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Welcome to Atrium University.
This site, funded by an educational grant from Atrium Medical Corporation, provides professional continuing education for credit in addition to a variety of tools for professional education.

Follow the tabs above to explore our offerings.

 

Professional Continuing Education For Nursing CE Credits
 

Managing Chest Drainage

This continuing education activity is designed to provide registered nurses with information about caring for patients with chest drainage. Our goal is for nurses to better understand the physiology and pathophysiology relating to conditions requiring chest drainage. Learning about the safe and effective use of chest drainage systems will allow registered nurses to provide high quality care for their patients to achieve optimal care outcomes.

 

We invite you to visit the new Nurse's Notebook site to complete this continuing education program.

Click Here to Visit Nurse's Notebook

 

   

 

 Competency Manual




 

Chest Drainage Competency Manual
This manual is designed to assist you as you plan your competency assessment
program for nurses caring for patients requiring chest drainage.

The competency manual is currently undergoing revision to provide the most up-to-date quality information, and will be available for download soon.

 

 Additional Drain Readings


If you'd like to learn more about mobile drainage, chest drain usage and pleural drainage in general, the following references are provided by Atrium University for your convenience. Where content is available on the web, links are indicated.

Adrales G, Huynh T, Broering B, et al.: A thoracostomy tube guideline improves management efficiency in trauma patients. Journal of Trauma, Injury, Infection & Critical Care 2002;52:210-216.

Ahrens T, Coleman RH: Ask the Experts: lung volume reduction surgery. Critical Care Nurse 1997;17(1):88-89.

Anderson B, Higgins L, Rozmus C: Critical pathways: application to selected patient outcomes following coronary artery bypass graft. Applied Nursing Research 1999;12(4):168-174.

Antunes G, Neville E, Duffy J, Ali N: BTS guidelines for the management of malignant pleural effusions. Thorax 2003;58(Suppl II):ii29-ii38.

Ayed AK: Suction versus water seal after thoracoscopy for primary spontaneous pneumothorax: prospective randomized study. Annals of Thoracic Surgery 2003;75:1593-1596.

Baumann MH: Less is more? Chest 2001;120(1):1-3.

Baumann MH: What size chest tube? What drainage system is ideal? And other chest tube management options. Current Opinions in Pulmonary Medicine 2003;9:276-281.

Baumann MH, Patel PB, Roney CW, Petrini MF: Comparison of function of commercially available pleural drainage units and catheters. Chest 2003;123:1878-1886.

Baumann MH, Strange C, Heffner JE et al.: Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001;119(2):590-602.

Berger P, Leemans R, Kuiper MA, van der Voort PHJ: Uncommon complications during chest tube placement: a potential role of tube material. Intensive Care Medicine 2003;29:1610-1611.

Broscious SK: Music: an intervention for pain during chest tube removal after open heart surgery. American Journal of Critical Care 1999;8(6):410 415.

Burrows CM, Mathews WC, Colt HG: Predicting survival in patients with recurrent symptomatic malignant pleural effusions. Chest 2000;117(1): 73-78.

Capps JS, Tyler ML, Rusch VW, Pierson DJ: Potential of chest drainage units to evacuate broncho-pleural air leaks. Chest 1985;88S:57S. [classic for discussion of physics]

Carroll P: A guide to mobile chest drains. RN 2002;65(5):56-60,65.

Carroll P: Ask the experts: dry suction chest drainage system. Critical Care Nurse 2003;23(4):73-74.

Carroll P: Chest drainage made easy. RN 1995;58(12):46-56.

Carroll P: Exploring chest drain options. RN 2000;63(10):50-54.

Carroll P: Mobile chest drainage: coming soon to a home near you. Home Healthcare Nurse 2002;20(7):434-441

Carroll PF: Patients with pleural air leaks. Focus on Critical Care 1987;14(3):48-51.

Carroll PL: The principles of vacuum and its use in the hospital environment. 1995. Ohmeda, Inc.; Columbia, MD.

Carson MM, Barton DM, Morrison CC, et al: Managing pain during mediastinal chest tube removal. Heart & Lung 1994;22(4):134-146.

Cerfolio RJ, Bass C, Katholi CR: Prospective randomized trial compared suction versus water seal for air leaks. Annals of Thoracic Surgery 2001;71(5):1613-1617.

Cerfolio RJ, Pickens A, Bass C, Katholi C: Fast-tracking pulmonary resections. Journal of Thoracic and Cardiovascular Surgery 2001; 122(2):318-324.

Cheng, D: Randomized assessment of resource use in fast-track cardiac surgery 1-Year after hospital discharge. Anesthesiology 2003; Mar; 98(3); 651.

Collop NA, Kim S, Sahn SA: Analysis of tube thoracostomy performed by pulmonologists at a teaching hospital. Chest 1997;112(3):709-713.

Consorta: Best Practice Models, Implementing CABG Best Practices. 2001.

Cox JE: Transthoracic needle aspiration biopsy: variables that affect risk of pneumothorax. Radiology 1999;212(1):165-168.

Crawford BK, Galloway AC, et al: Treatment of AIDS-related bronchopleural fistula by pleurectomy. Annals of Thoracic Surgery 1992;54:212-215.

Crocker HL, Ruffin RE: Patient-induced complications of a Heimlich flutter valve. Chest 1998;113(3), 838-839.

Cunnington J: Spontaneous pneumothorax. Clinical Evidence 2003;10:1738-1746.

Daganou M, Dimopoulou I, Michalopoulos N, et al.: Respiratory complications after coronary artery bypass surgery with unilateral or bilateral internal mammary artery grafting. Chest 1998;113(5):1285-1289.

Davies CWH, Gleeson FV, Davies RJO: BTS guidelines for the management of pleural infection. Thorax 2003;58(Suppl II):ii18-ii28.

Drazen JM, Epstein AM. Guidance concerning surgery for emphysema. Editorial. NEJM 2003;348:2134-2136.

Fox V, Gould D, Davies N, Owen S: Patients’ experiences of having an underwater seal chest drain: a replication study. Journal of Clinical Nursing 1999;8:684-692.

Gift AG, Bolgiano CS, Cunningham J: Sensations during chest tube removal. Heart & Lung 1991;20(2):131-137.

Golden P: Follow up chest radiographs after traumatic pneumothorax or hemothorax in the outpatient setting: a retrospective review. International Journal of Trauma Nursing 1999;5(3):88 94.

Gordon P, Norton JM: Managing chest tubes: what is based on research and what is not? Dimensions of Critical Care Nursing 1995;14(1):14-16.

Gordon P, Norton JM, Merrel R: Refining chest tube management: analysis of the state of practice. Dimensions of Critical Care Nursing 1995;14(1):6-13.

Gordon PA, Norton JM, et al: Positioning of chest tubes: effects on pressure and drainage. American Journal of Critical Care 1997;6(1):33-38.

Gray DT, Veenstra DL: Comparative economic analyses of minimally invasive direct coronary artery bypass surgery. Journal of Thoracic and Cardiovascular Surgery 2003;125:618-624.

Hagl C, Harringer W, Gohrbandt B, Haverich A: Site of pleural drain insertion and early postoperative pulmonary function following coronary artery bypass grafting with internal mammary artery. Chest 1999;115(3):757-761.

Hayes DD: Stemming the tide of pleural effusions. Nursing Management 2001;32(12):30-34.

Heimlich HJ: Heimlich valve for chest drainage. Medical Instrumentation 1983;17(1):29-31.

Heimlich HJ: Valve drainage of the pleural cavity. Diseases of the Chest 1968;53(3):282-287.

Hicks D, Moreno S: Pneumothorax Care Plan Map. Tucson Medical Center. Tucson, AZ 1994. Available through CINAHL.

Henry M, Arnold T, Harvey J: BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003;58(Suppl II):ii39-ii52.

Houston S, Jesurum J: The quick relaxation technique: effect on pain associated with chest tube removal. Applied Nursing Research 1999;12(4):196 205.

Hyde J, Sykes T, Graham T: Reducing morbidity from chest drains [editorial]. British Medical Journal 1997;314:914.

Irwin JP, O-Yurvati A, Peska D: Rapid ambulation post-thoracotomy with the Atrium Express Mini-500 system. Available online at: http://www.atriummed.com/PDF/RapidAmbulation.pdf

Jones PM, Hewer RD, Wofenden HD, Thomas PS: Subcutaneous emphysema associated with chest tube drainage. Respirology 2001;6:87-89.

Kam AC, O’Brien M, Kam PCA: Pleural drainage systems. Anaesthesia 1993;48:154-161.

Kinney MR, Kirchhoff KT, Puntillo KA: Chest tube removal practices in critical care units in the United States. American Journal of Critical Care 1995;4(6):419-424.

Kirby TJ, Ginsberg RJ: Management of pneumothorax and barotrauma. Clinics in Chest Medicine 1992;13(1):97-112.

Kirkwood P: Ask the experts: chest tube care and transport. Critical Care Nurse 2002;22(4):70-72.

Kirkwood P: Ask the experts: removing chest tubes and suction bubbling. Critical Care Nurse 2000;20(3):97-98.

Ko JP: Factors influencing pneumothorax rate at lung biopsy: are dwell time and angle of pleural puncture contributing factors? Radiology 2001; 218(2), 491-496.

Krishnan JA: High-frequency ventilation for acute lung injury and ARDS. Chest 2000;118(3):795-807.

Lazar HL, Fitzgerald CA, Ahmad T, Bao Y, Colton T, Shapira OM, et al.: Early discharge after coronary artery bypass graft surgery: are patients really going home earlier? Journal of Thoracic and Cardiovascular Surgery 2001;121(5):943-950.

Laws D, Neville E, Duffy K: BTS guidelines for the insertion of a chest drain. Thorax 2003;58(Suppl II):ii53-ii59.

Leavitt BJ, O’Connor GT, Olmstead EM, et al.: Use of the internal mammary artery graft and in-hospital mortality and other adverse outcomes associated with coronary artery bypass surgery. Circulation 2001;103:507-512.

Leonard M: A 21-year-old man with pneumothorax, subcutaneous emphysema, and a persistent air leak after chest tube insertion. Journal of Emergency Nursing 2003;29:5:425-426.

Light RW: Pneumothorax in the ICU: who is at risk and what can be done. Journal of Critical Illness 1997;12(2):77 80,83 84.

Luchette FA, Barrie PS, Oswanski MF et al.: Practice management guidelines for prophylactic antibiotic use in tube thoracostomy for traumatic hemopneumothorax: the EAST practice management guidelines work group. Journal of Trauma, Injury, Infection & Critical Care 2000;48(4):753-757.

Marshall MB, Deeb ME et al: Suction vs water seal after pulmonary resection: a randomized prospective study. Chest 2002;121(3):831-835.

Martino K, Merrit S, Boyakye K et al.: Prospective randomized trial of thoracostomy removal algorithms including commentary with author response. Journal of Trauma, Injury, Infection and Critical Care 1999;46(3):369 373.

Maskell NA, Butland RJA: BTS guidelines for the investigation of a unilateral pleural effusion in adults. Thorax 2003;58(Suppl II):ii8-ii17.

McKenna RJ, Fischel RJ, Brenner M, Gelb A: Use of the Heimlich valve to shorten hospital stay after lung reduction surgery for emphysema. Annals of Thoracic Surgery 1996;61:1115-1117.

Mimnaugh L, Winegar M, Mabrey Y, Davis, JE: Sensations experienced during removal of tubes in postoperative patients. Applied Nursing Research 1999;12(2):78 85.

Munnell ER: Thoracic drainage. Annals of Thoracic Surgery 1997;63:1497-1502.
National Cancer Institute: Malignant pleural effusion. 1998. Available online at: http://www.meds.com/pdq/effusion_pro.html

National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. NEJM 2003;348:2059-2073.

National Emphysema Treatment Trial Research Group. Cost effectiveness of lung-volume-reduction surgery for patients with severe emphysema. NEJM; 2003;348:2092-2102.

National Emphysema Treatment Trial Research Group. Rationale and design of the National Emphysema Treatment Trial: a prospective randomized trial of lung volume reduction surgery. Chest 1999;116:1750-1761.

Obney J, Barnes MJ, Lisagor PG, Cohen DJ: Is bigger better for draining the mediastinum and thorax? [abstract] Chest 2000;118(4):116S.

Owen S, Gould D: Underwater seal chest drains: the patient’s perspective. Journal of Clinical Nursing 1997;6(3):215-225.

