Copyright © 2008 Version Number: 6
NHS Lothian, Date developed: September 2008
University of Edinburgh & First review date: January 2009
NHS Education Scotland Next review date: January 2010
Copyright © 2008 Version Number: 6
NHS Lothian, Date developed: September 2008
University of Edinburgh & First review date: January 2009
NHS Education Scotland Next review date: January 2010
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Collaborative Working
This Multi-Professional Clinical Skills Pack aims to establish a standardised training for the insertion of and care of chest drains skills for medical, nursing and relevant allied health care professions. NHS Lothian, University of Edinburgh, NHS Education for Scotland and the Scottish Clinical Skills Managed Educational Network have developed it in collaboration.
The pack has been designed to be adaptable to the local context, with agreement between the collaborators to alter only sections 1, 3 and 4. All other sections are standardised and cannot be altered out-with the agreed review process.
Copyright © 2008 Version Number: 6
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University of Edinburgh & First review date: January 2009
NHS Education Scotland Next review date: January 2010
Chest Drain-Contents
Page No. Section 1
Rationale for the Chest Drain Programme 5
How to Use this Programme 5
Learning Outcomes – Chest drains 7
Section 2
Introduction 8
Indications for Chest Drain Insertion 10
Anatomy and Physiology 10
Patient Assessment 11
Risk Factors of Chest Drains 13
Procedural Guidelines: Chest Drain Insertion Generic Aspects 17 Procedural Guidelines: Technique 1: Insertion of Large-Bore Chest Drain Insertion 18 Procedural Guidelines: Technique 2: Insertion of Small-Bore Seldinger Chest Drain 22
Pre-hospital considerations 26
Procedural Guidelines: Pre-hospital chest drain insertion 29 On-going Care and Management of Patients with Chest Drains 31
Procedural Guidelines: Chest Drain Management 33
Procedural Guidelines: Removing a Chest Drain 34
Section 3
Theoretical Assessment (Chest Drains) 36 Supervised Practice Assessment (Assessment of Skill Acquisition: Large Bore Chest Drain
Insertion) 41
Supervised Practice Assessment (Assessment of Skill Acquisition: Small Bore Chest Drain
Insertion) 43
Supervised Practice Assessment (Assessment of Skill Acquisition: Pre-hospital Chest Drain
Insertion) 45
Supervised Practice Assessment (Assessment of Skill Acquisition: Chest Drain Management 47 Supervised Practice Assessment (Assessment of Skill Acquisition: Removal of Chest)
49
Section 4
Record of Completion of Programme: Large-Bore Chest Drain Insertion 51 Record of Completion: Small-Bore Seldinger Chest Drain Insertion 52 Record of Completion: Pre-hospital Chest Drain Insertion 53
Record of completion: Chest Drain Management 54
Record of Completion: Removal of Chest Drain 55
Practitioners’ Evaluation Questionnaire 56
References 58
Authors, Contributors & Reviewers 60
Appendices
A – Clinical Skills Framework for Practitioners 61 B – Chest Drain Procedural Checklist (Large Bore) 62 C – Chest Drain Procedural Checklist (Small Bore) 63 D – Chest Drain Procedural Checklist (Pre-hospital) 64 D – Chest Drain Procedural Checklist (Management) 65 E - Chest Drain Procedural Checklist (Removal) 66
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F – Chest Drain Equipment List (Large Bore) 67
G – Chest Drain Equipment List (Small Bore) 68
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Section 1
Rationale for the Chest Drain Programme
This clinical skills programme has been developed to enable practitioners to develop their knowledge and skills in the insertion of and the care of chest drains. Adopting a multi-professional approach to clinical skills training will promote standardised practice in the delivery of health care procedures, will encourage effective working relationships and will provide patients with access to multi-skilled, flexible health care practitioners. The programme is suitable for any health care practitioner currently working or training to work in the NHS, in the UK, who is involved as part of their work in the insertion of, removal of or the care of patients with chest drains in place.
How to Use this Programme
This clinical skills programme will support practitioners in their studying, enabling them to work at their own pace, and learning about chest drains in the context of their own practice.
Each participant should negotiate a suitable time frame for completion of the suggested activities contained within the programme with their assessor. Participants should aim to complete the programme within a 12 weeks time frame. Although, for students it may be possible to extend this time, to say, an academic year, to allow the student to have enough exposure to chest drains. It will be appropriate for some healthcare practitioners to undergo training in both the insertion and care of chest drains and some only the on-going management and removal of chest drains, depending on their scope of professional practice. However, all healthcare practitioners that may assist with the insertion of chest drains or care for patients with chest drains in place require some familiarity with the procedure and the under-pinning theory behind the skill.
