GMHA

NURSING SERVICES DEPARTMENT

Guidelines for Care:

Management of Patients
with a Chest Drainage
Unit
Loribelle Kim, RNC‐OB, Staff Nurse Training Officer‐ Acting
 OBJECTIVES:
1. Identify the indications, contraindications, and risks
associated with the use of a Chest tube/Chest Drainage Unit.

2. Identify and be familiar with the Chest Drainage Units

available in your designated unit.

3. Recall basic principles of the Chest Drainage Units (CDUs).

4. Recall Nursing Staff roles/responsibilities for patients with a

chest tube and Chest Drainage Unit.

5. Recall special considerations and KEY POINTS while patient

is on a Chest Drainage Unit.

6. Review GMHA Policy and Procedure 6353-11-H-14: Care of a

Patient with a Thoracic Drainage System and 6313-II-51.00:
Care of the patient with Chest Tubes
WHAT ARE INDICATIONS FOR A PATIENT
WITH A CHEST TUBE DRAINAGE SYSTEM?
 A Chest Drainage Unit (CDU) (also known as the
Thoracic drainage system) is a device that is connected
to a tube that is inserted into the pleural space of
the chest to evacuate air or fluid and/or help
regain negative pressure.
1. During or immediately after thoracic surgery,
chest tubes are positioned strategically in the
pleural space, sutured to the skin, and
connected to the CDU to remove the residual
air, and fluid from the pleural or mediastinal
space.
2. CDUs are also inserted to treat spontaneous
pneumothorax or hemothorax/pneumothorax
caused by trauma.
 INDICATIONS CONTINUED…

3. CDUs help drain substances

that may accumulate in the lungs
such as:
 AIR- Pnuemothorax
 BLOOD- Hemothorax
 FLUID- Pleural effusion
 LYMPHATIC FLUID- Chylothorax
 PUS- Emphyema
 This collection of air, fluid, or other substances in the
thoracic cavity can compromise cardiopulmonary
function and cause collapse of the lung.
4. Need for pleurodesis: A procedure used to treat
patient with recurrent pleural effusions or
recurrent pneumothorax.
5. Chemotherapy administration
 CHEST TUBE PLACEMENT:
 Site for chest tube placement
include:
 For pneumothorax (air)– 2nd or
3rd interspace along
midclavicular or 4th intercostal
space anterior axillary.
 For hemothorax (fluid)– 6th or
7th lateral interspace in the
midaxillary line.
CHEST TUBE CONTRAINDICATIONS AND
RISKS:

 There are no definite contraindications

especially when a patient is experiencing
respiratory distress.
 Risks may include:
 Infection at the site of insertion
 Bleeding at the site
 Subcutaneous emphysema
 Lung trauma and perforation of the diaphragm
 Bronchopleural fistula
 And most commonly, malposition of the chest tube
 WHAT IS A CHEST DRAINAGE UNIT?
 Most commonly used chest
drainage units use the water-
seal principle. (e.g. Pleur-
evac)
 Continuous wall suction unit
 Water-sealed unit (“no wall
suction”)
 This system:
 collects drainage
 creates a water seal
 controls suction
 allows air and fluid to escape
from the pleural cavity but
doesn’t allow air to re-enter to
restore negative pressure.
 TYPES OF CHEST DRAINAGE UNITS (CDU):
Type Description Indications for use
Standard CDU  Drainage of pleural  Following surgery that impacts on
cavity for air or any type the continuity of the thoracic cavity
of fluid with or without (eg, thoracic, cardiac, esophageal
the use of suction surgery)
 Up to 2,000mL capacity  Pneumothorax
 Replaced when full  Hemothorax
 Pleural effusion
 Pleurodesis

Smaller portable CDU  Drainage without use of  For ambulatory patients

suction  Home care
 Dry seal system that  Chronic conditions
prevents air leaks
 No lung reexpansion
occurs
 500mL max drainage
 Emptied when used in
home
TYPES OF CHEST DRAINAGE UNITS (CDU):

Indwelling pleural catheter  Small‐size chest tube or  Pneumothorax

pigtail catheter (smaller  Chronic drainage of
than standard 14Fr) fluid
 Can be irrigated if  Not for trauma or blood
occluded by health care  Can be used for
provider pleurodesis
 Less traumatic