Pacanowski JP, Waack ML, Daley BJ: Is routine roentgenography needed after closed tube thoracostomy removal? Journal of Trauma, Injury, Infection & Critical Care 2000;48(4):684-688.

Powner DJ: A review of “chest tubes” during donor care and after transplantation. Progress in Transplantation 2002;12:61-67.

Powner DJ, Cline CD, Rodman GH: Effect of chest-tube suction on gas flow through a bronchopleural fistula. Critical Care Medicine 1985;13(2):99-101. [classic for discussion of physics]

Proehl JA: One-way valve. In: JA Proehl (Ed.), Emergency nursing procedures. WB Saunders Company Philadelphia 1999. pp.137-139.

Puntillo K: Analgesics and chest tube removal pain. American Journal of Critical Care 1994;3(3):245.

Puntillo KA: Effects of interpleural bupivicaine on pleural chest tube removal pain: a randomized, controlled trial. American Journal of Critical Care 1996;5(2):102-108.

Puskas JD, Williams WH, Duke PG, et al. Off pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: A prospective, randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. Journal of Thoracic and Cardiovascular Surgery 2003;125:797-808.
Putnam, JB: Malignant pleural effusions. Surgical Clinics of North America 2002;82(4):867.

Rogers WB, Rogers RM: Understanding LVRS. RT The Journal for Respiratory Care Practitioners 1997;10(2):28,30,32,33,93.

Roman M, Weinstein A, Macaluso S: Primary spontaneous pneumothorax. MedSurg Nursing 2003;12(3):161-16.

Rusch VW, Capps JS, Tyler ML, Pierson DL: The performance of four pleural drainage systems in an animal model of bronchopleural fistula. Chest 1988;93:859-863. [classic for discussion of physics]

Russo L, Wiechmann RJ, Magovern JA et al.: Early chest tube removal after video-assisted thoracoscopic wedge resection of the lung. Annals of Thoracic Surgery 1998;66:1751-1754

Sahn SA: Malignant pleural effusions. Seminars in Respiratory and Critical Care Medicine 2001;22(6):607-615.

Saji H, Nakamura H, Tsuchida T et al.: The incidence and the risk of pneumothorax and chest tube placement after percutaneous CT-guided lung biopsy. Chest 2002;121(5):1521-1526.

Sandrick K: Fast tracking surgical management improves patient outcomes and reduced hospital length of stay. American College of Surgeons 1999. Available online at: http://www.meds.com/conrad/acs/fasttrack.html

Schlenker, EH: Cardiopulmonary anatomy and physiology. In: Hess, DR, MacIntyre, NR, Mishoe, SC, Galvin, WF, Adams, AB, Saposnick, AB (Eds.), Respiratory care principles and practice. WB Saunders Company Philadelphia 2002. pp.284.

Schmelz JO, Johnson D, Norton JM, Andrews M, Gordon PA: Effects of position of chest drainage tube on volume drained and pressure. American Journal of Critical Care 1999;8(5):319 323.

Schmidt U, Stalp M, Gerich T et al.: Chest tube decompression of blunt chest injuries by physicians in the field: effectiveness and complications. Journal of Trauma, Injury, Infection & Critical Care 1998;44(1):98-100.

Scholz JA: Nursing practice issues and answers. Issue: may a registered nurse remove a chest tube? Ohio Nurses Review 1997;72(4):16.

Scott F: Lung volume reduction surgery. Advance for Managers of Respiratory Care 1996;5(6):36-40.

Sittig SE: Ventilation for life. AARCTimes 2002;26(1):18,20-21.

Tang A, Hooper T, Hasan R: A regional survey of chest drains: evidence-based practice. Postgraduate Medical Journal 1999;75:471-474.

Tang ATM, Velissaris TJ, Weeden DF: An evidence-based approach to drainage of the pleural cavity: evaluation of best practice. Journal of Evaluation in Clinical Practice 2002;8(3):333-340.

Tattersall DJ, Traill ZC, Gleeson FV: Chest drains: does size matter? Clinical Radiology 2000;55:415-421.

Thompson SC, Wells S, Maxwell M: Chest tube removal after cardiac surgery. Critical Care Nurse 1997;17(1):34-38.

University of Arkansas for Medical Sciences Medical Center: Procedure for proper usage of the Heimlich valve 1996. Available at: http://www.uams.edu/nursingmanual/Procedures/procedure48.htm (Authorized students only)

Urschel JD, Parrott JCW, et al: Pneumothorax complicating cardiac surgery. Journal of Cardiovascular Surgery 1992;33:492-495.

Vricella LA, Trachiotis GD: Heimlich valve in the management of pneumothorax in patients with advanced AIDS. Chest 2001;120(1):15-18.

Ware JH: The national emphysema treatment trial – how strong is the evidence? NEJM 2003;348:2055-2056.

Weissberg D: Pneumothorax: Experience with 1,199 patients. Chest 2000;117:1279-1285.

Yamagami T, Nakamura T, Iida S, Kate T, Nishimura T: Management of pneumothorax after percutaneous CT-guided lung biopsy. Chest 2002:121:1159-1164.


Suggested Readings About Chest Tube Stripping

Duncan C, Erickson R: Pressures associated with chest tube stripping. Heart & Lung 1992;11(2):166-171.

Duncan CR, Erickson RS, Weigel RM: Effect of chest tube management on drainage after cardiac surgery. Heart & Lung 1987;16(1):1-9.

Gordon P, Norton JM, Merrel R: Refining chest tube management: analysis of the state of practice. Dimensions of Critical Care Nursing 1995;14(1):6-13.

Gordon P, Norton JM: Managing chest tubes: what is based on research and what is not? Dimensions of Critical Care Nursing 1995;14(1):14-16.

Gross, SB: Current challenges, concepts and controversies in chest tube management. AACN Clinical Issues in Critical Care 1993;4(2):260-275.

Isaacson JJ, George LT, Brewer MJ: The effect of chest tube manipulation on mediastinal drainage. Heart & Lung 1986;15(6):601-605.

Lim-Levy F, Babler SA, DeGroot-Kosolcharoen J et al.: Is milking and stripping chest tubes really necessary? Annals of Thoracic Surgery 1986;42(1):77-80.

Oakes LL, Hinds P, Rao B et al.: Chest tube stripping in pediatric oncology patients: an experimental study. American Journal of Critical Care 1993;2(4):293-301.

Pierce JD, Naftel DC: Effects of two chest tube clearance protocols on drainage in patients after myocardial revascularization surgery. Heart & Lung 1991;20(2):125-130.

Teplitz L: Update: Are milking and stripping chest tubes really necessary? Focus on Critical Care 1991;18(6):506-511.

 Atrium Interactive Computer-Based Training developed by Patricia Carroll, RN,C, CEN, RRT

Not all learning requires a large time commitment. These activities are shorter than typical continuing education activities to allow busy health care professionals the opportunity to learn in small doses.

Interactive Modules
These free interactive training modules provide a solid foundation in the use of thoracic drainage devices. Each module addresses a key element of knowledge for professionals caring for patients who require chest drainage. All modules use animated graphics and narration and integrate a self-assessment quiz.

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 Clinical Update


Clinical Update is an award-winning educational newsletter edited by Patricia Carroll, MS, RN-BC, CEN, RRT and celebrating its 15th year of publication in 2012. Each quarterly issue features new information regarding chest drainage, summaries of articles in the nursing literature and helpful web sites.

 

  Clinical Update Library, Current Issue to 1997 (Adobe Acrobat PDF)  
  Summer 2016 Chest drain research from 2015 continued
Also in this issue: Sepsis, penalties for readmission rates, personal chronotypes and skin failure.


  Winter-Spring 2016 Double issue, 2015 chest drain research
Also in this issue: Fecal transplants, ventilator adverse events, HCAHPS, and making interdisciplinary rounds more effective.
  Fall 2015 Big Data and Nursing Practice
Also in this issue: Fluid splashes and splatters, how well cleaning wipes work, and mask ventilation
  Summer 2015 Maintaining Chest Tube Patency
Also in this issue: The greatest influence on documentation, and "To Glove or Not to Glove"
  Winter-Spring 2015 Research Review 2014
Also in this issue: Acuity or geography for assignments, a study of ice application to reduce pain of arterial puncture, and cybersecurity for medical devices.
  Fall 2014 Nurses removing chest tubes
Also in this issue: Risk assessment for for C. difficile, authorship criteria in nursing journals, and whether a lab sample can be collected when starting an IV
  Summer 2014 Medical tape, information and guidelines
Also in this issue: Enhancing ICU rounds, a new alcohol intoxication scale, and a new angle on nurse bullying
  Spring 2014 Articles comparing gravity and suction drainage
Also in this issue: Implementation science for EBP, guidelines on tube feeding placement, and translation issues with EBP measurements
  Winter 2014 Summaries of 2013 published drain research
Also in this issue: Moral distress, hand hygiene, handheld devices at point of care, noise levels and enteral drug administration
  Fall 2013 Lessons learned on checklists and incentives from Keystone
Also in this issue: Infection control practices, verbal abuse by colleagues, and the CUSP program
  Summer 2013 Findings from NTI
Also in this issue: A legacy of data-driven decision making in nursing, and comprehensive nutrition management.
  Spring 2013 Pleural Pressure
Also in this issue: The cycle of comorbidities, early ICU mobility, an end of life education consortium, and creating infographics.
  Winter 2013 BMI and Cardiac Surgery Risk
Also in this issue: Work environment satisfaction, stethoscope disinfection, impacts of the ACA, and the infection risk of markers.
  Fall 2012 Patient Selection Key for Pigtail Catheters
Also in this issue: A featured article on progressive mobility activity protocol, assessing symptoms in critically ill patients unable to communicate, and evidence-based practice.
  Summer 2012 Autotransfusion for Jehovah's Witness paitents
Also in this issue: A pilot study on EOL care communication, self-management of chronic illness, and diaries for critically ill patients
  Spring 2012 Dressings for Chest Tubes
Also in this issue: Mortality and morbidity, bringing evidence to a practice island, and the latest web resources.
  Winter 2012 Patient Satisfaction
Also in this issue: The patient as expert, readmission warning signs, and purposeful rounding.
  Fall 2011 Is Thoracic Surgery Evidence-Based?
Also in this issue: How nurses redesign healthcare, infection prevention, a new weaning score, and incentive spirometry.
  June 2011 New Rules for Professional Education
Also in this issue: Protective equipment, simulation, sepsis nursing care, and work scheduling.
  March 2011 PEEP and CPAP Effects on Chest Drainage
Also in this issue: Family presence policy, patient decisions and staffing levels.
  December 2010 Reducing Infection Risk in Chest Surgery
Also in this issue: Reevaluating your practice, the TIGER initiative, and patient cost.
  September 2010 Alarm Fatigue
Also in this issue: What is an emergency?, evidence-based unit design
  June 2010 Chest Drain Management: Tradition or Evidence-Based?
Also in this issue: Curtain of protection, Airway Suction Practice, Lights at Night
  March 2010 DEHP-Free
Also in this issue: Stroke assessment, sepsis warning outside the ICU, and the essence of nursing.
  January 2010 H1N1 Special Edition
A special edition of Clinical Update dealing with barotrauma complications from H1N1 influenza.
  December 2009 Heparin Induced Thrombocytopenia
Also in this issue: Evidence to practice, care decisions, bedside computer disinfection, and discussion of of mental status in determining surgical approach.
  September 2009 Tracking Quality in Cardiac Surgery
Also in this issue: Multicultural cardiac care, drawing blood samples, and collaboration.
  June 2009 Chest Tube Positioning and Dependent Loops
Also in this issue: Differences in nursing and practice, infection cost, nursing managers
  March 2009 Mediastinitis
Also in this issue: Hand hygiene, extending your reach, nonspecialist cancer care.
  December 2008 Update on Chest Tube Insertion
Also in this issue: Respiratory research, moral distress, and the value of nursing care.
  September 2008 Mobility in Critical Care Patients
Also in this issue: Quality assessment, the health of shift workers, and patient safety
  June 2008 Air Transport for Patients with Chest Tubes
Also in this issue: Tradition or science, quality of life after traumatic surgery, blood pressure
  March 2008 Managing Air Leaks Through Chest Tubes
Also in this issue: Replicating a study, synergy, "Plug and Play in the ICU"
  December 2007 Identifying Malpositioned Chest Tubes
Also in this issue: JCAHO and Magnet, When is the Usual Routine an Error?, Job Satisfaction
  September 2007 Joint Commission's Patient Safety Goals for 2008
Also in this issue: Recognizing stress, factors associated with UTI, reducing MSRA risk
  June 2007 Treating Persistent Air Leak Following Lung Resection
Also in this issue: Evidence-Driven or Old Wives’ Tale?, APNs, Chaplains in the Unit
  March 2007 Is Bypass a Factor in Cognitive Decline After CABG?
Also in this issue: What Chart Audits Miss, ER to ICU Time
  December 2006Chest Drainage Research in 2006
Also in this issue: Rewarding Staff, Unforgettable Patient Care Events, Nurse/Patient Needs
  September 2006Chest Drainage and Hyperbaric Medicine
Also in this issue: Simulation, and the aging nursing workforce
 
  June 2006Reducing the Pain of Chest Tube Removal
Also in this issue: Conciousness assessment, AD to BSN questions, and information dissemination.
 
