Chest Drain Management

Introduction
Chest drains also known as under water sealed drains (UWSD) are inserted to allow draining of the
pleural spaces of air, blood or fluid, allowing expansion of the lungs and restoration of negative pressure
in the thoracic cavity. The underwater seal also prevents backflow of air or fluid into the pleural cavity.
Appropriate chest drain management is required to maintain respiratory function and haemodynamic
stability.Chest drains may be placed routinely in theatre, PICU & NNU; or in the emergency department
and ward areas in emergency situations.
Some cardiac surgical patients will have Redivac drains in the chest and these are different from UWSD.
Aim
To describe safe and competent management of (UWSD) chest drainsby the health care team
Definition of terms
Chylothorax: Collection of lymph fluid in the pleural space
Haemothorax: Collection of blood in the pleural space
Pneumothorax :Collection of air in the pleural space
Tension Pneumothorax:One way valve effect allowing air to enter the pleural space, but not to leave.
Air builds up forcing a mediastinal shift. This leads to decreased venous return to the heart and lung
collapse/compression causing acute life-threatening respiratory and cardiovascular compromise.
Ventilated patients are particularly high risk due to the positive pressure forcing more air into the pleural
space. Tension pneumothorax can result in rapid clinical deterioration and is an emergency situation
Pleural effusion: Exudate or transudate in the pleural space
Under Water Seal Drain (UWSD):Drainage system of 3 chambers consisting of a water seal, suction
control & drainage collection chamber. UWSD are designed to allow air or fluid to be removed from the
pleural cavity, while also preventing backflow of air or fluid into the pleural space.
Flutter valve (e.g. pneumostat, Heimlich valve):One way valve system that is small & portable for
transport or ambulant patients. Allows air or fluid to drain, but not to backflow into pleural cavity.
Indications for Insertion of a Chest Drain
o Post operatively e.g. cardiac surgery, thoracotomy
o Pneumothorax
o Haemothorax
o Chylothorax
o Pleural effusions

Insertion of a Chest Drain
the Chest Drain (Intercostal Catheter) Insertion Clinical Practice Guideline.
Fluid or air that accumulates in the pleural space will reduce lung expansion and lead to respiratory
compromise and hypoxia.
Insertion of an intercostal catheter (ICC) enables drainage of air or fluid from the pleural space, allowing
negative intra-thoracic pressures to be re-established leading to lung re-expansion.
Indications:
Pneumothorax
Haemothorax
Pleural effusion
Contraindications:
Need for immediate thoracotomy
Complications:
Pain
Thoracic or abdominal visceral trauma
Tension pneumothorax
Equipment
Special procedures tray
Under water sealed drain system (UWSD)
o use cell saver UWSD for massive haemothorax
Intercostal Catheter (guide sizes only)
o use smaller size for draining air
o larger size for draining blood/fluid
Newborn 8-12 FG
Infant 12-16 FG
Child 16-24 FG
Adolescent 20-32 FG
Spigot connector / tube adaptor - 2 sizes
Suction must be available and working
Sterile gloves & gown
Mask
Sterile towels x 2
500ml bottle of sterile water
Antiseptic solution
1% lignocaine + 1:100,000 adrenaline 5mL ampoule
5ml/10ml syringe and needle
Scalpel blade
Suture material - black silk or nylon with needle size 3.0 x 2
Sleek and Tegaderm x 2
Analgesia, Anaesthesia, Sedation
Local anaesthetic and intravenous analgesia are mandatory, as ICC placement is a painful procedure. The
use of sedation should always be discussed with a senior emergency doctor, as it can potentially worsen
the patient's clinical condition.
Procedure
Establish patient on continuous cardiac monitoring and pulse oximetry
Place conscious patient in a sitting position at 45 degrees with arm of same side placed above head
Palpate the fourth or fifth intercostal space just anterior to the mid-axillary line
Surgically prepare the area
Ensure local anaesthetic is infiltrated from subcutaneous tissue down to pleura.
Select the appropriate size I.C.C. and remove stylet.
Incise the skin parallel to the upper border of the rib below the chosen intercostal space. Incise down to
the fascia.
"Blunt dissect" (using an artery forcep) down to the pleura, enter the pleural space, and then widen the
hole by opening the forceps.
Sweep the pleural space with a gloved finger to widen the hole and push the lung away from the hole
(only possible in older children, beware of rib fractures in injured child).
Hold the tip of the catheter with a curved artery clamp and advance it into the pleural space, directing the
catheter posteriorly and superiorly.
Advance so that all apertures of the tube are in the chest and not visible
Attach the tube to UWSD below the patient's chest level
Anchor the drain and suture the wound. Tape in place with tegaderm sandwich and anchor the tube to the
patient's side.
Connect to the UWSD.
Watch for "swinging" of water in tube connection.
Post-Procedure Care
Reassess ABCs and ensure ICC is functioning
Reassess need for analgesia.
In children following the removal of the tube coverage with a large tegaderm is sufficient for closure
rather than a formal purse string suture.
Chest Drain Set Up
o Perform Hand Hygiene
o Open drain packaging in a clean, 'no-touch' manner
o Prepare drain as per manufacturers instructions
o Pass sterile end of tubing to Doctor inserting drain when they are ready
o Apply suction to drain if ordered
o Secure drain & tubing to bed and patient
o Secure all connections with cable ties
o Perform hand Hygiene