Practitioners should begin working through the pack prior to attending a simulated practice session. Practitioners should arrange supervised practice with an assessor in their own clinical area or within an undergraduate clinical placement. There are circumstances when practitioners will require supervised practice out-with their own clinical area and this should be negotiated with supervisors/managers. Supervised practice should only occur following attendance at a simulated practice session. Unsupervised practice should only occur when the assessor deems the practitioner competent (successful completion of both theoretical and practical assessments). An assessor will be a practitioner who is competent in the skill of chest drain insertion or management and familiar with this programme. A flow diagram explaining the process of clinical skills training can be found at Appendix A. Throughout the text, activities are provided which will encourage the use of reflective, decision-making, observational and cognitive skills.
N.B The Professional Issues good practice study guide is a core pack designed to prevent repetition of content in subsequent packs. All practitioners must complete the
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Professional Issues pack prior to commencing any other skills pack. Some activities in subsequent packs will require you to refer back to the Professional Issues good practice study guide. The study guide is available in hard copy on the mobile unit or from the CS MEN office (email [email protected]).
Assessment includes:
Answers to theoretical assessments must be checked by the assessor using the marking guide and the procedural checklists provided. Assessors should guide practitioners to reference material in the resource pack if the practitioner does not provide similar answers to the marking guide.
Practitioners will be assessed using procedural checklists during simulated practice sessions. Practitioners successfully completing this assessment are deemed safe to undergo supervised practice in their clinical areas.
Assessors must use the ‘Assessment of Skill Acquisition’ tool provided to assess the practitioners’ practical application of the skill during supervised practice. The Assessment of Skill Acquisition form should be completed a minimum of 3 times. The number of assessments required will depend on individual competency. Completed assessment forms should be retained by the practitioner and not the assessor. The practitioners who are deemed not yet competent must undergo a further period of supervised practice.
For some, such as undergraduate students, completion of simulated practice and theoretical assessment will be all that is required to complete the pack. However, the student, either Nursing, AHP or Medical will still require to undergo supervised practice and ‘Assessment of Skill Acquisition’ at the post-graduate level if Chest Drain competencies are required.
Evaluation:
This is a new clinical skills training pack, therefore we would like to know what you thought of the pack by taking a few minutes to fill in the evaluation form on completion.
To ensure accurate recording and update of the clinical skills database, please ensure you return the completion certificate enclosed when you have finished the pack.
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Learning Outcomes – Chest Drains
Aim: On completion of the chest drain programme (completion of the pack, attendance at simulated practice session, supervised practice and successful completion of assessments) the practitioner will be competent in the clinical skill of the insertion of or removal of a chest drain and the management of a patient with a chest drain in place.
Learning outcomes have been mapped against the Knowledge and Skills Framework (KSF) competencies and successful completion will contribute towards Core dimensions 1-6, Health & Wellbeing dimensions 1-8, Information and Knowledge dimensions 1-3 and General dimensions 1-2 & 7-8. Core dimensions covered include Communications (C1-2), Personal and People Development (C2-3), Health, Safety and Security (C3-3), Service Improvement (C4-2), Quality (C5-3) and Equality and Diversity (C6-1). Specific dimensions have been mapped against the learning outcomes below.
N.B. Any KSF classifications are only indicative and any links to specific dimension levels may vary as individuals will differ in what they take from a learning experience and in how they will apply that learning within the workplace.
Competency Standard Performance Indicators
Understands and debates professional issues in relation to chest drain insertion and management
(Aligned to KSF specific dimensions: HWB2-2, HWB3-2, HWB4-3, HWB5-3, IK3-2, G2-1)
Applies ethical principles and guidelines to inform decision making in practice, supports equality and values diversity Actively involves the patient in the decision making process. Demonstrates the ability to work in accordance with legal
and statutory guidelines.
Exercises autonomy and initiative.
Demonstrates responsibility and accountability for own, and applicable others’ practice.
Maintains accurate record keeping.
Performs accurate assessment of patient requiring insertion of a chest drain (Aligned to KSF specific dimensions: HWB7-2, HWB 6, HWB 3, HWB 4, IK 1-4, IK 2-3, IK 3-3)
Demonstrates knowledge of the anatomy and physiology of the pleural cavity and thoracic wall.
Identifies and analyses the appropriateness of chest drain insertion.
Provides patient education regarding chest drains to aid decision-making.
Recognises when assistance and supervision is required from seniors.
Selects appropriate chest drain equipment with rationale for choice.
Identifies the potential psychological impact of chest drain insertion for the patient.
Discusses the indications for chest drain insertion. Details the precautions of chest drain insertion.
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in the procedure of chest drain insertion
(Aligned to KSF specific dimensions: HWB 7, HWB 9)
Assembles necessary equipment, in accordance with devised checklists.