  March 2006New Guidelines for CPR and Emergency Cardiac Care
Also in this issue: Gastric tube insertion, state of the RN workforce, and "What satisfies nurses?"
 
  December 2005 Special Year-End Double Issue
A review of studies published in 2005 about chest tube management. Full reference list included.
 
  June 2005 Age Appropriate Competencies: Caring for Children
Also in this issue: Alcohol withdrawl, nursing organizations, evidence-based practice
Click Here for Bonus Reference Chart
 
  March 2005 Mobilizing Patients With Chest Drainage
Also in this issue: Health Literacy, Patient Safety Alerts, Integrating Research and Practice
 
  Dec 2004 Toward Evidence-Based Chest Drainage
Also in this issue: Blood Conservation in Cardiac Surgery, Titanium Rib, Co-Manager Model
 
  Sept 2004 Saving Time and Money with Chest Drainage
Also in this issue: Cost of Hand Hygiene, Pneumonia Guidelines, Perspectives from Patricia Benner
 
  June 2004 The Challenges of Different Chest Tubes Part 2
Also in this issue: Staff Retention, Sleep Deprivation, Pelvic Fractures
 
  March 2004 The Challenges of Different Chest Tubes
Also in this issue: Open Chest in the ICU, The Effects of Noise in your Unit
 
  Dec 2003 Chest Tube Insertion (Part 2)
Also in this issue: Reliable Pain Scores, Pain Management, Thumbs Up for Nurses
 
  Sept 2003 Chest Tube Insertion (Part 1)
Also in this issue: Nurse/Physician Relationships, Declining CE Attendance
 
  June 2003 Does Lung Volume Reduction Surgery Work?
Also in this issue: Aging and Shift Work, Family Presence, Decreasing Medication Errors
 
  March 2003 Chest Trauma Across the Lifespan
Also in this issue: Cardiac Surgery Pain, Evidence-Based Pain Management, Lifelong Learning
 
  Dec 2002 Malignant Pleural Effusions
Also in this issue: Violent Situations, Family-Centered Care, Non-Credentialed Assistive Workers
 
  Sept 2002 Suction or Gravity Drainage?
Also in this issue: Degrees, Employee Perception, Responsibility for Error Reporting
 
  June 2002 Innovations in Chest Drainage—Mobile Chest Drainage Part 2
Also in this issue: Developing a Nursing Portfolio, Preceptors
 
  March 2002 New Innovations in Chest Drainage —A Mobile Chest Drain
Also in this issue: Non-Credentialed Personnel, Ethical Issues and the Nursing Shortage
 
  Dec 2001 Answers To Your Questions About Chest Drainage
Also in this issue: What’s Your Med Error IQ? , What Makes Nurses Stick to a Magnet Hospital?
 
  Sept 2001 Management of Spontaneous Pneumothorax: Part 2
Also in this issue: Multiple Rib Fractures, Cost of Nursing Interventions, Patient Expectations
 
  June 2001 Management Of Spontaneous Pneumothorax: Part 1
Also in this issue: Does Absenteeism Make You Sick?, Newbies
 
  March 2001 Is Your JCAHO Visit Sounding Painful?
Also in this issue: Are You Narcophobic?
 
  Dec 2000 The Nurse's Role In Chest Tube Removal
Also in this issue: APRNs Still Practice Nursing, Leading Outside Your Comfort Zone
 
  Sept 2000 Loculated Pneumothorax: A Special Challenge in Critical Care
Also in this issue: Helping nurses use research, Generational Issues
 
  June 2000 New Technology in Chest Drainage: The Dry Control Drain
Also in this issue: Follow up for trauma patients, patients as consumers
 
  March 2000 Regulating Chest Drainage Suction
Also in this issue: Measuring ANCPs Impact, Hospitalists, Pressure Chart
 
  Sept 1999 A Quick Review Of Lung Surgery Procedures
Also in this issue: Ethnicity and Drug Metabolism, Research-Based Practice
 
  June 1999 The Nurse’s Role In Product Selection
Also in this issue: Certification, Leadership Effectiveness
 
  March 1999 Caring For Pneumonectomy Patients
Also in this issue: Raise Morale And Retain Staff, Marketing 101
 
  Dec 1998 Ambulating Patients With Chest Drainage
Also in this issue: Fibrinolytic Therapy for Pleural Effusion, Managing Pleural Efflusions
 
  Sept 1998 New Developments In Chest Tube Technology
Also in this issue: Families and Critical Care, Nurse Educator In The Clinical Setting
 
  Mar 1998 Latex-Free Chest Drains
Also in this issue: Nursing Research at the Bedside, Early Extubation After CABG
 
  Dec 1997 The Water Seal... a Window Into the Pleural Space
Also in this issue: Communicating with Intubated Patients, A Critical Thinking Game
 

 

 

 

 

 

 

 

 

 

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 Evidence Center



NTI 2016
 

 
NTI 2015
 

 
NTI 2014
 



 About Atrium University

Atrium University was established in 1999 to provide nurses with an easy way to identify educational materials provided by Atrium Medical Corporation.

In 2010, to comply with new guidelines regarding commercial support of professional continuing education, Atrium University has been moved to its own Web site dedicated solely to professional education without product-specific information.


Atrium University has partnered with Patricia Carroll, MS, RN-BC, CEN, RRT, a registered nurse and registered respiratory therapist who is a recognized expert in cardiopulmonary care to develop educational materials. Pat published her first article on managing patients with chest tubes in 1986 and since then has written 12 peer-reviewed articles about caring for patients with chest drainage that are indexed in PubMed. She has contributed to nursing textbooks, video and computer-based instruction about chest drainage.

Until she retired from traveling in 2005, Pat spoke at the American Association for Critical-Care Nurses National Teaching Institute for twenty consecutive years. She is also a professional continuing education specialist, board certified in nursing professional development by the American Nurses Credentialing Center. She is a faculty member in the School of Health Sciences at Excelsior College.

Atrium University is funded by an unrestricted educational grant from Atrium Medical Corporation.



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 Ask the Expert

 

Do you have a clinical question? Need information about caring for patients with chest tubes that is not already provided on this site? Are you writing or updating evidence-based policies and procedures?

Note: This is not designed for urgent questions.
If you need an immediate response, call your chest drain manufacturer.

 
   
 

Most Recent "Ask the Expert!" Question: (Select to view the answer)

 
  Good morning. I am fairly new to this institution, and am wondering about the use of Xerofrom gauze with chest tubes. I stopped using these a number of years ago (except after conclusion of therapy), and the policy here is to use them. What is the evidenced=based practice for the use of Xeroform around the chest tube after insertion?
   
Question Archives:
 
   
  Good morning. I am fairly new to this institution, and am wondering about the use of Xerofrom gauze with chest tubes. I stopped using these a number of years ago (except after conclusion of therapy), and the policy here is to use them. What is the evidenced=based practice for the use of Xeroform around the chest tube after insertion?
   
  Our hospital uses the Express Dry Seal drainage system. We recently had a patient being treated for a spontaneous pneumothorax who developed a leak at the insertion site due to movement of the tube. The patient suddenly started to develop a tension pneumothorax with chest pain, shortness of breath and tachycardia with heart rate of 180. What is the most appropriate immediate actions the nurses should have taken to deal with this emergency? The nurses on duty applied Vaseline gauze to the insertion site and the surgeon ended up replacing the tube. Thank you!
   
  What is best practice recommendations for post chest tube removal incision site care. Should a transparent dressing be used and when should showering be allowed post removal?
   
  What is the minimum amount of suction that should be applied to the chest tubes inserted into the chest following heart surgery while the patient is still being closed at the surgical field?
   
 

When a patient's chest tube is connected to an atrium express dry seal system, should you always see fluctuating in the tube? The patient had a pneumothorax and after chest tube insertion there was no bubbling or fluctuations. Nor was there tidaling in the air leak chamber. Could this be a normal finding if the pneumo resolved with chest tube placement or was the chest tube not placed properly. XRay was not available at time of assessment.

   
  If you saw an order that read Chest tube #1 to 20 cm underwater suction what would you think. 20cm waterseal or chest tube to 20 cm wall suction?
   
  What is best practice now when a patient's chest tube canister tubing disconnects from the actual chest tube? Meaning, the chest tube is sticking out of the patient sucking air. Are we still putting the tubing in sterile water?
   
  Is it more accurate to discontinue suction when assessing for a continued pleural air leak or to assess for bubbling in the water seal chamber while suction continues (I am referring to the Atrium Oasis dry suction chest drain). A patient with a pneumothorax 3 days prior had minimal bubbling while on -20cm suction, but no bubbling when suction removed. Would I assume he still had air within the pleural space since there was bubbling while on suction? Thank you.
   
  Can you please advise whether continuous bubbling should be present in the air leak chamber whilst on continuous wall suction in a patient with a spontaneous pneumothorax who is breathing spontaneously with a dry suction drain? By the way - if the patient was ventilated, what would the difference be?
   
  Is there any information about how much PEEP or CPAP is transmitted to the pleural space?
   
  Is it necessary to clamp a chest tube prior to d/c the chest tube? What is best practice to go from suction to water seal, then clamp and d/c or suction to water seal and then d/c? Can you give me any contact information on references for best practice on clamping chest tubes prior to discontinuation?
   
  I have been asked to do a chest tube competency for our surgical unit staff and have not had any experience myself. After viewing the video about managing chest drainage and asking others here questions I am still a little confused about the water seal chamber. Bubbling in the chamber can be both good and bad, one indicates an air leak, the other indicates a normal condition. I'm just not sure how to distinguish between good and bad exactly. Also someone here told me that when the water level rises in the water seal chamber that also can be good and bad. Again could you explain this? I am also confused about tidaling as it says you should see this but it can be normal not to occur. Everything about this chamber seems to be a contradiction. How do I know what is good vs bad?
   
  Hi, I am wondering what the best practice is for air transporting a patient with a pneumothorax treated with a chest tube. Is a commercial 3 bottle system sufficient or should you also place a Heimlich valve with the 3 bottle system or simply a Heimlich valve for air transport. Thanks, Derek
   
  Is there any research to show that the water (wet) suction is more reliable than your dry suction? What are the advantages/disadvantages of each?
   
  What causes subcutaneous emphysema in a patient with a pleural chest tube with a persistent air leak? Is it treatable and what assessments should be considered in patient care?
   
  Hi, I am a practicing clinical RN at a adult transplant ICU in a large teaching hospital. The residents in our hospital always argue with me on how to write chest tube orders. So there is water seal, which does not require any suction, except gravity. Sometime they would write -20 cm water seal suction. Is this a valid order to write? My understanding is that you either put it to water seal, or -20 cm water suction, which is control by the chamber to the most left in Atrium Ocean model. Please help me. Thank you very much.
   
  We are a pediatric cardiovascular critical care unit.  We use the Atrium chest tubes chambers and also use the JP bulb/pigtail chest tubes when our patients arrive from OR.  Our practice is to strip the chest tubes due to the fear of clotting since they are so small, get an CXR as soon as we DC the chest tube and sometimes delay on Chest tube discontinuation.  I have found that in our patients of age 4 and up, when we strip the chest tube their pain level increase causing us to medicate appropriate and many times delaying transfer to the floor. I was wondering if there is any literature and information I can have to prepare my self and bring this wonderful information to my educators and find a way to present this to the staff.
   
  What happens if the nurse accidentally connects the suction tubing to the oxygen, is there a feature in the Atrium that will prevent the air from entering the lungs? Sometimes there is a commotion at the bedside post op and a possibility like this can happen. Thank you in advance for the answer.
   