Management
Chest drains should not be clamped
o There is a risk of the patient developing a tension pneumothorax if a drain is clamped while an air leak is
present
Start of shift checks
o Patient assessment
o Chest drain assessment
o Equipment
o Other considerations e.g physiotherapy referral
Patient Assessment
Vital signs
o PICU and NNU patients should be on continuous monitoring
o
HR, SaO2, BP, RR
Routine vital signs:
o For ward areas:
On insertion of chest drain monitor patient observations of HR, SaO2, BP, RR:
15 minutely for 1 hour
1 hourly for 4 hours
Includes HR, SaO2, BP, RR and temperature
1-4 hourly as indicated by patient condition
Pain
o Chest tubes are painful as the parietal pleura is very sensitive. Patients require regular pain relief for
comfort, and to allow them to complete physiotherapy or mobilise
o Pain assessment should be conducted frequently and documented
Drain insertion site
o Observe for signs of infection and inflammation and document findings
o Check dressing is clean and intact
o Observe sutures remain intact & secure (particularly long term drains where sutures may erode over time)

Assessment of chest tube and system tubing should occur at the beginning of the shift and every hour
throughout the shift
UWSD Unit & tubing
o Never lift drain above chest level
o The unit and all tubing should be below patients chest level to facilitate drainage
o Tubing should have no kinks or obstructions that may inhibit drainage
o Ensure all connections between chest tubes and drainage unit are tight and secure
Connections should have cable ties in place
o Tubing should be anchored to the patients skin to prevent pulling of the drain
o In PICU and NNU tubing should also be secured to patient bed to prevent accidental removal
o Ensure the unit is securely positioned on its stand or hanging on the bed
o Ensure the water seal is maintained at 2cm at all times
Suction
o Suction is not always required, and may lead to tissue trauma and prolongation of an air leak in some
patients
o If suction is required orders should be written by medical staff
Some clinical areas may use the orange 'Chest Drain Orders" sticker. This should be placed in the patient
progress notes.


o Wall suction should be set at >80mmHg or higher
o Suction on the Drainage unit should be set to the prescribed level
-5 cmH
2
0 is commonly used for neonates
-10 cmH
2
0 to -20 cmH
2
0 is usually used by convention for children
o To check suction:
Atrium Oasis UWSD:
The bellows should be out to the '?' mark @ 20 cmH
2
0
Any visible expansion of the bellows is adequate for suction <20 cmH20
If the bellows deflate, check the wall suction is still working, set to > 80mmHg and that the suction tubing
is not kinked
o Atrium Ocean UWSD:
The water level in the suction chamber should be at prescribed level
The level may drop due to evaporation, top up as per manufacturers instructions
Drainage
o Milking of chest drains is only to be done with written orders from medical staff. Milking drains creates a
high negative pressure that can cause pain, tissue trauma and bleeding
o Volume
Document hourly the amount of fluid in the drainage chamber on the Fluid Balance Chart
Calculate and document total hourly output if multiple drains
Calculate and document cumulative total output
Notify medical staff if there is a sudden increase in amount of drainage
greater than 5mls/kg in 1 hour
greater than 3mls/kg consistently for 3 hours
Blocked drains are a major concern for cardiac surgical patients due to the risk of cardiac tamponade
notify medical staff if a drain with ongoing loss suddenly stops draining
If the chamber tips over and blood has spilt into next chamber, simply tip the chamber up to allow blood
to flow to original chamber
o Colour and Consistency
Monitor the colour/type of the drainage. If there is a change eg. Haemoserous to bright red or serous to
creamy, notify medical staff.
Air Leak (bubbling)
o An air leak will be characterised by intermittent bubbling in the water seal chamber when the patient with
a pneumothorax exhales or coughs.
o The severity of the leak will be indicated by numerical grading on the UWSD (1-small leak 5-large leak)
o Continuous bubbling of this chamber indicates large air leak between the drain & the patient. Check drain
for disconnection, dislodgement and loose connection, and assess patient condition. Notify medical staff
immediately if problem cannot be remedied.
o Document on Fluid Balance Chart
Oscillation (swing)
o The water in the water seal chamber will rise and fall (swing) with respirations. This will diminish as the
pneumothorax resolves.
o Watch for unexpected cessation of swing as this may indicate the tube is blocked or kinked.
o Cardiac surgical patients may have some of their drains in the mediastinum in which case there will be no
swing in the water seal chamber.
o Document on Fluid Balance Chart