Practises skill competently (see checklists)
Justifies the skill/procedural checklists of chest drain insertion using evidence (published and other sources) Critically analyses the clinical risks associated with chest
drain insertion and takes appropriate action to minimise risks.
Demonstrates competence in the management and removal of chest drains (Aligned to KSF specific dimensions: HWB 7, HWB 9, HWB 2)
Practises skill competently (see checklists)
Justifies the skill/procedural checklists of chest drain
management using evidence (published and other sources) Critically analyses the clinical risks associated with chest
drain management and takes appropriate action to minimise these risks
Engages in evaluation and critical analysis post procedure.
(Aligned to KSF specific dimensions: HWB6-3, HWB 7, G1-2, G2-2)
Responds promptly and appropriately to complications. Takes action to prevent commonly known associated
complications of chest drain insertion and management. Recognises limitations and accesses assistance as required. Reflects on attitude, behaviour (skill) and cognitions post
procedure.
Appraises context in which skills were practised.
Identifies learning, which has occurred to influence future practice.
Identifies area/enquiries for further learning.
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Section 2
Introduction
Chest drains are inserted into the pleural cavity to remove air or fluid. They are used in many different clinical areas such as
In a trauma patient in the Emergency Department a chest drain may be used to remove blood or air from the pleural cavity or decompress a Tension Pneumothorax
In a patient with lung cancer in the Respiratory ward a chest drain may be used to drain a malignant pleural effusion
Therefore doctors, nurses and allied health professionals throughout many settings need to be able to either insert or care for chest drains safely and competently.
This multi-professional chest drain pack is designed for different levels of competencies as required within your clinical environment and scope of professional practice. The competencies that can be selected from this pack are that of
Large bore chest drain insertion including pre-hospital insertion Small bore chest drain insertion using Seldinger technique Management, including removal of a chest drain
This pack does not cover the insertion of or on-going management of chest drains in children as this is a highly specialised area of practice.
Figure 1 Large bore chest drains on x-ray in patient with multiple rib fractures and surgical emphysema Chest drain insertion has been shown to be associated with 3% early and 8% late complications. Also a recent report (May 2008) from the National Patient Safety Agency (NPSA) has highlighted some of the risks
associated with chest drain insertion. They report 12 deaths directly related to chest drain insertion between 2005 and 2008 in England. Some of these deaths were due to damage caused to major structures such as the heart and liver during chest drain insertion. Other adverse events related to poor chest drain management, such as inappropriate clamping of the drain.
Best Practice StatementChest drains should only be inserted and cared for by competent staff who are properly trained in this procedure with appropriate supervision
Rationale: There are significant risks associated with the insertion and management of chest drains.
Source of Evidence: BTS guidelines and NPSA
Large bore chest drain Tip of drain in axilla
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Indications for Chest Drain Insertion
There are many reasons why chest drains are inserted in the clinical area.
Chest drains are considered to be either large (24-32 F gauge) or small bore (10-14 F gauge). Small bore chest drains are normally inserted by the Seldinger or ‘needle over wire’ technique.
Figure 2 Large bore chest drain (32 F gauge)
Figure 3 Small bore Seldinger chest drain (12 gauge) The following lists potential indications, but is not exhaustive: -
Large-bore chest drains
Traumatic haemothorax (blunt or penetrating)
Tension pneumothorax (only after needle decompression is performed) Traumatic simple pneumothorax
Post cardiac and thoracic surgery Drainage of pus from an empyema Smaller-bore chest drains
Simple pneumothorax with lung that does not re-expand with aspiration or recurs Secondary pneumothorax in patient with lung disease
Pneumothorax in any ventilated patient
Removal of fluid from a malignant pleural effusion
Connector for underwater drainage
system tubing
Flexible introducer Holes in side of drain Forceps for blunt
dissection
Connector for underwater drainage
system tubing Holes in side of drain
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Anatomy and Physiology
In order to insert, remove and manage chest drains safely and competently practitioners need an
understanding of the anatomy and physiology of the chest wall and pleural cavities. A Study has shown that while nurses tend to have a good knowledge of the management of chest drains, they are less clear about the underpinning theory, including the indications for chest drain insertion.
The anatomy of the thoracic wall is important to think about when preparing for chest drain insertion.
Between each of the ribs lie the intercostal spaces, which are breached over by the intercostal muscles. Each intercostal space has a nerve, artery and vein running through it. These vessels lie and run just under the rib. This means that a chest drain should be inserted just above the upper border of the rib to avoid damage to the neuro-vascular bundle. The long thoracic nerve runs down the lateral border of the thorax and so chest drains should be inserted anterior to the mid-axillary line to avoid damage to this structure.