  At our facility we are trying to decide on a practice change where nurses in critical care as well as on all floors would assist an MD with Chest Tube insertions, set-up, and maintaining the chest tube(s). Tradionally, Resp Therapists have gathered the equipment, set-up the atrium and rounded daily on the patients with chest tubes outside of critical care (as the experts).Is it standard practice in the U.S. for nurses on all floors to be able to assist with insertion,set up the drainage system, and totally maintain the system...or just in specific units to maintain competency/profciency? Some of our medical floor nurses have not cared for a patient with chest tubes for a year or more (ie. Neuro, GI/Endo, Med Tele). Please advise on best practice.
   
  When attaching the chest tube to suction do you connect thru the suction canister or do you connect directly to the gauge? If using the canister to connect, please provide a reason why or direct me to literature surrounding this method.
   
  Is there any current information that you can share regarding milking/stripping the tubing? At the hospital I currently work at, we do neither, but would like literature supporting that. When searching the web, I find conflicting reports.
   
  Per your website/modules, the suction control(bubbling) should be controlled by the head wall suction source. We have battles with our surgeons who adjust the bubbling from the valve. Does it make a difference? Also, in our old chest tube systems, we drew cultures through the self sealing tubing. On our newer systems, there is a port where the draining tubing connects to the atrium draining system. Is that valve for collecting pleural specimans? Thanks!
   
 
   
 

Good morning. I am fairly new to this institution, and am wondering about the use of Xerofrom gauze with chest tubes. I stopped using these a number of years ago (except after conclusion of therapy), and the policy here is to use them. What is the evidenced=based practice for the use of Xeroform around the chest tube after insertion?

As with many aspects of chest drainage, we have reached consensus on a number of practices, but there has been little or no research that supports them -- until recently. I get more questions about chest tube dressings than any other aspect of care.

There was a poster at the American Association of Critical-Care Nurses National Teaching Institute reporting on a study done by nurses at Massachusetts General Hospital (1). The thoracic surgery service stopped using petroleum gauze a decade ago. The nurses examined records of all thoracic surgery patients who had chest tubes from 2005 to 2010 (n=4361) and a subset of 321 lung cancer patients who had lobectomy between January 2009 and December 2010.
Overall, there was a 3.1% incidence of air leak, with 8% in the cancer group. Wound infection rate was 0.48% in all patients and 0.3% in the cancer group. Neither the air leaks nor wound infections were attributable to dressing materials. They use and recommend a simple dry occlusive gauze dressing.

Many surgeons insist on using petroleum gauze at chest tube sites even though no evidence supports this practice (2,3). The first research article on potential negative effects of petroleum gauze was published in 2012 (4).
Researchers exposed suture knots tied with four different materials – polydioxanone (PDS-II), silk, glycolide/lactide copolymer (Polysorb), and polyglyconate – to either petroleum gauze or to normal saline-soaked gauze. Some knots failed by untying rather than breakage; 5 of 6 that untied were exposed to petroleum. Knots exposed to petroleum broke at significantly lower tensile strength than those exposed to saline, with silk and polydioxanone failing at statistically significantly lower tensile loads. 

These are the first studies to support eliminating petroleum gauze from routine chest tube dressings and from dressings used after tube removal when sutures are present. A 5" x 9" Xeroform dressing costs $2.42, and every little bit helps when we can reduce costs of routine dressing changes.

 

 

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Our hospital uses the Express Dry Seal drainage system. We recently had a patient being treated for a spontaneous pneumothorax who developed a leak at the insertion site due to movement of the tube. The patient suddenly started to develop a tension pneumothorax with chest pain, shortness of breath and tachycardia with heart rate of 180. What is the most appropriate immediate actions the nurses should have taken to deal with this emergency? The nurses on duty applied Vaseline gauze to the insertion site and the surgeon ended up replacing the tube. Thank you!

I am a bit confused as to how a patient with a leak around the chest tube developed a tension pneumothorax. A tension pneumothorax occurs when there is a leak from the lung but no opening in the chest wall for air to escape. If there is a chest tube and a leak at the insertion site, that should allow air to leave the chest without building up under pressure. But the important thing is that the condition was recognized and treated.

As for managing a chest tube with a leak around it, assess the patient and carefully examine the chest drain to make sure the tube is still patent. It is unusual for loose tubes to be occluded, but ensuring patency is always important. Then, take down the dressing and examine the insertion site. If any of the drainage holes in the tube is visible, the tube will have to be replaced. The tube should never be advanced into the chest because of the risk of infection. If the tube is still in the right position, but loose, replacing the skin suture can often solve the problem.

I was unable to find research that specifically addresses managing patients with chest tube dislodgement. So, I turned to management of open pneumothorax since that is essentially what is created when a chest tube is dislodged.

In general, when we are considering a patient whose chest tube has dislodged, the key point is whether there is also a leak from the lung. Was there bubbling in the water seal air leak meter before the tube came out? If not, the opening can safely be sealed with an occlusive dressing.

If there is an opening in the lung, or you don’t know, sealing the opening in the chest wall could allow reaccumulation of pneumothorax and potentially lead to tension pneumothorax, particularly if the patient is receiving mechanical ventilation. In this situation, the goal is to allow air to leave the pleural space without drawing more air in from the atmosphere. The literature recommends a sterile dressing taped on three sides, to create a one-way valve effect. (1-4 )

In military healthcare, the idea of taping a dressing on three sides is impractical when working with front-line battle injuries. This has led to development of the chest seal, most commonly a 15cm adhesive disc with a one-way valve vent in the center.(5)   There are currently 3 chest seals on the market. All vents decompress the chest; the difference is adherence in real-world conditions of blood, dirt and hair on the skin beneath the seal. (5-7)

In summary, the literature on chest trauma recommends taping a dressing on three sides to simulate a one-way valve allowing air to leave the pleural space and not re-enter.

When a chest tube is loose or dislodged, the key is knowing if there is an opening in the lung, which would require a new chest tube and would be a contraindication to an occlusive dressing that could lead to recurrent pneumothorax.

 

 

 

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What is best practice recommendations for post chest tube removal incision site care. Should a transparent dressing be used and when should showering be allowed post removal?

While I was unable to find any literature about showering, I do have some information on dressings. There is no specific research on chest tube dressings after tube removal either, but research on sternotomy dressings provides some useful guidance.

Various dressing materials have been evaluated: dry absorbent pad, hydrocolloid, hydroactive, Bioclusive, and medicated pad or film (1-5).  The ideal dressing should maintain a moist environment, be gas permeable, protect from contamination, allow ongoing assessment, be comfortable, cost effective, and removed without causing tissue trauma (4,5). Postoperative dressings should stimulate superficial epithelialization at the wound surface (1,4,5).

First Author Material Days Material Days Findings Notes
Teshima5 Hyrocolloid 7 Film with iodophor then 2 91% complete healing hydrocolloid
98% complete healing with film
Both dressings were occlusive
Hydrocolloid did not require change
      Absorbent pad 5 9% did not complete time w/ hydrocolloid; 6% film had dermatitis
Significantly more SSI with film
Hydrocolloid less $ with less nursing time
Segers6 Adhesive drape over dry gauze pad 2 then changed daily Absorbent knitted cellulose pad with adhesive frame 1 changed daily No difference After 72 hours if no exudate or infection, uncovered
Alvarez7 Absorbent pad with adhesive frame 5 Transparent polyurethane 14 Significantly reduced sternal and leg wound infection for CABG with polyurethane  
Wynne9 Absorbent pad with adhesive frame 2 Hydrocolloid OR Transparent adhesive film 5 No difference in infections between three dressing types Patients generally not aware of dressing nor found moving
Wikiblad8 Absorbent pad Changed only if leaking or exudate Hydrocolloid OR Hydroactive film Changed only if leaking or exudate Hydroactive: significantly poorer wound healing 52%
Pad: 90%
Hydrocolloid: 77%
Absorbent pad easier to change & less painful, slightly more nursing time, but overall preferred

 

Hydrocolloid dressings allow for the best seal around the wound and are water resistant for bathing. So that can give you a start with regard to showering after chest tube removal. They are not transparent, so clinicians need to be comfortable with other assessments, because frequent dressing changes defeat the purpose of the hydrocolloid material(4). Transparent adhesive film provides another, water resistant option.

A wet dressing increases infection risk, so if a non-water resistant dressing is in place, that the dressing would need to be changed after a shower. If you are not using one of the water resistant dressings described, it might be preferable to discuss with your surgeons whether to remove the dressing before the shower.

Skin covered with occlusive tape that prevented water loss increased bacterial growth from 1000/cm2 to millions (6).
Another factor to consider with chest tube dressings is skin damage related to adhesive removal with repeated dressing changes (5). Impaired skin integrity is a significant risk factor for infection. Hydroactive film caused more tissue damage compared with traditional paper tape or hydrocolloid(4). As few as four tape strippings can cause cellular damage to the epidermis, and irritation can also alter the skin’s protective properties. A study on CABG patients compared paper tape (Micropore), and polyethylene tape (Transpore)(6). The tapes’ adhesives were the same. Initially, a dry gauze dressing was anchored with cloth tape in the OR; at the first dressing change, patients were randomly assigned to one of the two study tapes for dressing changes on POD 2 & 3. The paper tape resulted in significantly less irritation and significantly less stripping. Researchers attributed the differences to the paper tape’s gas permeability that also allowed moisture to evaporate.

Finally, a study on tape blisters in hip surgery patients found that the risk of a blister was 41% with silk non-stretchable tape and 10% with perforated cloth tape (7).

Finally, a Cochrane Review from 2014 examined studies of surgical wound dressings. They note there is insufficient evidence to recommend one dressing type over another. Their recommendation is to base the decision on cost and clinical needs, such as exudate management or water-resistant nature (8).

When should the patient take a shower? That would need to be an individualized assessment weighing the benefit of the shower against the potential risk and inconvenience of having to change the dressing as a result of the shower.

Remember, dressings should be changed only when necessary because of the risk of skin damage from tape stripping, not by the clock or calendar. In my experience, the chest tube insertion site is not the determining factor on showering; it’s whether the patient is steady enough on his or her feet to be able to take a shower safely.

 

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What is the minimum amount of suction that should be applied to the chest tubes inserted into the chest following heart surgery while the patient is still being closed at the surgical field?

Questions about the level of suction that is appropriate for chest drains are common, and unfortunately, there hasn’t been any research to help us determine the appropriate level.

The level of -20cmH2O for suction is arbitrary. There is nothing magic about the level and no research to back up 20cm as more beneficial than 15cm or 30cm. In fact, the level was probably simply determined by the size of the original bottles. 

The literature that specifies suction levels describes levels ranging from 5cmH2O to 25cmH2O for cardiac surgery (1-3). But, the research does not compare suction levels to determine optimal levels for various conditions. That said, -20cmH2O is the level most commonly used for adults.

I am intrigued by your specifying “while the patient is still being closed.” If the chest is open and the drainage holes in the chest tube are in any way exposed to the atmosphere, atmospheric air will be preferentially pulled through the chest tubes when suction is applied because air is less dense than fluid. Once the chest is closed, suction applied to the tube will then draw fluid and any air present out of the chest.

I would not apply suction to the chest tubes until the chest is closed without specific instruction from the surgeon.

 

 

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When a patient's chest tube is connected to an atrium express dry seal system, should you always see fluctuating in the tube? The patient had a pneumothorax and after chest tube insertion there was no bubbling or fluctuations. Nor was there tidaling in the air leak chamber. Could this be a normal finding if the pneumo resolved with chest tube placement or was the chest tube not placed properly. XRay was not available at time of assessment.

This is a tough question to answer.  The answer depends on the size of the original pneumothorax, the size of the chest tube, and whether and when suction is applied to the drain.

It’s probably easier to talk about circumstances where tidalling may not be seen. Most commonly, tidalling is not seen when the lung is fully inflated and the pleural space is back to being a “potential” space except for the presence of the chest tube. Tidalling can also be absent if the tube is blocked or if it is not in the pleural space. If a small bore catheter or “pigtail” catheter is used, it may be difficult to see tidalling in the chest drain.

In the situation you describe, it is entirely possible that the patient had a pneumothorax through a tiny opening in the lung that sealed, the chest tube was inserted, and the air left the chest through the tube before the drain was connected. If the patient took a few deep breaths and coughed, the lung may have fully inflated. Or, if the tube was attached to the drain and suction applied before an assessment for bubbling or tidalling, the air may have been evacuated that way. It can also be difficult to assess tidalling when suction is applied.