Heimlich valve  One‐way “flutter valve”  Evacuates air from the

 Removes air as patient pleural space
exhales  Used for emergency
 Valve opens when transport, homecare,
pleural space pressure > and long‐term care
than atmospheric units.
pressure & closes when
the reverse occurs
WHAT IS THE CHEST DRAINAGE UNIT
(CONT’D):
 The water seal drainage system is a single unit
with three chambers.
 1st chamber: “collection chamber”; receives
fluid and air from the chest cavity through the
collecting tube attached to the chest tube.
 2nd chamber: “water-seal chamber”; with 2cm
of water acting as a one-way valve, allowing
drainage out but preventing backflow.
 3rd chamber: “controlled suction”;
 Type 1-Continuous wall suction unit
 Type 2-Water-seal unit (“no wall suction”)
TYPE OF CHEST DRAINAGE UNIT USED IN GMHA:

Continuous Wall
Suction Unit

VS

Water‐Seal Unit
(no wall suction)
2 COMMON TYPES OF ORDERS FOR THE
CHEST DRAINAGE UNIT USED IN GMH:
 Continuous Wall Suction Unit
 connected to a wall suction source
 uses a suction monitor bellow that balances wall suction.
 a restrictive device or regulator is used to dial the desired negative
pressure
 No bubbling
 No water evacuation

 Water-Seal Unit (“no wall suction”)

 regulated by height of water in the suction control chamber when
connected to the wall suction.
 8-15cm for neonates
20cm for all others in the chamber


 You should hear and see bubbling while it’s working.

 Water can evaporate over time.
 drains by gravity
Nursing Roles and Responsibilities:
How to manage a patient with
a chest drainage unit
 First: CHECK the patient !!!
1. INITIAL ASSESSMENT:
 Asses patient’s clinical status and vital signs.
 Encourage the patient to report breathing difficulty immediately.

2. Check the rate and the quality of the patient’s respirations

 Auscultate breath sounds EVERY shift.
 Diminished or absent breathe sounds may indicate that the lung has not
yet re-expanded.
 Observe and report immediately signs of rapid, shallow breathing,
cyanosis, pressure in the chest, subcutaneous emphysema or symptoms of
hemorrhage.
 Second: CHECK the Drainage Unit!!!

3. Do an initial assessment of the

drainage unit.

 Check the suction control dial to

ensure that it is in the correct setting. If
the suction is ordered, check to see if the
orange float appears in the suction
indicator window.
 Make sure that the drainage unit is
balanced and stabilized around the
patient.
 CHECK the connections !!!
4. Check the tube connections periodically. Make sure all
tube connections are sealed air tight and secured.

 Tape, if necessary. The tube should be as straight as

possible and coiled below level of chest without dependent
loops.
 Make sure the tubing does not loop or interfere with the
movement of the patient.
 Do not let the patient lie on collecting/tubing drainage.
 Milking and stripping of chest tubes to maintain patency is
NOT recommended. (This may cause increase in intrapleural
pressures and damage the pleural tissue.)
 If it is necessary to help the drainage move through the
tubing, apply a gentle squeeze-and-release motion to small
segments of the chest tube between your fingers.
 CHECK for fluctuations !!!
5. In a continuous wall suction, the unit is
connected to a suction source and gentle
bubbling will be heard.

6. Check for fluctuation in the water-seal chamber

as the patient breathes.
 Normal fluctuations of 5-10cm reflect pressure
changes in the pleural space during respiration. To
check for fluctuation when a suction system is being
used, momentarily disconnect the suction system so
that air vent is opened, and observe for fluctuation.
 CHECK for fluctuations !!!
7. Fluctuations of fluid in the chamber will stop when:
 The lung has re-expanded
 The tubing is obstructed by blood clots or fibrin.
 A dependent loop develops.
 CHECK for bubbling !!!
8. Check for intermittent bubbling in the water-
seal chamber. This occurs normally when the
system is removing air from the pleural cavity.
If bubbling isn’t readily apparent during quiet
breathing, have the patient take a deep breath
or cough. Absence of bubbling indicates that the
pleural space has sealed.
 CHECK for bubbling !!!
9. If excessive bubbling is present in the water-seal
chamber, especially if suction is being used, rule out a
leak in the drainage system.