Figure 4 The neuro-vascular bundle inferior to the rib
Remember that the normal lungs are covered with a thin layer of pleural fluid that acts a bit like two wet pieces of glass i.e. they can move sideways but it is difficult to separate them. The intra-pleural pressure in this fluid is below atmospheric pressure, thereby stopping the lungs collapsing away from the thoracic cavity. If air enters the pleural space (pneumothorax) then the lungs will collapse.
For a chest drain to work it must be connected to an airtight seal with an underwater collecting chamber (1,2 or 3 chambers) or a one way (Heimlich) valve with collecting bag. Underwater seal drainage systems are not used in pre-hospital situations. In a patient with a chest drain in place, on expiration, positive intra-pleural pressure is generated. This causes fluid or air in the pleural cavity to be expelled which with an underwater unit will then drain or bubbles one-way through the water. Air passes to the outside air and fluid or blood collects in the bottle. The drain tubing should always be 3 cm below the water level (often pre-marked on bottles). Gravity and differences in pleural pressures between the thoracic cavity and the atmosphere allow this to happen although gravity will work in reverse if the drainage system is lifted above the chest drain when fluid or air will be sucked back into the chest.
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Figure 5 underwater seal apparatus
Figure 6 Showing correct position of drain below patient
Activity
Describe why a chest drain should always be inserted above rather than below a rib?
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Risk Assessment
Contraindications
Lung adhered to the chest wall on x-ray
Bullous lung disease (caution as what looks like a pneumothorax may in fact be a bulla)
Bleeding disorder (relative contraindication if INR raised or platelets low, balanced with degree of urgency of drain insertion)
Best Practice StatementUnless in an emergency the patient should have a chest x-ray performed before drain insertion
Rationale: Confirm that drain insertion is indicated and confirm side of placement
Source of Evidence: BTS guidelines
Precautions
Patients currently receiving anti-coagulant therapy – increased bleeding time post procedure Patients with chronic respiratory problems who may not be able to tolerate lying flat
Patients with chronic obstructive pulmonary disease- confirm that an apparent pneumothorax is not a bulla before inserting a drain
Patients with a tension pneumothorax should have needle decompression performed prior to insertion of a chest drain
Best Practice StatementIn non-urgent chest drain placement consideration should be given to the use of USS to guide insertion
Rationale: Make sure drain inserted into right area and minimise risk of damage to other structures
Source of Evidence: NPSA
NPSA - Questions to ask yourself before inserting a chest drain
1.
Does it need to be done?
2.
Does it need to be done now?
3.
Am I competent to do this?
4.
Is supervision available?
5.
Am I familiar with the equipment?
6.
Does patient require a large ‘trauma drain’ with open technique or
a smaller drain with Seldinger technique?
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Psychological considerations
Previous personal experience – the patient may have had an unpleasant experience of having a chest drain inserted previously. 50% reported significant pain on chest drain insertion (BTS)
Needle phobia – consider cautious administration of a low dose of IV benzodiazepenes. Fear - reassure the patient
Understanding – having too much/too little information
Best Practice StatementAlways give analgesia and consider anxiolytics unless contra-indications
Rationale: Minimise pain and anxiety.
Source of Evidence: BTS guidelines
Patient Education
Communicating and informing the patient of exactly what the procedure involves can reduce anxiety and fears. The patient should be made aware of why he/she is having the procedure, the benefits and the potential complications before obtaining informed consent. Establish if the patient has any known allergies prior to the procedure – the patient may have an allergic reaction to local anaesthetic.
It is important that the patient should know about care of their chest drain, including important safety
aspects, however this can normally wait until after the drain has been inserted and will be dealt with after the procedure.
Patient Positioning and site of insertion
Lie patient down if they are able to with the hand of the arm on the side that the drain is going to be inserted into behind the patient’s head or held abducted and externally rotated by an assistant.
Chest drains should be inserted through the safe triangle as this minimises risk to surrounding structures (long thoracic nerve, muscle, breast, axillary structures). Insertion through the safe triangle (4th or 5th intercostal
spaces in anterior axillary line) also helps to prevent the drain being placed too low with the potentially fatal risks of damage to the liver and spleen.
Boundaries of safe triangle are Lateral border of pectoralis major anterior, mid-axillary line posterior, level of nipple inferior.
Griffiths in 2005 noted that 45% of junior doctors chose a point of insertion out with the safe triangle, with
25% choosing a point too low (risks damage to liver and spleen).
Occasionally drains are placed in an anterior or posterior position to access a loculated collection of fluid. This is a specialised procedure and should be performed under ultrasound guidance wherever possible and only by those who are competent in this procedure.