While the recent literature has recommended against an automatic chest x-ray after tube removal in the asymptomatic patient, experts universally require a chest x-ray after a chest tube is inserted, for two reasons. First, to see if the condition for which the tube was needed has resolved, and second, to assess the location of the tube. Unfortunately, in 2015, there were still reports of chest tubes being inserted below the diaphragm by inexperienced clinicians (1).

 

 

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If you saw an order that read Chest tube #1 to 20 cm underwater suction what would you think. 20cm waterseal or chest tube to 20 cm wall suction?

A three-bottle chest drain system has a bottle to collect drainage; a bottle with a straw under water to create a one-way valve so air can leave the chest and not return (the water seal); and a suction control bottle, in which the level of water determines the maximum amount of suction that is transmitted to the chest (typically at a level of 20cm). Those three original bottles are combined in today’s disposable chest drains. In some cases, the water seal chamber and water-filled suction control chamber are replaced with mechanical devices.

So, I would interpret an order reading “chest tube #1 to 20cm underwater suction” as a chest drain with a water seal (underwater) and suction of -20cmH20. But what I think isn’t as important as what the person who wrote the order was thinking. You should never have to guess. Another common area of confusion is “put patient to water seal,” meaning gravity drainage without external suction applied.

The literature shows being “correct” is not as safe as being consistent in terminology. I’m sure you have been through inservices on handoffs, but clear orders are equally important.1-3 Root causes of sentinel events have consistently been communication problems more than 60% of the time since 1995.2 One study of malpractice claims showed communication errors were postoperative 32% of the time, between one transmitter and one receiver 64%, information communicated was inaccurately received 44%, and between persons from two different disciplines 34% of the time.1

How can this problem be addressed? First, a common terminology needs to be agreed to by a multidisciplinary team of nurses and surgeons. (I’m sure with a little investigation, you’ll see chest drainage is not the only terminology issue.) Standardized postoperative orders and clinical pathways incorporating the agreed upon terminology will not only reinforce the terms but set standards so deviations can be clarified (suction not ordered when expected and vice versa).3 Finally, house staff need to be oriented to hospital policy and protocol; one survival skills curriculum presented through the month of July focuses on communication skills, writing orders and progress notes, and problem solving by simulating “midnight” calls from nurses about a variety of patient scenarios.4 This would be an ideal opportunity to clarify just the issue you raise.

 

 

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What is best practice now when a patient's chest tube canister tubing disconnects from the actual chest tube? Meaning, the chest tube is sticking out of the patient sucking air. Are we still putting the tubing in sterile water?

I’m not aware of any literature that describes research on this matter and couldn’t find any on a quick search. I avoid clamping chest tubes whenever possible. A disconnected chest tube is an open pneumothorax. People don’t die from open pneumothorax; they can die from tension pneumothorax, which can occur when a chest tube is blocked from a kink or a clot or a clamp.

Instead of clamping the tube, you’re right -- I would stick the tube about 2 inches under the surface of a small bottle of sterile water or sterile saline. That creates a do-it-yourself water seal so air can leave and not re-enter the chest. Then, you’ve got time to pause, assess the situation and decide what to do while the patient is protected. I remember how relieved I was when we stopped taping clamps to the wall above the head of the bed and made sure there was a small bottle of sterile fluid at each bedside instead.

In addition, I wouldn’t worry about timing the reconnect to the patient’s breathing. If the patient is awake and cooperative, you can just have him cough a couple of times once the system is back in working order and that will force any air out of the chest.

For institutional backup, I’d also recommend consulting with your infection control specialist regarding the potential for cleaning the connector with a disinfectant before reconnecting. That practitioner would be most familiar with your practice area and policy and procedure relating to infection prevention and would be a great resource for such a question. You may also want to run it by the surgeons or pulmonary specialists that place and manage the patients with tubes. That way, you'd have all your bases covered.

 

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Is it more accurate to discontinue suction when assessing for a continued pleural air leak or to assess for bubbling in the water seal chamber while suction continues (I am referring to the Atrium Oasis dry suction chest drain). A patient with a pneumothorax 3 days prior had minimal bubbling while on -20cm suction, but no bubbling when suction removed. Would I assume he still had air within the pleural space since there was bubbling while on suction? Thank you.

This is a great question because there are new thoughts about suction and air leaks. Whether suction or gravity is best has been debated for years. For patients who are not receiving positive pressure mechanical ventilation, those without suction have shorter times with the chest tube than those receiving suction. The studies are primarily looking at postoperative patients, so patients with simple pneumothorax are likely to do even better without suction.

In fact, in an article just published, even though evidence for not using suction in routine cases is clear, “clinical practice is not aligned with the Level 1a evidence”(1).

Here’s the current thinking. Suction pulls a greater volume of air through any opening in lung tissue. When air is actively moving through the opening, it separates tissue, which then cannot come together and heal (2). The hypothesis that suction promotes faster leak closure is disproven in a recent trauma study (3). And the increased fluid drainage noted in some studies is likely due to pleural irritation & weeping – not better drainage of fluid that would normally be present (4).

So, bubbling visible in the water seal may be a true leak, but the lung may not have been able to heal because of the suction. When there is bubbling on suction, but it is not present when suction is removed, I start to think about the possibility of a small leak in the system – most commonly at the connectors. Suction will pull air through any small leak, resulting in bubbling that is not from the lung.

To assess suction artifact, use a tubing clamp and occlude the tube where it leaves the chest. Quickly check to see if bubbling is still there with the drain connected to suction. If bubbling is present, you know it is not from the lung.
In my practice, if a patient is not receiving positive pressure ventilation, I routinely pinch the suction tube closed momentarily to assess for air leak (bubbling in the water seal or air leak meter). In my area, physicians typically go to gravity drainage before tube removal. By occluding the tube I am always assessing without suction, so the assessments are consistent.

For more information on suction or gravity drainage, you can check out the Atrium University web site and look under “evidence.”

 

 

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In the hospital where I used to work, we did autotransfusion from the chest drain by connecting IV tubing directly to the drain. I’m now working in a critical care unit where we use bags that go between the patient tube and the drain. If we have a Jehovah’s Witness patient who requires a closed-loop system, is there any way to do that with the bag system?

Technically, continuous autotransfusion from the bag can be done to meet the patient’s need. But it is an off-label use, so check with your hospital’s policy and procedure team and the chest drain manufacturer before you do it yourself. Just be aware that not all Jehovah’s Witness patients will accept autologous transfusion.

In 2000, a clarification on transfusion practices was published by the Governing Body.1 Citing Deuteronomy 12:26: “The blood of your sacrifices must be poured beside the altar of the Lord your God,”  it emphasizes the instruction to “pour the blood out.” This opens the door to approaches in which the blood is maintained in contact with the vascular system and never “poured out” of the body. Since this clarification, many of the faith will accept hemodiluted cardiopulmonary bypass and continuous autotransfusion postoperatively in which a closed-loop system is used.2,3  However, the guidance states,


Believers also make personal choices regarding fractionated components such as albumin, cryoprecipitate, immunoglobulin, interferon and replacement factors such as for hemophilia.3It’s important to discuss the options with the patient preoperatively so that all members of the postoperative care team know what the patient will and will not accept.4 You can review the Clinical Update newsletter from Summer 2012 at the Atrium University site for a more detailed review of autologous transfusion in Jehovah’s Witness patients.

Once a patient agrees to a continuous-loop autotransfusion, you can set it up with the same principles you used for the drain with the access line from the collection chamber. If you typically keep the drain on the floor, you’ll want to raise it up and hang it on the bed frame to keep the connector at the bottom of the ATS bag up off the floor; this will also make it easier to match the level of the IV pump with the level of the bag during blood collection and reinfusion.

As with the drain with the access line, when infusing from the bag, you will need an IV pump that is compatible with blood infusion, a microemboli filter, and nonvented tubing. Anticoagulant use is up to the physician, and the American Association of Blood Banks Guidelines for Blood Recovery and Reinfusion in Surgery and Trauma5 strongly advises coordination with the transfusion service to establish standards, policies and protocols for intermittent and continuous closed-loop autotransfusion.

You’ll wait to infuse until there is enough blood in the bag for infusion without the risk of emptying the bag completely (which could allow air to enter the IV tubing). Typically, that’s around 250mL to 300mL. You’ll need to check your drain’s instructions for use to determine how to read the volume of blood in the ATS bag since applying suction during chest drainage will slightly alter the shape of the bag. Also remember that the measurements on the bag are not as precise as those on the drain’s collection chamber, so be sure to leave yourself a greater margin when setting infusion rates.

The general procedure is:

 

Typically, the volume of infusion is adjusted hourly based on the amount of blood collected in the bag the previous hour.

Before implementing this practice, be sure to check with your chest drain manufacturer for any special considerations. Follow your regular policies and protocols for blood transfusion, using the IV pump, and standard precautions.

 

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Can you please advise whether continuous bubbling should be present in the air leak chamber whilst on continuous wall suction in a patient with a spontaneous pneumothorax who is breathing spontaneously with a dry suction drain? By the way - if the patient was ventilated, what would the difference be?


You’ll see bubbling in the water seal chamber when air enters the system. That is most commonly from the lung, but can also be from a leak somewhere else in the system; for example, if the tube has moved and one of the eyelets of the chest tube is outside the chest.

Negative pressure from suction pulls air from a leak through the drain and positive pressure from the chest -- a strong cough, positive pressure ventilation, or a manual resuscitation bag – will push air into the drain. So, if a patient has a pneumothorax or a postoperative leak from the lung, suction will cause continuous bubbling and may make a leak look worse than it is. You’ll see the same pattern caused by PEEP on a ventilator because it is continuous positive pressure pushing air out of the leak. To accurately assess the patient breathing spontaneously with suction, momentarily disconnect the suction tube from the drain, check for bubbling, and then reconnect the tubing. You may be able to pinch the suction tubing closed to accomplish the same thing. I recommend avoiding wall vacuum adjustments for assessment purposes because it is too easy to forget to put it back on.

Otherwise, you would see intermittent bubbling that corresponds to respirations. With a ventilator, you’ll see bubbling on inspiration; if the person is breathing spontaneously, you should see bubbling on exhalation, or with a cough.
A spontaneously breathing person with a spontaneous pneumothorax probably does not need suction. The British Thoracic Society Pleural Disease Guideline 2010 states “suction should not be routinely employed” for managing spontaneous pneumothorax.1 You may also find the Clinical Update for June 2010 useful. While it discusses suction for postoperative patients, the concepts apply to spontaneous pneumothorax as well. 

 

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Is there any information about how much PEEP or CPAP is transmitted to the pleural space?

The amount of PEEP transmitted to the pleural space is determined by the compliance of the chest wall and the lung. If lung compliance is low (the lung is stiff), but the chest wall compliance is high, meaning it expands freely, very little PEEP is transmitted to the pleural space, resulting in high transpulmonary pressure (the difference between intrapulmonary pressure and pleural pressure).1 If lung compliance is high and the chest wall compliance is low (chest wall expansion is limited due to external factors, such as obesity or skeletal conditions), much more PEEP is transmitted to the pleural space. In this case, pleural pressure can be significantly higher than atmospheric pressure.1-3

 

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Is it necessary to clamp a chest tube prior to d/c the chest tube? What is best practice to go from suction to water seal, then clamp and d/c or suction to water seal and then d/c? Can you give me any contact information on references for best practice on clamping chest tubes prior to discontinuation? Thank you.

Theresa Austin, MSN-L ,RN
RN Clinical Education Specialist- Pediatric Service line
Cardon Children's Medical Center at Banner Desert Medical Center

To clamp or not to clamp? That is the question. I was not able to find any research that compared clamping with no clamping. For this response, I am thinking about patients with pleural tubes who are not receiving mechanical ventilation; I’d never clamp a tube if a patient were receiving positive pressure. As for other non-critical patients (typically postoperative) If I were writing the orders, I would prefer to have pleural tubes clamped the night before anticipated removal, and if the patient did fine, pull the tube on morning rounds. The argument in favor of clamping is that if the patient gets breathless or shows other signs of recurring pneumothorax, it is much easier to simply open the clamp rather than face the risk of pulling the tube too soon and having to replace it. I think clamping to simulate removal in order to assess the patient is hard to argue with, but is not evidence-based. Otherwise, I would not clamp a tube  -- even to change out a chest drain. I’d be concerned that I might get called from the bedside for an emergency and not open the clamp; it’s the same reason I don’t turn off monitor alarms – I just silence them.