Equipment by the bedside
o Drain Clamps: At least 2 drain clamps per drain
o For use in emergency only e.g. accidental disconnection
o Two suction outlets: One for chest drain & one for airway management
Other Considerations
o Referral to physiotherapist should be made to enhance chest movement and prevent a chest infection
Patient Positioning
o Patients who are ambulant post operatively will have fewer complications and shorter lengths of stay.
Consider converting to a portable flutter valve system such as the pneumostat to facilitate this If chest
drain will be required for prolonged period
o If a patient is on strict bed rest or is an infant, regular changes in position should be encouraged to
promote drainage, unless clinical condition prevents doing so
Patient Transport
o If the patient needs to be transferred to another department or is ambulant, the suction should be
disconnected and left open to air.
o DO NOT CLAMP THE TUBE
Clamps must not be used on the patient for transport because of the risk of tension pneumothorax
o Ensure the chamber is below the patients chest level during transport
o Flutter Valve systems (pneumostat, Heimlich) may be used for patient interhospital transfers (e.g. NETS
and PETS)
Specimen Collection
o Collect drainage specimens for culture through the needless sampling port located by the in line
connector.
o Equipment Required
Specimen container
Alcohol swab
10ml syringe
Dressing pack
Gloves
Eye Protection
o Procedure:
1. Wait for the fluid to collect in a loop of the tubing
2. Perform hand hygiene, then don gloves & eye protection
3. Clean the sampling port with an alcohol wipe and leave to dry for 20 seconds
4. Clamp the tubing above where the fluid has collected
5. Connect a 10ml Luer lock syringe to the sampling port and aspirate the fluid out of the tubing
6. Place fluid in sterile specimen container
7. Once the syringe is disconnected remove all clamps and kinks
8. Perform hand hygiene
Chest Drain Dressings
o Dressings should be changed if:
no longer dry and intact, or signs of infection e.g. redness, swelling, exudate
Infected drain sites require daily changing, or when wet or soiled
No evidence for routine dressing change after 3 or 7 days
This procedure is a risk for accidental drain removal so avoid unnecessary dressing changes
o Exact type of dressing may depend on treating medical team
For cardiac surgical patients with drains inserted intraoperatively:
use split gauze & mefix dressing
ensure dressing does not communicate with sternotomy dressing or wound
For all other chest drains
Sandwich between occlusive dressing
Allows site visibility & prevents pressure on skin
If site oozing dress with split gauze and occlusive dressing
o Ensure drain is secure
To prevent it falling out use a 'tag' of tape to secure to skin
Apply comfeel or similar to protect fragile skin from 'tag' of tape

Changing the Chamber
o Indications
The chest drain chamber needs to be replaced when it is full or when the UWSD system sterility has
been compromised eg. Accidental disconnection.
o Equipment Required
New UWSD
Dressing pack
Gloves
Eye Protection
o Procedure
0. Perform hand hygiene
1. Use personal protective equipment to protect from possible body fluid exposure
2. Using an aseptic technique, remove the unit from packaging and place adjacent to old chamber
3. Prepare the new UWSD as per manufacturers directions supplied with drain
4. Ensure patients drain is clamped to prevent air being sucked back into chest
5. Disconnect old chamber by holding down the clip on the in line connector to pull the tubing away from
the chamber.
6. Insert the tubing into the new chamber until you hear it click Unclamp the chest drain
7. Check drain is back on suction
8. Place old chamber into yellow infectious waste bag & tie
9. Perform hand hygiene
Splitting the UWSD Chambers
o Indications
When 2 chest drains are connected via a Y-connector into 1 drainage chamber there may be a need to
have them split into 2 chambers to determine if 1 drain is draining more than the other
o Equipment Required
New UWSD
Dressing pack
Gloves
Eye Protection
Chlorhexidine
Scissors
Connector
Cable tie wraps
Cable tie gun
Pliers
o Procedure (also see figure below)
0. Perform hand hygiene
1. Use personal protective equipment to protect from possible body fluid exposure
2. Place newly prepared drainage system in a position adjacent to the old system as set up as per chest drain
set up.
3. Clamp all tubing
4. Cut the tie wraps with the Pliers
5. Remove the Y connector and attached tubing
6. Clean ends of exposed drains And wait 20 seconds
7. Attach drainage system to chest drain
8. Repeat with second chamber
9. Place tie wraps around connection site and pull to tighten
10. Tighten further using Cable tie Gun
11. Once secure remove clamps and check for signs suction has returned