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Figure 7 Safe Triangle
Best Practice StatementMake sure that the drain is to be inserted through the safe triangle
Rationale: Minimise risk of damage to underlying structures
Source of Evidence: NPSA and BTS guidelines
Patient Safety
The procedure should ALWAYS be carried out in an environment with full resuscitation equipment, including suction. The patient should be monitored, receive oxygen and have an intravenous cannula inserted before the procedure. As well as the competent practitioner who will insert the drain there should be an assistant present who is trained in the care of chest drains AT ALL TIMES. This assistant is required to open packs and equipment so that asepsis is maintained. They are also responsible for monitoring the patient and double-checking safety aspects such as side of insertion.
Activity
List the boundaries of the safe triangle and explain why drains should only be inserted through this area Mid-axillary line Level of nipple Lateral border of pec major
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Risk Factors of Chest Drain Insertion
As with any invasive procedure, there are risks to the patient and practitioner. Practitioners need to be able to assess the risk and decide if the benefits outweigh the risks, to reduce risks where possible and to be able to troubleshoot when things do not go to plan. The table below is not exhaustive, but highlights some of the risks and problems associated with the procedure.
Risks Associated with Chest Drain Insertion
Risk Cause Practitioner’s Action
Trauma to underlying structures Use of metal trochar
Poor anatomical placement (liver, spleen) or poor patient positioning Dilator damage in Seldinger technique Needle damage in Seldinger technique Damage to neurovascular bundle Damage to long thoracic nerve
Metal trochars should NEVER be used Make sure the drain is inserted in the safe triangle, or use USS if available
Do not insert dilator deeper than needed to dilate chest wall
Aspirate as you gently insert the Seldinger needle
Insert drain along top of a rib
Chose site just anterior to mid-axillary line Explore pleural space before inserting drain
Pain Inadequate analgesia
Inadequate local anaesthetic Failure to consider benzodiazepenes
Consider morphine and midazolam, IV titrated to effect, make sure local anaesthetic inserted down to level of rib and pleura
Local Anaesthetic toxicity Failure to consider safe local anaesthetic
dosages of up to 3mg / kg In an average adult 10ml 1.0% Plain lignocaine is sufficient, (20ml maximum). Procedure should be carried out where full resuscitation equipment available
Re-expansion pulmonary
oedema Rapid evacuation of air or fluid from the thoracic cavity No more than 1.5 L should be actively aspirated from a pnuemothorax, empyema or effusion in one go
Haemorrhage Coagulopathy or thrombocytopaenia
Damage to underlying organs In routine drain insertion correct coagulation problems if possible Avoid trochar use
Careful use of needle and dilator in Seldinger technique
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Procedural Guidelines: Chest Drain Insertion Generic Aspects
An equipment list is available at Appendices G&H and a Procedural Checklist can be found at Appendices B&C. These will be of use to you during the simulated practice session.
Introduce yourself to the patient. Ensure that you have the correct patient by checking name, date of birth and CHI against arm band and notes
Examine the patient’s chest and confirm clinical findings. CONFIRM SIDE ON WHICH DRAIN IS TO BE INSERTED ON BOTH PATIENT AND X-RAY
Explain the procedure to the patient and obtain informed consent. Check for allergies (NPSA recommends that written consent should be obtained where possible)
Gather appropriate equipment and select chest drain size (12F small bore 32F large bore). DO NOT SELECT A DRAIN THAT HAS A METAL TROCHAR
Ensure patient is lying comfortably with the arm on the side on which the drain is to be inserted behind the head (alternatively if the drain is to remove fluid or pus the patient may sit upright leaning over a pillow or table)
Identify the ‘SAFE TRIANGLE’ and choose point of insertion above a rib to avoid the neurovascular bundle
Infiltrate local anaesthetic (maximum 3mg/kg, 10ml 1% Plain lignocaine in 70kg adult is usually sufficient), initially by drawing up a skin bleb with an orange needle and then using a green needle to infiltrate through the soft tissues onto the rib and pleura aspirating as the needle is advanced
Administer analgesia (Intravenous Morphine titrated to effect) unless contra-indicated and consider use of an anxiolytic (Midazolam 1-2mg titrated to effect with caution as can cause respiratory depression)
Best Practice StatementIn the case of a drain being inserted because of chest trauma give intravenous broad-spectrum antibiotics
Rationale: Reduces risk of empyema by 5%
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TECHNIQUE 1 – insertion of a large-bore chest drain
Ensure full aseptic conditions are followed at all times
Perform surgical hand wash, don surgical gown, mask and sterile gloves
Open chest drain pack keeping contents sterile, take suture, antiseptic skin preparation, underwater seal system and chest drain from assistant
Clean the skin using an antiseptic skin preparation such as chlorhexidine and swabs in a circular motion from the point of insertion out in a circular motion
Apply sterile drapes to maintain sterile field
Make an incision parallel to the rib where the drain is to be inserted. Ensure that this is big enough for the drain (approximately 2-3cm) and goes through all the layers of the skin only
Figure 8 Skin Incision
Many practitioners insert ‘stay and close’ sutures at this point and clip them to the towels. This avoids the later risk of puncturing the drain with the suture needle