As for the literature, a frequently referenced approach, called “provocative clamping,” is described in a letter to the editor of Annals of Thoracic Surgery  as one way to manage patients with prolonged air leak.1 It’s provocative because it involves clamping a tube in a patient with a known leak from the surface of the lung. But one of the best resources is a letter to the editor of Chest in which a writer is in favor of clamping and provides 8 references to support his position. In response, the author of the original article responds with 5 references that support not clamping the tube2. (available online here: http://chestjournal.chestpubs.org/content/119/4/1292.full  with links to available full text references)

There has been some good evidence on suction versus gravity drainage after lung surgery. University of Pennsylvania researchers reported their experience randomizing postoperative pulmonary resection patients (not including LVRS) into two groups. One group’s chest drains remained connected to the vacuum regulator with the suction control chamber set for a level of –20 cmH2O; the others were disconnected from the wall vacuum and remained on gravity drainage with the water seal of the chest drain.3 Sixty-eight patients who underwent pulmonary wedge resection were included with 34 in each arm of the study. The two groups were evenly matched; 15 patients in each group had an air leak at the end of the operation. All patients were connected to wall vacuum in the operating room to re-expand the lung at the end of the case. Vacuum was disconnected for transport to the PACU. There, patients were randomized to resume vacuum or to stay on gravity water seal drainage – two days earlier than in a previous study4. If a pneumothorax >25% was present on a chest radiograph in the gravity drainage group, the chest drain was reconnected to wall vacuum with a suction level of –10 cmH2O until the pneumothorax was <10%. (Note that none of the patients was symptomatic.) Then, gravity drainage was reestablished.  Patients on the wall vacuum protocol had suction control chambers set to –20 cmH2O.

Patients with air leaks in the gravity water seal drainage group had a mean leak duration of 1.50 days. In the wall vacuum group, mean leak duration was 3.27 days. Chest tubes in the gravity water seal patients remained in place a mean of 3.33 days; in the wall vacuum group, the mean duration was 5.47 days. Even when taking the length of staple lines into account, the differences between the two groups remained. The researchers found that the duration of air leaks in the gravity water seal group was about one-half the time of the wall vacuum group. Since many argue that suction is critical to apposition of the pleurae postoperatively, these researchers initially used suction on all patients in the operating room. These researchers note that visually, the bubbling is more vigorous in the water seal chamber when the chest drain is connected to wall vacuum, indicating a greater flow of air out of the lung. They suggest that the benefit of reducing airflow, thereby allowing the suture line to be more closely approximated, aids healing and outweighs any benefit of pleural apposition.

The researchers conclude that placing patients on gravity water seal drainage helps resolve air leaks after pulmonary surgery more quickly than when suction is used. They state that routinely using wall vacuum postoperatively is counterproductive.

Overall, the literature supports using gravity drainage and significantly limiting or avoiding use of suction altogether unless there is a specific indication for suction based on a careful patient assessment5-12. Based on these findings, I would go to water seal as soon as possible and remove the tube from there. There is no need to clamp the tube unless you wish to simulate chest tube removal to determine patient tolerance.

 

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I have been asked to do a chest tube competency for our surgical unit staff and have not had any experience myself. After viewing the video about managing chest drainage and asking others here questions I am still a little confused about the water seal chamber. Bubbling in the chamber can be both good and bad, one indicates an air leak, the other indicates a normal condition. I'm just not sure how to distinguish between good and bad exactly. Also someone here told me that when the water level rises in the water seal chamber that also can be good and bad. Again could you explain this? I am also confused about tidaling as it says you should see this but it can be normal not to occur. Everything about this chamber seems to be a contradiction. How do I know what is good vs bad?

Rather than thinking about good vs. bad, it might be easier to think about whether bubbling is expected or unexpected. Bubbling occurs in the water seal chamber when air is entering the chest drain. When you first apply suction, there should be a little bubbling in the water seal as air is pulled through from the collection chamber. If no other air enters the system, the bubbling should soon stop. Bubbling continues when air is entering the system. What is going on with your patient? If the tube has not been in for long and the patient had a pneumothorax or lung resection surgery, you should expect bubbling. What have previous nursing assessments shown? If the patient is 18 hours post-op and has had bubbling in the water seal since leaving the OR, I wouldn’t be worried at all. However, if the patient is 36 hours post op and I am seeing bubbling after 24 hours of no bubbling, I’d want to investigate further. If an air leak is not expected from your patient assessment, there may be a leak in the system – somewhere between the chest tube and the drain itself. An air leak can be “normal” when it is expected and makes sense with the rest of the patient assessment. On the other hand, if you expect bubbling and don’t see it and the patient is short of breath with significantly diminished breath sounds on the side with the chest tube, the tube could be blocked and again, require additional assessment.

 Here’s an analogy: let’s say a 32 year old man comes in to the ER with a broken wrist after slipping on an icy sidewalk. You put him on a monitor for sedation for a closed reduction, and you notice he’s in bigeminy. That becomes an incidental finding that doesn’t need treatment. If, however, you see the same rhythm in a patient having an MI with unstable blood pressure, it would need more investigation and probably speedy treatment.

As for the fluid in the water seal chamber, the water seal is a manometer that can measure intrapleural pressures. Pressure changes in the pleural space that occur with breathing will be seen as fluctuations  in the level of the water within the tube. These fluctuations,  called "tidalling," may be as great as 5 to 10 cmH2O with normal spontaneous breathing. The water level will go up (more negative) during inspiration, and go down (return to baseline) during exhalation. If the patient is receiving positive pressure ventilation, the water level will go down (more positive) during inspiration, and go back up (return to baseline) during exhalation, reflecting the higher positive pressure in the chest with mechanical ventilation. If there is no tidalling, it could mean that:

  • The tubing is kinked
  • The tubing is clamped
  • The patient is lying on the tubing
  • There is a dependent, fluid-filled  loop in the tubing
  • Lung tissue or adhesions are blocking the catheter eyelets
  • No air is leaking into the pleural space and the lung has re-expanded

Once again, your complete patient assessment and knowledge of what’s been going on over the past 24 to 48 hours will help you interpret these findings.

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Hi, I am wondering what the best practice is for air transporting a patient with a pneumothorax treated with a chest tube. Is a commercial 3 bottle system sufficient or should you also place a Heimlich valve with the 3 bottle system or simply a Heimlich valve for air transport. Thanks, Derek

Heimlich valves were designed by Dr. Harry Heimlich to facilitate air transport of wounded service members in Vietnam.1 The problem with Heimlich valves is the lack of a way to collect fluid drainage. Allowing fluid to flow onto the floor of the aircraft as it was done originally in combat violates standard precautions, and jury-rigging some sort of collection bag presents the risk of outflow obstruction with subsequent tension pneumothorax. These challenges led to the development of the Pneumostat chest drain valve about 10 years ago. This closed unit includes a self-contained 30 mL collection chamber to catch any fluid that may drain from the pleural space in a patient with pneumothorax. The two valves are comparable in size as illustrated here.

Patients with potential for greater volumes of fluid drainage, or longer transport times can use the Express Mini 500 drain. It is a full-featured chest drain about 9 inches high and 5 inches wide with a collection chamber capacity of 500cc, a mechanical one-way valve, option for suction (-20cmH2O if connected to a vacuum source), and safety features present in larger, more traditional drains. It is made of plastic, without risk of breakage you may see with bottles.
Historically, the U.S. Military required placing a Heimlich valve as close to the patient as possible and then connecting the tube to a chest drain. That’s because flight condition simulation testing demonstrated that during rapid decompression and descent, water could be sucked out of the water seal chamber, leaving the patient unprotected. This instruction was revised in 2008 after testing of the Atrium model 4050 drain. Since this drain has a dry, mechanical one-way valve rather than a water- dependent one-way valve, there is no danger of losing the patient protection with changes in cabin pressure. While the Express Mini and the 4050 use water to demonstrate air leak, the water does not create the one-way valve; thus, no Heimlich is needed. In fact, the instructions warn against using a Heimlich with this type of drain. In addition, these drains with mechanical suction regulators and one-way valves are less position-sensitive than the water-based drains.

The decision to use a Heimlich with a drain should be based on the type of drain used and the pressure swings patients would be exposed to during transport. The Air Force tested for 8000 to 45000 feet altitude. If your patients will not be exposed to these conditions, I would not recommend combining a Heimlich with a traditional drain. Having two one-way valves could increase resistance to air leaving the chest.

In preparing patients for air transport, it is essential to carefully review a chest radiograph for the presence of extrapulmonary air. Unfortunately, there is no research that predicts the amount of extrapulmonary air that may be acceptable for flight.2 Other diagnostic imaging such as ultrasound and CT scan may be used to confirm the diagnosis. It is also important to consider the mechanism of injury and the risk for pneumothorax during the transport period. For example, a patient with flail chest (multiple ribs fractured in multiple places) is at high risk for lung injury, even if a pneumothorax is not evident on initial evaluation. Consider the altitude of the planned air transport, the length of the anticipated trip, and whether the patient will require positive pressure ventilation, which increases risk for tension pneumothorax.3

If there is any question about the presence or size of a pneumothorax, it should be treated before flight. Patients with untreated pneumothorax are at risk for significant expansion of the trapped air at altitude which can change a small, clinically insignificant pneumothorax into a life-threatening tension pneumothorax. Increasing intrapleural pressure can cause desaturation and hemodynamic compromise.2,4 In-flight chest decompression is fraught with hazard and should be avoided if at all possible.

 

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Is there any research to show that the water (wet) suction is more reliable than your dry suction? What are the advantages/disadvantages of each?

I’m happy to discuss wet and dry suction in general. For individual product specifications, I’ll have to refer you to the manufacturer of the chest drain(s) you use. I am not aware of any published research comparing the two approaches. Both will protect the patient and provide a window to the pleural space through the water seal chamber for assessment.

A water column is the original method used to control the amount of negative pressure that can be transmitted to the chest. When disposable integrated drains were developed, this was transformed into a suction control chamber. The level of the water in this chamber determines the limit of the negative pressure that can be transmitted to the chest. Challenges with water-based systems are the noise of the bubbling, and the potential for water evaporation. As water evaporates and the water level drops, the amount of negative pressure transmitted to the chest will also decrease. In addition, water-filled units take longer to set up, they weigh more when operating (a potential issue for transport), and if the drain is knocked over, the water can spill over into other chambers.

There are basically two types of dry suction. A small minority of drains operate with a restrictive orifice mechanism. In these drains, you would adjust a small knob that makes the path by which air leaves the drain larger or smaller in diameter, which indirectly limits the negative pressure. The problem with this is that it severely limits air flow out of the drain. A patient with a pneumothorax may have retained air as a result, particularly if on a ventilator. In addition, there is no self-adjustment if there is a change in the amount of flow from the vacuum source or from the patient.

The other, much more common, type is a self-regulating dry suction in which a small regulator is built into the drain. As long as there is adequate flow from the wall (which will be indicated on the drain) it will accurately adjust to changes in the source vacuum or the patient to maintain suction at the level set on the drain. It’s also silent. No bubbling is needed. In addition, these drains provide a wider range of suction levels, from -10cmH2O to -40cmH2O; there’s no evaporation to worry about; if the drain is knocked over, there is much less water to move between chambers; it’s lighter during operation; and it’s quicker to set-up. However, all these conveniences come with a higher price per drain.

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What causes subcutaneous emphysema in a patient with a pleural chest tube with a persistent air leak? Is it treatable and what assessments should be considered in patient care?

Subcutaneous air, also called subcutaneous emphysema or surgical emphysema, occurs in patients with chest tubes when air leaks under enough pressure to track along the tissue planes in the deepest layer of the skin, the subcutaneous layer. This can occur at the drain site or at a different site of pleural injury.1

Air or fluid will take the path of least resistance. For patients with pneumothorax or a postoperative air leak, that is usually through the chest tube. However, there are situations in which the path through the tissue is accessible and less resistant to air flow than the route through the chest tube:

Two retrospective reviews have examined the association of subcutaneous air with chest drainage. In one, 18% of chest tube patients had subcutaneous air (SQ).2 Of these, 80% were patients with pneumothorax or postthoracotomy; 20% had pleural effusions. Compared with a paired cohort at 3%, 20% of SQ patients had errors in tube placement. The other study looked at a database of patients with pulmonary resection in which 6% had clinically apparent SQ.5 Patients with poor preoperative pulmonary function, air leaks, and previous thoracotomy were more likely to have SQ. The researchers discovered that patients whose SQ did not resolve with chest drain suction had postop lung adherence to the intercostal space that had been opened, causing an alveolar-subcutaneous fistula. After a 16-minute (median time) VATS procedure to resolve the adhesion, the air was redirected to the pleural space, and 98% of patients’ SQ was resolved within 24 hours.5 

Case studies have been published describing clinical conditions associated with subcutaneous emphysema, including bronchial disruption from blunt chest trauma following extrication after an earthquake,6a motor vehicle crash,7 and a bicycle accident.8  It can also be the first sign of an iatrogenic pneumothorax following subclavian venous catheter4 or pacemaker1insertion.