 Try to located the leak by clamping the tube momentarily at

various points along its length.
 Begin clamping at the tube's proximal end, and work down
toward the drainage system, paying special attention to the seal
around the connections.
 If a connection is loose, push it back together and tape it securely.
The bubbling will stop when a clamp is placed between the air
leak and the water seal.
 If you clamp along the tube's entire length and the bubbling
doesn't stop, the drainage unit may be cracked and needs
replacement.
 CHECK the drainage !!!
10. NOTE: Character, consistency, and amount of drainage.
Mark the date and time of the original fluid level, then
every shift on the CDU.
 Don’t forget to chart on nurse’s notes and I/O
flowsheet every shift.
11. If the drainage collection chamber fills, replace it. To do
this, clamp the tube close to the insertion site, exchange
the system, remove the clamps and re-tape the
connection.
 NEVER leave a chest tube clamped for more than
a minute.
 DO NOT clamp chest tubes of neonates who are
on positive pressure ventilation.
 CHECK range of motion !!!
12. Put the arm and shoulder of the affected side through
ROM exercises several times daily. Some pain medication
may be necessary.
 Encourage the patient to assume a position of comfort.
Encourage good body alignment. When the patient is in a
lateral position, place a rolled towel under the tubing to
protect it from the weight of the patient’s body. Encourage the
patient to change position frequently.
 CHECK positioning & transport !!!
13. Encourage the patient to breathe deeply and cough at
frequent intervals to help drain the pleural space and
expand the lungs. Also tell him to sit upright for optimal
lung expansion. If there are signs of incisional pain,
adequate pain medication is indicated.
14. If the patient has to be transported to another area, place
the drainage system below the chest level (as close to
the floor as possible).
15. If the tube becomes disconnected, cut off the
contaminated tips of the chest tube and tubing, insert a
sterile connector in the chest tube and tubing, and
reattach to the drainage system. Otherwise, DO NOT
clamp the chest tube for more than one minute during
transport.
 CHECK the dressing !!!
16. Check the chest tube dressing at least every 8
hours. Palpate the area surrounding the
dressing for crepitus or subcutaneous
emphysema, which indicates that air is leaking
into the subcutaneous tissue surrounding the
insertion site. Change the chest tube
dressing as ordered or when necessary.
 Apply a sterile 4x4 occlusive dressing with Vaseline
gauze around the chest tube insertion site.
 For Neonates: dressing needs not be changed unless
wet, dirty, or loose. Place a slit 2x2 gauze under that
tube and on top of the tube.
 Tape securely in place.
 CHECK the Chest tube !!!

17. If
the chest tube gets dislodged,
do not push tubes back into the
patient.
 To prevent air from being sucked into pleural cavity,
apply a sterile pressure dressing and notify MD
immediately.
 If not completely dislodged, but slips out slightly to
expose an air hold in the tube:
 apply petroleum jelly gauze over the hole
 For Neonates: apply 2x2 with polysporine ointment
 THEN CALL MD.
 CHECK the order !!!

18. DAILY chest X‐Rays must be ordered by the physician.

 ALTERNATIVE TO CDUS:
HEIMLICH CHEST DRAINAGE VALVE
 Also known as the “flutter valve,”
drains the chest cavity without using a
CDU.
 Connects to chest tubing and allows
fluid and air to pass in only one
direction.
 Should NEVER BE CLAMPED.
 Regulated suction can be attached to it
if necessary.
 Valve drains into a plastic bag that
can be held at any level, allowing the
patient undergoing chest drainage to
be ambulatory simply by carrying the
bag.
SPECIAL CONSIDERATIONS:
STOP COCKS USED FOR CHEST TUBE
DRAINAGE

 A suction control stopcock

conveniently regulates vacuum to
the chest drain.
 It provides control of suction
bubbling and allows efficient use
with any unregulated suction
source.
 The stopcock must be on for initial
system set up and SHOULD NOT
be turned off during patient use.
 KEY POINTS TO REMEMBER!!!
 CHECK the water level in the water-seal chamber every 8
hours.
 DOUBLE CHECK on initial assessments and before leaving
your patient: ALL tubes are connected and that drainage unit
is balanced and stabilized.
 AVOID lifting the drainage system above the patient’s chest.
 Milking and stripping of chest tubes to maintain patency is
NOT recommended.
 NEVER leave a chest tube clamped for more than a minute.
 WATCH for leaks of air in the drainage system as indicated by
constant bubbling in the water-seal chamber.
 A stop cock SHOULD NOT be turned off during patient use.
 Tell the patient to report breathing difficulty IMMEDIATELY.
 DOCUMENT: nurse’s notes & I/O every 8 hours.
 Follow up if there is a DAILY CHEST X-RAY ordered
by the physician.
GMHA POLICY: CARE OF THE PATIENT
WITH A THORACIC DRAINAGE SYSTEM
GMHA POLICY:
CARE OF THE PATIENT WITH CHEST TUBES
REFERENCES:
 Nettina, S. (Ed.) (2010). The Lippincott Manual of
Nursing Practice (9th ed.). Philadelphia, PA:
Lippincott-Raven Publishes
 GMHA Policy: Care of the Patient With A Thoracic
Drainage System and Care of the Patient With A
Chest Tube
 GMHA Policy: Assisting With Chest Tube Removal

 Rn.com: AMN Healthcare Education Services (2013).

Chest Tube Management. Retrieved September 4,
2018 from https://lms.rn.com/getpdf.php/1933.pdf.
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