Using large forceps (Kelly’s or similar) blunt dissect through the subcutaneous tissues (open and close forceps to separate rather than cut tissues. Make sure that you dissect down onto the upper border of the rib and open the pleura (you should feel a sudden give and sometimes a hiss of air or flow of blood)
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Best Practice StatementBlunt dissection should always be used rather than a metal trochar to gain access to the pleural cavity
Rationale: Minimise risk of damage to underlying structures
Source of Evidence Descriptor: BTS guidelines
Carefully insert a finger into the pleural cavity and sweep round to make sure that the lung is not adhered to the chest wall, avoid damage to the lung with your finger (CAUTION if the patient has rib fractures as these may puncture your glove)
Estimate depth of insertion by looking at the markings on the drain and distance from apex of the lung to your incision. All the holes along the length of the drain need to be within the pleural space. Note: holes that are invisible due to being deeper than the skin but superificial enough to lie within the subcutaneous tissue will still cause surgical emphysema
Insert the drain through the hole in the pleura and into the cavity; aim the drain towards the apex (some drains come with a plastic introducer which helps to facilitate this). Remove the introducer and place a thumb over the end of the drain
Figure 10 Drain insertion DO NOT LET GO OF THE DRAIN until it is safely sutured in place
Attach the end of the drain onto the underwater drainage system (making sure that the drain is 3cm below the water level) and place the chest drain bottle below the patient
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Check that the water in the chest drain is bubbling or swinging, if in doubt ask the patient to cough gently
Tie (if inserted previously) or insert a stay suture and a close (mattress) suture that can be used to close the wound when the drain is removed. Make sure you use a strong suture like 1.0 silk or it may snap. Ensure that your stay suture is tight and slightly indents the drain
Figure 12 ‘Stay and close sutures’ Figure 13 ‘Stay and close sutures’
Figure 14 Sutures tied to maintain air-tight seal
Best Practice StatementAll large bore chest drains should be sutured in place, purse-string sutures should not be used
Rationale: To prevent dislodgement of drain and unsightly scarring
Source of Evidence Descriptor: BTS guidelines
Remove the drapes
Secure the drain to the skin using some cut swabs and a dry adhesive dressing, such as cut
MEPORE©. There is no role for vast watertight dressings Like SLEEK as these can increase the risk of wound infection ‘CLOSE’ horizontal mattress suture ‘STAY’ Normal Suture
‘CLOSE’ horizontal mattress suture-leave ends long and curl round drain so it can be readily accessed to close the wound once the drain is
removed ‘STAY’ Normal Suture tied at level of the skin and not as a purse string around the
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Figure 15 Cut dry adhesive dressing.
Dispose of all waste and sharps appropriately
Obtain an urgent chest-x-ray to confirm position and document findings yourself
Check routine observations post drain insertion, and record, start a chart for recording chest drain activity
Record procedure details, including any complications and results of chest x-ray in the patient’s notes.
Best Practice StatementLarge bore chest drains should be used to drain blood or pus as small-bore chest drains may block. Small bore chest drains are as effective as large bore in draining pneumothoraces and cause less pain and scarring
Rationale: selection of appropriate drain size
Source of Evidence Descriptor: BTS guidelines
After the procedure it is important that the patient should be given important chest drain advice. This predominantly concerns safety, what they can and cannot do, information about how to mobilise, changing position and breathing. They should be advised that they should make sure that the chest drainage system should be kept below the level of the chest at all times. They must seek help immediately if the drain becomes disconnected or they develop respiratory symptoms.
Activity
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TECHNIQUE 2 – Insertion of small-bore Seldinger chest drain
Ensure full aseptic conditions are maintained at all times Perform surgical hand wash, don apron and sterile gloves
Open pack keeping contents sterile, take additional equipment from assistant in a sterile fashion Clean the skin using Antiseptic skin preparation such as Chlorhexidine
Apply sterile drape
Make a small incision (3-5 mm) in the skin where the drain is to be inserted
Using the needle and syringe in the pack gently insert (avoiding excess force) towards the upper border of the chosen rib aspirating continuously until air in the syringe confirms the position of the needle in the pleural cavity
Figure 16 Insert needle while aspirating
Best Practice StatementAir or fluid must be aspirated before wire is inserted (stop and get help or arrange USS guidance if you cannot achieve this). Both the needle and dilator should be inserted without force
Rationale: Confirm correct position and minimise risk of damage to underlying structures
Source of Evidence: BTS guidelines and NPSA
Hold the needle steady and remove the syringe. Feed the wire gently through the needle into the pleural cavity (AT ANY STAGE IN THE PROCEDURE ONE HAND SHOULD ALWAYS BE
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Figure 17 Insertion of guide wire
Remove the needle leaving the guide-wire in place, make sure that the wire does not shear. Feed the first dilator down over the wire and into the pleural cavity. It may be necessary to make the incision a few mm bigger. Repeat the process for the second dilator if present. Note: the dilator only needs to be inserted to a depth that is sufficient for the chest wall to be dilated. Over insertion of the dilator risks damage to thoracic structures and has been identified by NPSA as a significant cause of morbidity with the Seldinger technique.