There have also been reports of air entering the epidural space9 and vertebral artery dissection10 after subcutaneous air from pneumothorax tracked into the neck. The posterior mediastinum and neck can communicate through fascial planes, and from there, air can move into the spinal canal through the intervertebral foramen, the opening for the spinal nerve.9

While most instances of subcutaneous air relating to chest drainage are troubling cosmetically, it usually resolves without further problem.1,3 However, in rare cases, air in the neck can lead to airway obstruction, first evidenced by a change in voice.1,5 In addition, air in the tissue planes of the chest can cause a restrictive limit on respirations,1,8 similar to that seen with edema following chest wall thermal burns. The most important care is to determine why the subcutaneous leak is occurring and to correct that problem.2If the tube isn’t functioning properly, the patient could be at risk for recurrent pneumothorax and even tension pneumothorax, particularly with positive pressure ventilation.1 

Subcutaneous air, also called subcutaneous emphysema or surgical emphysema, occurs in patients with chest tubes when air leaks under enough pressure to track along the tissue planes in the deepest layer of the skin, the subcutaneous layer. This can occur at the drain site or at a different site of pleural injury.1

Air or fluid will take the path of least resistance. For patients with pneumothorax or a postoperative air leak, that is usually through the chest tube. However, there are situations in which the path through the tissue is accessible and less resistant to air flow than the route through the chest tube:

Figure 2 Palpating subcutaneous air
(courtesy trauma.org)

Nursing assessment of any patient with a chest tube should include regularly palpating the chest wall surrounding the tube. There is no routine need to remove the dressing; this palpation can be done over and around the dressing. If air accumulation is sudden and extensive, it will be easily visible. As with any evidence of a significant change, check airway, breathing and circulation first and then proceed to the drain.

Once subcutaneous air is detected, a thorough, but rapid assessment is important to determine if there is a problem with the chest drain system that can be easily fixed. Trace the tube from where it leaves the chest to the drain to ensure it is not pinched, kinked, or clamped; ensure there is no fluid in the tubing that could collect in a dependent loop.3 If suction is ordered, check the suction control chamber to make sure there is bubbling or that the suction indicator is visible in a dry control drain. If no suction is ordered, check to make sure the drain is open to atmosphere; if there is a stopcock on the suction tubing, make sure it is fully open.

If the drain is not connected to suction, the next step is usually to get an order to connect to suction and for a chest x-ray to check for pneumothorax, chest tube position, and lack of lung re-expansion.3,5,7,9 Sometimes, restarting or increasing the level of suction may solve the problem. If the patient is not on a ventilator and there are no contraindications, administering oxygen with a non-rebreather mask will facilitate resorption of nitrogen from the tissues.1

If no cause is evident, carefully remove the dressing to inspect the chest tube as it leaves the chest wall. Chest tubes have openings in the distal end to facilitate drainage. The number and position of the holes depends on the particular tube. In addition, tubes have a blue line that will show on an x-ray. The opening closest to the skin will be on the line enabling the position to be checked on a chest x-ray as a gap in the line (see arrow).2 Even if the opening isn’t visible at the incision, it may be outside the pleural space, allowing air to flow into the subcutaneous tissue. If the tube has pulled out slightly, it will have to be replaced. The tube is no longer sterile once it crosses the incision, so it cannot be pushed back into the chest. 

Keep in mind that even if  tube malposition didn’t cause the subcutaneous air, as air accumulates, the skin becomes “thicker” and this can cause the tube to slide out of proper position.2  If the tube doesn’t seem to be working, the physician may choose to add another tube or replace the potentially malfunctioning tube.4,9

Once the chest tube situation has been addressed, and the patient is no longer at risk, additional nursing care will need to focus on skin care. In a large majority of cases, air will be reabsorbed without sequelae. There have been some reports of incising the fascia to allow air to escape, inserting angiocatheters connected to suction into the subcutaneous space, and tissue massage, and a detailed report describes the use of a negative pressure wound therapy dressing, complete with information on integrating this dressing with chest drainage.11 The time for resolution will depend on the cause, the control of the cause, and the area affected. In the meantime, meticulous care of the distended skin and protection from friction and shear forces will reduce the risk for skin breakdown.

 

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Hi, I am a practicing clinical RN at a adult transplant ICU in a large teaching hospital. The residents in our hospital always argue with me on how to write chest tube orders. So there is water seal, which does not require any suction, except gravity. Sometime they would write -20 cm water seal suction. Is this a valid order to write? My understanding is that you either put it to water seal, or -20 cm water suction, which is control by the chamber to the most left in Atrium Ocean model. Please help me. Thank you very much.

Unfortunately, I was unable to find any standards for how orders are written for chest drainage. However, there are some interesting studies about communicating accurately and potential errors that can result from communication errors, which is what you describe.

All patients with chest tubes have a water seal (or a mechanical equivalent in dry seal drains) which is the one-way valve that allows air to leave the chest and prevents it from re-entering. Applying suction to the chest tube is an option; as you describe, some patients have suction applied and others do not. It seems that the physician literature uses the term “water seal” to describe a situation in which suction is not being used. I have used and prefer to describe a drain with no suction as being “gravity drainage,” since it describes how drainage is leaving the chest. If you have suction, the negative pressure pulls air and fluid out of the chest; without suction, it is the pressure differential caused by the position of the drain below the chest – gravity -- that allows air and fluid to drain.

Using this terminology, orders would read  

  Chest drain to -XX cmH2O suction drainage
  Chest drain to gravity drainage

But, as the literature shows, being “correct” may not be as safe as being consistent in terminology. I’m sure you have been through inservices on handoffs, but clear orders are equally important.1-3 Root causes of sentinel events have consistently been communication problems more than 60% of the time since 1995.2 One study of malpractice claims showed communication errors were postoperative 32% of the time, between one transmitter and one receiver 64%, information communicated was inaccurately received 44%, and between persons from two different disciplines 34% of the time1 – each of these factors apply to your concern.

How can this problem be addressed? First, a common terminology needs to be agreed to by a multidisciplinary team of nurses and surgeons. (I’m sure with a little investigation, you’ll see chest drainage is not the only terminology issue.) Standardized postoperative orders and clinical pathways incorporating the agreed upon terminology will not only reinforce the terms but set standards so deviations can be clarified (suction not ordered when expected and vice versa).3 Finally, house staff need to be oriented to hospital policy and protocol; one survival skills curriculum presented through the month of July focuses on communication skills, writing orders and progress notes, and problem solving by simulating “midnight” calls from nurses about a variety of patient scenarios.4 This would be an ideal opportunity to clarify just the issue you raise.

 

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We are a pediatric cardiovascular critical care unit.  We use the Atrium chest tubes chambers and also use the JP bulb/pigtail chest tubes when our patients arrive from OR.  Our practice is to strip the chest tubes due to the fear of clotting since they are so small, get an CXR as soon as we DC the chest tube and sometimes delay on Chest tube discontinuation.  I have found that in our patients of age 4 and up, when we strip the chest tube their pain level increase causing us to medicate appropriate and many times delaying transfer to the floor. I was wondering if there is any literature and information I can have to prepare my self and bring this wonderful information to my educators and find a way to present this to the staff.

I've had a chance to search and review the literature, and there is only one study that has examined pain associated with stripping chest tubes. The good news is that it examines pain in children with chest tube stripping, but the bad news for our purposes is that it is only pleural tubes.1

In this study, 16 children aged 3 to 18 with cancer who had thoracotomy were separated into two groups: the control group, with 8, had tubes stripped every 2 hours for the first 48 hours postop, and the experimental group had no tube manipulation. Pain was assessed with two different instruments immediately before and after stripping in the control group, and at similar intervals in the experimental group.

Patients who did not have tubes stripped had higher pain scores on the faces scale within the first 8 hours of surgery and at 24 hours postop compared with the group in which tubes were stripped. There was no difference with the visual analog scale at any time between the groups.

In addition, there was no difference in body temperature, breath sounds or radiograph between the groups.

Like you, I believe that stripping causes pain. The authors of this study note that the assessments were conducted after stripping, so the discomfort might have been missed.

Other studies of pain in cardiac surgery patients were done in adults, and not as specific as to examine stripping. One study of 705 cardiac surgery patients looked at pain relating to activity, pain on each postop day, and the relationship of pain to type of cardiac surgical procedure, to chest tubes, and to intubation.2 In order, the most pain was associated with coughing, moving or turning in bed, getting up to a chair or to walk, deep breathing, and at rest either lying in bed or sitting in a chair. Levels of pain at rest, with coughing, and when getting out of bed were significantly lower on the day after chest tubes were removed.

Two studies examined the patient's experience of having chest tubes.3,4 While these studies looked only at patients with pleural tubes, they note that the discomfort experienced was consistent with deep somatic / visceral pain, and that this discomfort interfered with sleep. There was little pain relating to the superficial surgical wound or the dressings. Patients reported intense pain when there were sudden movements such as coughing.

There are additional studies in the surgical literature,5-8 but they are not as descriptive or specific as these 4 nursing studies. One, of note, points out that "pain caused by the chest drain was their worst memory of the whole experience of undergoing cardiac surgery."

If you have the opportunity, assessing pain with and after stripping mediastinal tubes in children would be a great contribution to the literature, and Oakes' article provides enough detail that you could replicate that process. There is no doubt that the mere presence of tubes increases postoperative pain.

The other issue you raise is the use of a wound drain rather than a traditional chest tube.The wound drain has a silicone wall through the middle of the drain to create drainage channels. These take up room where fluid could flow. A tube’s ability to evacuate the chest is only as good as the smallest or most restrictive part of the tube. The transition zone (the area where there is a changeover from the multilumen catheter to the single lumen catheter) is the most restrictive area of a three-zone wound drain, whereas a traditional drain’s flow rate through a single lumen is constant throughout the length of the tube.

A tube’s stated size is determined by its outer diameter, not the flow area inside. When the inner diameter is factored in, a traditional 20 Fr chest tube allows for slightly greater flow than the 24 Fr wound drain, and more than 2½ times the flow of a 19 Fr wound drain. Thus, a surgeon who might be using a 24Fr wound drain in an effort to achieve better drainage can get a higher flow rate with a smaller traditional tube that will disturb less tissue. Obney and colleagues10 concluded that “larger is not necessarily better when draining the chest.” The key is not to focus on the tube’s outer diameter, but rather the flow rate through the tube.

Research shows no advantage to using wound drains instead of traditional thoracic catheters,8 and one case report describes life threatening hypovolemic shock resulting from a nonfunctioning wound drain used as a chest tube. 11

When examining research or manufacturer's literature, note whether flows are measured using blood or saline. Saline will flow three times faster than blood since it is less viscous, so if you are comparing manufacturer’s flow data, be sure you are comparing fluids of the same consistency.

Next is the use of a bulb drain instead of a traditional chest drain. A bulb drain creates unmeasured, unregulated suction that is then applied to the surgical site. The suction level is highest when the empty reservoir is first attached to the wound drain, and it drops as drainage collects in the reservoir. How high? When a 100mL bulb reservoir is initially compressed and attached to a drain, it generates approximately -161 cmH2O suction 12 – far more than the carefully regulated -20 cmH2O vacuum levels set on a chest drain attached to a thoracic catheter. As the reservoir fills, tissues are exposed to varying levels of suction, and the clinician at the bedside has no way of knowing the level of suction being applied to the pericardial or pleural space. As drainage collects in the reservoir, negative pressures rise to near zero, and the flow rate out of the chest drops. In the Carruthers study 12, drains lost any measureable suction when the reservoirs were half-full.. A pressure gradient between the patient and any drain is required to facilitate drainage, so if pressures equalize, drainage stops. This principle of physics may explain why you may be seeing clots in the tubes -- sluggish bloody drainage is much more likely to clot within a wound drain.

