Description of the fluid
Explanation and possible causes
Serous, slightly yellow
Normal pleural fluid
Purulent, murky
Sanguineous
Hemothorax: injury of a blood vessel (i.e. intercostal vessel)
White or milky (rare)
Chylus: due to injury of the ductus thoracic
Black (very rare)
Distinct fungal infection, melanoma, pancreatopleural fistula
Green/brown, high viscosity, sour smell (very rare)
Esophagopleural fistula
The fluid output threshold for chest drain removal differs from hospital to hospital. In general the underlying disease and the quality of the fluid have to be taken in account (i.e. empyema drains are removed when fluid cultures are negative). Chest tubes can be safely removed with daily fluid output of up to 450 ml as long as the fluid is non suspicious [2, 3, 15].
If there is any doubt about the quality of the pleural fluid then analysis should be done. Most drainage systems have a sample port with a membrane either in the tubing or the collection chamber. The protocol for taking a sample is more or less the same as taking a sample from a urinary catheter: The sample port is disinfected and then sterilely sampled with a syringe after waiting 30 seconds. This is then sent to the lab. If the fluid is suspicious for an empyema then a corresponding microbiological analysis should be done. Milky fluid suspicious for a chylothorax should be sent for a triglyceride level as well as a triglyceride level in the patient’s blood [1].
8.1.2.2 Air Leak
An “air leak” is due to leakage from the lung parenchyma or a bronchus. An air leak becomes visible as bubbling in the water seal chamber in an analogue system or as a precise and objective numeric number when using an electronic system. The appearance and clinical course of such an air leak has to be watched and documented. According to experience, an air leak may change over time with quite a wide range. Sometimes the difference is due to patient positioning (i.e. bigger in an upright position compared to when lying supine). Sudden changes such as the appearance of a new air leak or sudden cessation of a leak must be reported to the physician in charge immediately. In the latter case, the system and the tube should be checked regarding patency. As the appearance or persistence of an air leak is a contraindication to drain removal one must ensure that the air leak is “real”. Air leaks can also be due to issues with the tubing and/or the system and these must be ruled out. The same approach of checking the tubing and system should be undertaken when a huge, persisting air leak is observed (Table 8.2).
Table 8.2
Overview of possible problems, causes and solutions
Problem | Potential causes | Trouble shooting |
|---|---|---|
Sudden appearance of a large air leak | Disconnection, Leakage in the system, New parenchymal damage, bronchial stump insufficiency | Check connection, if necessary reconnect tubing Check tightness of the system: clamp tubing next to the patient, if air leak persists >> change system Check skin incision: is the incision too wide? Is air being sucked in from outside? Has the drain slipped out? |
Cessation of air leak and/or fluid production abruptly | Drain is clogged | Check tubing for clogging Milk or strip the tube if needed |
Dyspnea | Drain is clogged, No suction, Pneumonia, if shortly after drain insertion consider reexpansion edema (rare) | Check suction source, if necessary hook up a suction source If necessary check the system for a leak if no negative pressure is generated Check tubing concerning clamping, if necessary take off the clamp Check tubing for clogging, if necessary milk or strip tube If no or minimal improvement: call the physician in charge Severe dyspnea: always call the physician in charge Signs of pneumonia: fever, tachycardia, tachypnea: always call the physician in charge |
Face and neck swelling | Subcutaneous emphysema due to a clogged chest tube or other reasons for insufficient therapy (i.e. malposition of the chest tube | Check for clogging, leakage, assess the skin incision and position of the drain, and set pressure Inform the physician in charge |
Severe pain | Pain related to the chest tube, Pneumothorax | Check function of the drain and system (set pressure, patency) Drug administration If necessary adjust pain medication Discuss with the physician and physiotherapist |
Extreme increase in output (also Table 8.1) | According to clinical situation: Cardiac causes? Bleeding? Chylothorax? Infection? | Precise observation and documentation: amount, appearance, color, smell Inform physician in charge If necessary take a sample |
Dressing saturation | Skin incision too big, infection of skin incision | Check skin incision, if necessary inform physician in charge |
8.1.3 Management of Chest Drain Systems
The chest drain system should be positioned in such a way that all relevant components (collection chamber, manometer or water seal) can be checked easily during each contact with the patient. Furthermore an unintended overthrow of the system must be avoided. Most systems must be placed underneath the chest as this is the only way to guarantee unhampered drainage. Electronic systems with double lumen technique can be positioned anywhere.
8.1.3.1 Siphon
To avoid the so called siphon effect, the tubing has to be arranged in a way that a loop is not created. As fluid accumulates in this loop the negative pressure set at the manometer or the pressure chamber is reduced by the height of the fluid column (i.e. the pressure is set at −20 cm of water, the fluid column in the siphon is 20 cm as well and therefore no negative pressure is applied to the pleural cavity). Working with a water seal without a suction source, a siphon of 20 cm will generate a negative pressure of −20 cm of water in the pleural space. Therefore the tubing must always be placed in a way to avoid a siphon. Whenever a siphon filled with fluid is noticed, the fluid has to be directed towards the system’s collection chamber.
This situation appears only can occur when using an analogue system without the possibility of monitoring the pressure next to the patient. If one is using an electronic system with double lumen tubing, the siphon effect does not exist [10].
Chest drains should never be clamped for patient transport.
8.1.3.2 Mobilization and Transport
Patient’s mobilization and the need for transport can lead to some practical problems when a drainage system is in use. Mobilization limitation may be due to the drainage system needing to be connected to a suction source. When the patient needs to leave the bed to be transported to another location (i.e. the radiological department) the analogue system usually has to be disconnected from the wall suction source. Most commonly wall suction is the common way of generating negative pressure when using these analogue systems. One must remember that the drain should never be clamped because the patient is being moved! Clamping the drain is widely done, but has no advantages. Doing so can be life threatening as a tension pneumothorax can occur as air from an air leak can no longer be evacuated from the chest cavity. In a patient with an air leak, disconnection from suction can lead to lung collapse. Usually this problem is easily solved by reconnecting the system to suction. Clamping for a very short time only should only be done when needed for canister and/or tubing changing under close observation.
A chest drain cannot be an obstacle for patient mobilization!
In general, the following considerations should be taken into account when mobilizing a patient:
The patient has to have adequate pain control. Moving chest drains can cause significant pain due to irritation of the corresponding intercostal nerve [12]. Routine pain assessment using a numeric ranking scale (NRS) in conjunction with appropriate analgesic medications is a neccessity.
Some chest drain systems have long tubing that can act as a tripping hazard. Patients must be supported and well educated to avoid an accident.
When it is necessary to obtain negative pressure during mobilization and/or transport the chest drain system has to be connected to a mobile suction source. In general all analogue systems can be hooked up with an electronic driven suction source.
If oxygen or walking assistance devise are needed, they should be made available for use.
When the patient is being mobilized for the first time after surgery or chest drain insertion, nursing staff should explain the process of moving with the apparatus attached. There should be adequate assistance provided to ensure mobilization is safe and optimized.
The patient needs to know to immediately call for help if there is a change in condition such as dyspnea or if the chest drain system gets disconnected.
8.1.3.3 Changing the System and Securing Connections
Partial or complete change of the chest drain system is indicated when the collection canister is full or the system is damaged. The system needs to be reassembled according to the instructions for use. The water seal chamber and suction chamber are filled with water if a wet system is used. The tubing is clamped for a short time period so that the old system or full canister can be replaced. One must ensure the most hygienic exchange possible because contamination of the connection site must be avoided.
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