Figure 18 Insert dilator without force
Remove the dilator leaving the wire in place. Estimate the depth of insertion on the scale on the drain from the apex to the skin.
Feed the 12F chest drain over the wire until it is in the pleural cavity to desired depth
Figure 19 Feed drain over wire
Remove the wire making sure that the chest drain stays in position DO NOT LET GO OF THE DRAIN NOW
Attach the end of the drain onto the underwater seal system and make sure that the chest drain bottle is placed below the patient
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Figure 20 Connect to tubing
Check that the water in the chest drain is bubbling or swinging, if in doubt ask the patient to cough gently
An adhesive dry dressing such as MEPORE© is normally all that is required to secure the drain to the skin
Remove the drape
Dispose of all waste and sharps appropriately
Obtain an urgent chest-x-ray to confirm position and document findings yourself
Check routine observations post drain insertion, and record, start a chart for recording chest drain activity
Record procedure details, including any complications and results of chest x-ray in the patient’s notes
Activity
Why must air or fluid be aspirated from the pleural cavity before the guide wire is inserted when placing a small bore chest drain using the Seldinger technique?
Modifications 1: The use of USS in chest drain insertion
Ultrasound (USS) is used to localise fluid to guide the insertion of a chest drain, which is particularly useful if fluid is locualted. Bedside USS such as the FAST scans used in initial trauma care can also localise a
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misplacement and the safest practice is to insert the drain while USS guidance is present rather than at a later stage. USS is recommended if blind aspiration of an effusion fails on the first attempt.
As the use of bedside USS grows rapidly within specialities such as Emergency Medicine and Surgery, it may become standard practice that all chest drains are inserted under USS guidance.
Best Practice StatementUltrasound guidance is strongly recommended when inserting a drain for fluid
Rationale: Minimise risk of damage to underlying structures
Source of Evidence Descriptor: NPSA
Modifications 2: The Use of Flutter valves
In some specialised respiratory environments a flutter valve can be inserted onto the drain rather than the traditional underwater seal drainage system. This one-way valve allows air to leave the pleural space but not re-enter. This system has some advantages in the on-going management of conditions such as a complicated pneumothorax, as it allows the patient to be more mobile and potentially be able to be discharged home with a drain in place. These valves should only be used in specialised clinical settings and have no role in the initial generic management of a patient who needs a chest drain. Note: there are case reports of patients
accidentally reversing their own Heimlich valves leading to Tension Pneumothorax.
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Pre-hospital considerations
It is vitally important in the pre-hospital setting to ensure that chest drains are only inserted by practitioners who are competent in this procedure. In making the decision as to whether or not to insert a chest drain you must balance the risks and benefits of inserting a drain in what is a difficult environment, with limited asepsis and adding delay to transfer for definitive hospital care. In most environments drain insertion should not be performed, rather the patient should be taken to hospital as quickly as possible for chest drain insertion there. e.g. Suspected simple pneumothorax with no respiratory embarrassment is not an indication for chest drain insertion in pre-hospital care. However, in some rural areas where there are significant distances to definitive care then it may be necessary to insert a drain.
Indications:
The only absolute indication for a pre-hospital chest drain is chest pathology causing significant respiratory embarrassment, with hypoxia that will be relieved by drain insertion. Examples include:
Tension pneumothorax - Not responding to needle decompression Tension Pneumothorax - Re-accumulating after needle decompression
Note: Tension pneumothorax may be relieved sufficiently well with needle decompression alone, obviating the need for chest drain. In this circumstance the patient should be rapidly transferred to hospital under close observation.