Removal of Chest Drains
o Must be a written order by medical staff
o Indications
Absence of an air leak (pneumothorax)
Drainage diminishes to little or nothing
No evidence of respiratory compromise
Chest x-ray showing lung re-expansion
o Equipment required
Dressing trolley with Yellow Infectious waste bag attached
Dressing pack (sterile towel, sterile gauze)
Sterile Gloves
Steristrips
Suture Cutter
Band Aids
Normal Saline
Clamps
Eye Protection
Occlusive dressing
Sharps container
o Patient preparation
Ensure Patient is fasted, has adequate pain control, sedation and distraction therapy (see procedural
sedation guideline)
Consider environment i.e. treatment room, privacy screens if in ward area etc
Heparin infusions for cardiac patients should not be discontinued prior to drain removal
o Procedure
0. Perform hand hygiene
1. Opening dressing pack and add sterile equipment and 0.9% saline
2. Don disposable gloves
3. Remove all dressings around the area
4. Clamp drain tubing
If there are multiple drains insitu, clamp all drains before removal. Once the required drains are removed,
unclamp remaining drains
5. Remove disposable gloves, perform hand hygiene and don sterile gloves
6. Place sterile towel under tubes
7. Clean around catheter insertion site and 1-2cm of the tubing with 0.9% Saline
8. If purse string present (cardiac patients) unwind in preparation for assistant to tie
9. Remove suture securing drain (ensuring purse string suture not cut)
10. Instruct patient exhale and hold if they are old enough to cooperate; if not, time removal with exhalation
as best as possible.
11. Pinching the edges of the skin together, remove the drain using smooth, but fast, continuous traction.
12. The assistant pulls purse string suture closed as soon as the drain is removed, tying 2 knots and ensuring
the suture is not pulled too tight. Cut tails of suture about 2cm from knot
If there is no purse string present remove drain and quickly seal hole with occlusive dressing
13. Instruct patient to breathe normally again
14. Apply occlusive dressing (bandaid for cardiac children) over site
15. Remove and discard equipment into a yellow infectious waste bag and tie
16. Perform hand hygiene
o Post Procedure Care
Attend to patients comfort and sedation score as per procedural sedation guideline
CXR should be performed post drain removal
Patients in PICU may wait until routine daily CXR if clinically well
Clinical status is the best indicator of a reaccumulation of air or fluid. CXR should be performed if patient
condition deteriorates
Monitor vital signs closely (HR, SaO2, RR and BP) on removal and then every hour for 4 hours post
removal, and then as per clinical condition
Document the removal of drain in progress notes and on patient care record
Remove sutures 5 days post drain removal
Dressing to remain insitu for 24 hours post removal unless dirty
Complications post drain removal include pneumothorax, bleeding and infection of the drain site
Complications and Troubleshooting
Pneumothorax
o Signs and symptoms include: Decreased SaO2, increased WOB, diminished breath sounds, decreased
chest movement, complaints of chest pain, tachycardia or bradycardia, hypotension
o Notify medical staff
o Request urgent CXR
o Ensure drain system is intact with no leaks, or blockages such as kinks or clamps
o Prepare for insertion/ repositioning of chest drain
Bleeding at the drain site
o Don gloves
o Apply pressure to insertion site
o Place occlusive dressing over site
o Notify medical staff
o Check Coagulation results
o Check drain chamber to ensure no excessive blood loss
Infection of insertion site
o Notify medical staff
o Swab wound site
o Consider blood cultures
Accidental disconnection of system
o Clamp the drain tubing. Clean ends of drain and reconnect. Ensure all connections are cable tied. If a new
drainage system is needed cover the exposed patient end of the drain with sterile dressing while new drain
is setup. Ensure clamp removed when problem resolved
o Check vital signs
o Alert medical staff
Accidental drain removal
o Apply pressure to the exit site and seal with steri-strips. Place an occlusive dressing over the top
o Check vital signs
o Alert medical staff.
Purse string cut or not present
o Small bore drains such as pigtails do not require purse strings. Simply apply an occlusive dressing.
o For large bore drains:
Pinch or apply pressure to the exit site
Apply steri-strips to close exit site and cover with an occlusive dressing
Notify the responsible medical team to review patient and consider need for a suture
Unable to remove chest drain
o If the drain is unable to be removed with reasonable traction being applied, notify the responsible medical
team
Family Centred Care
o Explain purpose of chest drain to family and when it is likely to be removed
o Discuss the need for pain relief for the child to be comfortable enough to move and participate in
physiotherapy