Frequent reservoir emptying is necessary to maintain negative pressure. This practice opens what should be a closed system, increasing risk for infection as well. We do not know the effect of creating additional negative pressure within a wound drain system through stripping.

In summary, there is no doubt that there is more pain experienced by patients with chest tubes, and that the presence of chest tubes interferes with sleep. There is a body of literature that shows that there is no advantage to stripping chest tubes, and that the procedure can generate dangerously high pressures, as we discussed at NTI. Your concerns about clot formation are not misplaced given the reduced area available for flow in the wound drain and the variable negative pressure in the bulb reservoir. Your surgeons could use a smaller traditional tube and achieve higher flow rates. Connecting the traditional tube to a regular chest drain gives you a truly closed system that does not require opening to empty fluid, while at the same time providing you with a constant, reliable level of negative pressure and all of the safety features you lose when you use a bulb reservoir for chest drainage.

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What happens if the nurse accidentally connects the suction tubing to the oxygen, is there a feature in the Atrium that will prevent the air from entering the lungs? Sometimes there is a commotion at the bedside post op and a possibility like this can happen. Thank you in advance for the answer.

Thanks for your question to "Ask the Expert" on the Atrium University Web site. I am the "dean" of Atrium U and handle the questions.

Today's disposable unibody chest drains have a positive pressure relief valve built in. This detects a build-up of positive pressure and vents it to the atmosphere before it could harm the patient. A flow of oxygen into the drain would create positive pressure. You should check with the chest drain manufacturer to learn the specifics about the pressure at which the valve will release on the particular drain you're using.

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At our facility we are trying to decide on a practice change where nurses in critical care as well as on all floors would assist an MD with Chest Tube insertions, set-up, and maintaining the chest tube(s). Tradionally, Resp Therapists have gathered the equipment, set-up the atrium and rounded daily on the patients with chest tubes outside of critical care (as the experts).Is it standard practice in the U.S. for nurses on all floors to be able to assist with insertion,set up the drainage system, and totally maintain the system...or just in specific units to maintain competency/profciency? Some of our medical floor nurses have not cared for a patient with chest tubes for a year or more (ie. Neuro, GI/Endo, Med Tele). Please advise on best practice.

I love getting questions like yours because I learn something new every time. I have not heard of a practice as you describe. As a respiratory therapist myself, I always felt like I had an advantage in understanding chest drainage because of the classes in physics I had to take. Quite frankly, I learned very little about chest drainage in my nursing education. But in the U.S., this is traditionally a nursing role.

I don't see anything wrong with the respiratory therapist being a key member of the team caring for patients receiving chest drainage. However, nurses must have basic competency in assessment and patient management to be safe and to recognize potential complications early.

I could not find anything in the literature about the respiratory therapist's role in chest drain management or chest tube insertion in the hospital. I only found mentions of therapists' role during critical care transport. By contrast, the American College of Chest Physicians1 guideline for interventional procedures says about tube thoracostomy,
The only required personnel is the dedicated operator placing the tube. An RN or nurse assistant may be useful to set up the sterile field, position the patient, and prepare the collection device.

That said, staffing is also a consideration. If respiratory therapists have a system in place to assist at procedures such as chest tube insertion and bronchoscopy, I'm not sure I would change that in order to have nurses assist with the procedure and add to their already busy shifts. But that's only for the procedure, not for patient assessment and care.

Brunner & Suddarth's Textbook of Medical-Surgical Nursing (2010) has a chapter on respiratory care modalities that includes a lengthy discussion on the nurse's role in caring for patients with chest drainage. The chapter is available for free download here . There is also a good overview of the nurse's role and responsibilities in MEDSURG Nursing2.

Two of my favorite articles on nurses' knowledge and educating nursing about chest drainage are written by two nurses from Dublin, Ireland.3,4 While it's important to keep in mind that they are discussing the U.K., the general lack of knowledge is, unfortunately, not limited to nurses across the Atlantic.

As I noted earlier, all nurses who care for patients with chest drainage must have a baseline of knowledge and know the warning signs of potential problems. As for nurses who care for these patients only occasionally, there are a number of options. You have experts already in your respiratory therapists, so they could act as consultants to the nurses who care for these patients less often. My experience in both small and large hospitals has been with nurse educators who were available hospital-wide 24/7 as resources for clinical staff. A third option is to use your rapid response team members as clinical consultants as well.

You said you used Atrium drains; are you aware that the toll-free number on the front of each drain is covered by a product expert 24/7/365? That's another great alternative.

And finally, we have a number of resources for education on the Atrium University site at www.AtriumU.com . I invite you to explore the tabs on the home page to see the different things we have developed.

And if you will allow me one final point, remember that competence is not just knowledge. When nurses are competent, they have the requisite knowledge, skills, self-awareness of one's own limitations and capabilities, and attitudes to perform in a given setting, and performing successfully. We've all known those who were "book smart" but couldn't transfer that knowledge to the bedside. Don't forget to check the clinical practice application of the knowledge you would assess with checklists and quizzes.

 

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When attaching the chest tube to suction do you connect thru the suction canister or do you connect directly to the gauge? If using the canister to connect, please provide a reason why or direct me to literature surrounding this method..

There are standards that call for suction canisters between any patient connection and wall vacuum. The leading standards regarding hospital vacuum systems is the NFPA 991, which establishes various minimum safety practices and requirements for hospitals. The standards discuss the need to protect the entire vacuum system.

Specifically, the sections and recommendations are:
A-5.1.15.7.4   Suction collection bottles that are used as part of patient treatment equipment should be equipped with an overflow shutoff device to prevent carryover of fluids into equipment of the piping system. It is recommended that a separate vacuum trap with shutoff be used in between the suction collection bottle and the vacuum system station inlet.

C.9.1.4.5  Trap bottles should be fixed to the wall or other appropriate stationary object to prevent tipping and subsequent spillage of liquid contents into the source of suction.

C.9.1.4.5.1  Trap bottles should be utilized between collection bottles and the source of suction to prevent spillage.

C.9.1.4.5.4  The overflow-preventive mechanism of the trap bottle should be cleaned each time the bottle is emptied and should be tested periodically to ensure proper functioning.

The Unified Facilities Criteria (UFC) 4-510-01 from the Department of Defense provides mandatory policies and procedures for all military medical facilities. Increasingly, these have become the defacto standards for all hospitals and the latest update was published in May 2014.

Section 9-5.16.5  ...vacuum bottles shall be used at all vacuum inlets to prevent liquids and solids from entering the piping network. Vacuum bottles shall be provided with an overflow shut-off device to prevent carryover of fluids or solids into the piping system. (p. 96)

These standards do not have exceptions for specific applications. They reply to all medical suction, regardless of whether you are directly removing material into a collection bottle, such as with endotracheal or gastric suction, or using vacuum through another device such as a chest drain.

You can download the UFC at http://www.wbdg.org/ccb/DOD/UFC/ufc_4_510_01.pdf

The NFPA standards are not available for free download, but your hospital will have them.

For additional information on hospital vacuum and medical suction, Ohio Medical has resources you can download for free here: http://ohiomedical.com/publications.aspx

In the interest of full disclosure, I want you to know I wrote a few of those documents. We developed them because there are so few resources about proper use of suction for clinicians.

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Is there any current information that you can share regarding milking/stripping the tubing? At the hospital I currently work at, we do neither, but would like literature supporting that. When searching the web, I find conflicting reports.

The first study that examined chest tube stripping was published in 1982; the nurse researchers discovered pressures as low as -400 cmH2O with stripping.1 The authors provided a detailed explanation of exactly how they manipulated the tube and how pressures were measured. Since then, however, there has been no standardized terminology or methods for assessing tube manipulation. Various articles have looked at milking, fan-folding, tapping, squeezing and “gentle stripping,” but few have specifically and carefully described each tube manipulation technique.

That said, the literature shows that tubing manipulation does not improve fluid drainage from the chest after cardiac surgery.2-7 The two most recent publications are a “best evidence review” for cardiac surgery from 2008 that concluded, “no clinical or physiological advantages have been demonstrated in the use of manipulation compared to no manipulation;”2 and a prospective, randomized study of pulmonary resection patients from 2010 that concluded “postoperative morbidity and mortality was not improved and therefore chest tube milking cannot be recommended as a routine postoperative procedure.”8

Of particular interest, the pulmonary researchers noted that without improved outcomes, an increase in pleural fluid with routine tube manipulation could instead result from tissue irritation and trauma related to tube manipulation, and not improved physics of fluid evacuation from the chest.8

Results of a survey of surgeons and nurses about care of patients with chest tubes published in 2009 produced interesting results.9 Surgeons were asked: “Which statement best suits your attitude toward chest tube ‘stripping’?” In response, 74% “allowed it,” 23% “discouraged it,” and 4% “absolutely forbid it.” (higher than 100% due to rounding). By contrast, when nurses were asked, “Does your institution allow nurses to strip chest tubes and chest drainage tubing to remove clots?” 28% said yes and 72% said no – precisely the opposite of the surgeon responses.

Surgeons were also asked, “[how satisfied are you with the] currently available techniques for nurses to deal with active chest tube clogging (e.g., tapping, folding, squeezing, and milking the tube) in the setting of bleeding?“ 2% said the techniques were completely unsatisfactory, 49% usually unsatisfactory, and 49% usually satisfactory.

We don’t yet know what causes chest tube blockage, how often it occurs or how to prevent it (except in cases of empyema). That knowledge would put this issue to rest, as we could address the cause rather than this old practice that is not based on scientific study. Without any clear advantage and knowledge of potential hazards, I would not support stripping or milking tubes.

 

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Per your website/modules, the suction control(bubbling) should be controlled by the head wall suction source. We have battles with our surgeons who adjust the bubbling from the valve. Does it make a difference? Also, in our old chest tube systems, we drew cultures through the self sealing tubing. On our newer systems, there is a port where the draining tubing connects to the atrium draining system. Is that valve for collecting pleural specimans? Thanks!

Let's start with the suction question. The stopcock was added to the suction tubing to allow adjustments in flow to the suction control chamber when wall vacuum is unregulated or when two drains are connected with a wye to a single vacuum regulator.

When working with a single drain, I much prefer leaving the stopcock open completely and adjusting from the wall vacuum regulator, as you note. That way, there is nothing to limit flow to the drain and you have full control from the wall. But, if the wall regulator is difficult to reach or has the potential to get confused with regulators for nasogastric or endotracheal suction, the stopcock is a safe and viable option. Just be sure that any time the patient is transported or disconnected from the wall vacuum, the stopcock is fully opened since that's how air will leave the system.

It's important to make sure that everyone knows just what is being adjusted. The amount of negative pressure transmitted to the chest is determined by the level of water in the suction control chamber. The adjustments at the vacuum regulator or with the stopcock only changes the amount of bubbling by increasing or decreasing the total flow through the drain. Once the bubbles begin, that's your signal that any excess negative pressure is being vented to the atmosphere through the bubbles. The stopcock only adjusts flow, not negative pressure.

As for sampling drainage, the two leading drain manufacturers offer the following advice:

From Teleflex:

Autotransfusion connectors (red and blue) are provided in the patient tube. See instructions for autotransfusion use. A self-sealing sampling port is provided in the connector for taking samples of patient drainage. Use an 18 gauge (or smaller) needle, attached to a syringe, for withdrawing samples.

 

From Atrium/Maquet:

Sampling of patient drainage must be in accordance with approved hospital infection control standards. Selected models include a needleless luer port on the patient tube connector for sampling patient drainage. Alcohol swab the luer port prior to syringe attachment (no needle). Fluid samples can also be taken directly from the patient tube by forming a temporary dependent loop and inserting a 20 gauge needle at an obtuse angle. Alcohol swab the patient tube prior to inserting syringe at a shallow angle. Do not puncture patient tube with an 18 gauge or larger needle.

 

Every time you open a drain, instructions for use are included in the packaging. In those instructions, you'll see whether the patient connecting tubing will self-seal after being punctured with a needle and what size needle to use. Some drains have a port for the needle puncture and others have a needleless port. The needleless port is located alongside the tubing connector near the drain. For maximum safety, I would only use a needle as a last resort. If you need additional clarification, contact your drain manufacturer who can give you advice based on your particular drain's features. Be sure to follow your facility's infection control standards for collecting and processing any drainage sample.

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For product-specific inservice-type educational materials, please check with the chest drain manufacturer.