, there is a lot to think about when nursing chest drain patients! Be sure to add the following considerations to your nursing plans for these patients:
Aseptic technique
Aseptic technique is vital. We need to avoid introducing contamination into the pleural space. So gloves should be worn when the drain is emptied or handled, and sterile gloves should be worn when the insertion site is directly handled, cleaned, bandaged, or if you are instilling fluid or medication into the drain.
Top tip: As an extra protector against contamination, I often place two needle-free ports on the end of my chest drains. The one directly in contact with the drain does not get changed, but the one connected to it I change at each drainage. This helps to minimise the introduction of contamination when connecting syringes to the system. I also cover these ports with alcohol disinfecting caps as an extra layer of protection!
Drain care
In addition to draining the drain and maintaining aseptic technique, the catheter site should be inspected for kinking, inflammation or discharge, cleaned, and redressed at least once every 12 hours.
I like to cover the insertion site with a sterile adhesive dressing, then wrap the tube itself in laparotomy swabs. The swabs act as padding, minimising the discomfort associated with the tube pushing against the chest wall. I then secure the tubes to the side of the patient underneath a surgifix vest.
Comfort
Chest drains can be uncomfortable for our patients. This means that keeping a close eye on their pain level is an important nursing consideration. Pain score your chest drain patients regularly, and administer analgesia at appropriate intervals. You can also use local anaesthetic agents to provide additional analgesia, in addition to systemic opioids.
Note: Local blocks can also be used prior to placement as some additional analgesia!
Administering medications or fluid
Unless there is a contraindication to, I like to administer local anaesthetic agents via the drain to provide additional analgesia. This is usually achieved with bupivacaine (marcain) solution, diluted in sterile water, administered every 6 hours. Bupivacaine can sting as it has a low pH, so we often add bicarbonate to the solution, to increase the pH and neutralise the solution (bear in mind, though, that doing this reduces its duration of action!)
When administering medications via the drain, we do this through a filter. I quite like making a sterile one-way system, so medications go in through one port, and fluid/air is drained through another, as you can see below.
When the local anaesthetic agent is introduced, ideally the patient should lie on the side of administration for a period (if it is safe to do so). If you’re draining the patient, you should drain them first, then instil the local anaesthetic - to ensure it remains in the chest and working until the next drainage time.
We can also instil fluid via the chest drain in patients with pyothorax, in a procedure known as pleural lavage. This is performed to loosen the debris and solid pus in the thoracic cavity, allowing them to be removed more easily. To do this:
10ml/kg of sterile warmed saline or hartmanns is administered via the drain
The patient is monitored carefully for 15-20 minutes, encouraging them to move around if able to do so
The fluid is then removed, noting the volumes administered and retrieved
Ideally, more fluid should be removed than was administered, and the fluid should appear cloudier and more cellular than when it was administered.
Respiratory monitoring
All of our chest drain patients have had these devices placed because they have respiratory compromise. This means that careful respiratory monitoring is vital in our nursing plans for these patients. The respiratory rate, pattern and effort should be assessed at a frequency tailored to the individual patient, alongside SPO2 monitoring if able.
If our patients are receiving oxygen therapy, we should also be recording the level of oxygen administered, and regularly doing things like checking the patient’s temperature (if they’re in an oxygen kennel) and lubricating the eyes regularly.
Preventing interference
Preventing self-trauma or removal of the chest drain(s) is absolutely key in our patients. If the drain becomes damaged or removed, it will result in a continuous pneumothorax. Where large volumes of air will enter the thoracic cavity through the hole in the drain. So any patient with the potential to self-traumatise their drain should have an Elizabethan collar placed, and the drain checked regularly for any signs of interference.
So my top takeaways for chest drain use and care are: aseptic technique, preventing iatrogenic pneumothorax, careful drainage, respiratory monitoring and managing pain! Make sure these are on your nursing plans for these patients and you’ve got it sorted. I hope that this helps you nurse these patients and you don’t have the same worries I did as a student!
Don’t forget to download the recording form through the link above, and drop me a DM on instagram when you’ve got your copy!
References and Further Reading
Abreu, T. 2019. How to place and maintain chest drains. [Online]. VIN. Available from: https://www.vin.com/apputil/content/defaultadv1.aspx?pId=23848&catId=135015&id=9257799&ind=51&objTypeID=17
Davis, H. 2020. Nursing a patient with a traumatic pneumothorax. [Online]. Today’s Veterinary Nurse. Available from: https://todaysveterinarynurse.com/emergency-medicine-critical-care/nursing-a-patient-with-a-traumatic-pneumothorax/
Day, SL. 2014. Thoracostomy tube placement, drainage and management in dogs and cats. Veterinary Nursing Journal, 29(2), pp. 42-46.
Lee, J. 2017. How to perform an autologous blood patch pleurodesis in a dog. [Online]. VETgirl Veterinary CE Blog. Available from: https://vetgirlontherun.com/how-to-perform-an-autologous-blood-patch-pleurodesis-in-a-dog-vetgirl-veterinary-continuing-education-blog/
Powell, L. 2013. Chest tube placement. [Online]. Clinician’s Brief. Available from: https://www.cliniciansbrief.com/article/chest-tube-placement