Figure 22 pre-hospital Portex© chest drain kit Needle decompression of Tension Pneumothorax
Identify 2nd intercostal space in mid-clavicular line on affected
side of chest Clean skin
Insert large-bore cannula just above rib in 2nd IC space Remove needle and make sure that air either hisses from or
can be aspirated from the cannula Do not occlude the cannula
Watch cannula carefully to male sure it does not get occluded or kinked
Drain
Drainage bag
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Clinical Signs of Tension Pneumothorax
Trachea deviated away from affected side Absent air entry on affected side
Hyper-resonance on affected side Distended neck veins
Signs of pneumothorax and patient severely compromised i.e. haemodynamic and respiratory failure Obviously a chest x-ray prior to drain insertion will not be available so good clinical examination and
judgement is vital. Inserting a drain pre-hospital is high risk as the procedure will be carried out in a less than adequate environment. It is important to think about the anatomy of the chest wall and its landmarks whilst exposing and positioning the patient optimally. Ensure that the site for insertion is in the safe triangle and not too low with the risks of damage to the liver and spleen. Remember that the anatomy can be even more difficult to identify in obese patients.
Activity
Identify the 4th or 5th intercostal space in the anterior axillary line on yourself or a colleague and
reflect on your findings
Note: the 4th and 5th intercostal spaces are higher than you think they will be and normally lie
just below axillary fold
Try to maintain asepsis as much as possible, although the compromise may be an antiseptic skin spray such as BETADINE, sterile gloves and a dressing pack. Ensure that a trained paramedic or similar practitioner is able to assist with the procedure. Always make sure that the drain is firmly sutured in place so it does not dislodge during transfer to hospital.
The biggest pre-hospital modification is that an underwater seal drainage system will not be available. The compromise is to attach a drainage bag, similar to a urine bag, with a one-way valve that will allow blood or fluid to escape from the pleural space.
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Questions to ask yourself before inserting a pre-hospital chest drain?
Does this need to be done and has needle decompression relieved symptoms sufficiently? Does it need to be done now or can it wait until the
patient gets to hospital?
Am I competent to perform this procedure? Can I identify the anatomy well enough to safely
insert the drain?
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Procedural guidelines: pre-hospital chest drain insertion
An equipment list is available at Appendix I and a Procedural Checklist can be found at Appendix D. These will be of use to you during the simulated practice session.
The procedure should be carried out in a well-lit environment with full resuscitation equipment. The patient should be monitored, receive oxygen and have an intravenous cannula inserted before the procedure. As well as the competent practitioner who will insert the drain there should be an assistant present who is trained in the care of chest drains. In a patient with a suspected Tension Pneumothorax needle decompression should
ALWAYS be performed prior to chest drain insertion. Examine the patient and confirm clinical findings.
Position patient adequately with the arm on the side on which the drain is to be inserted behind the head.
Gather appropriate equipment
Best Practice StatementDiscard metal trochar
Rationale: Risk of internal damage
Source of Evidence Descriptor
:
BTS guidelines
Identify the ‘SAFE TRIANGLE’ and choose point of insertion above a rib to avoid the neurovascular bundle
Infiltrate local anaesthetic (maximum 3mg/kg 20ml 1% Plain lignocaine in 70kg adult), initially by drawing up a skin bleb with an orange needle and then using a green needle to infiltrate through the soft tissues onto the rib and pleura aspirating as the needle is advanced
Maintain asepsis as much as possible
Clean hands with alcohol gel and don sterile gloves Open chest drain pack keeping contents sterile Clean the skin using antiseptic skin spray
Make a horizontal incision where the drain is to be inserted. Ensure that this is big enough for the drain (approximately 2-3cm) and goes through all the layers of the skin only
Using forceps (come with Portex© frontline kit) blunt dissect through the subcutaneous tissues (open and close forceps to separate rather than cut tissues. Make sure that you dissect down onto the upper border of the rib and open the pleura (you should feel a sudden give and sometimes a hiss of air or flow of blood)
Insert a finger into the pleural cavity and sweep round to make sure that the lung is not adhered to the chest wall (CAUTION if the patient has rib fractures as these may puncture your glove)
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Estimate depth of insertion by looking at the markings on the drain and distance from apex of the lung to your incision. All the holes along the length of the drain need to be within the pleural space.
Insert the drain through the hole in the pleura and into the cavity; aim the drain towards the apex DO NOT LET GO OF THE DRAIN until it is safely sutured in place
Attach the end of the drain onto the closed drainage bag and tubing, make sure air is draining freely Insert a stay suture and a close (mattress) suture that can be used to close the wound when the drain
is removed. Make sure you use a strong suture like 1.0 silk or it may snap. Ensure that your stay suture is tight and slightly indents the drain
Secure the drain to the skin using some cut swabs and SLEEK to ensure additional drain security in pre-hospital environment
Dispose of all waste and sharps appropriately
Record procedure details, including any complications
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On-going Care and Management of Patients With chest drains
Ideally patients with chest drains in place should be managed in appropriate clinical areas (assessment units, emergency departments, critical care areas, respiratory or thoracic surgery wards) although this may not always be feasible. Nevertheless, all healthcare professionals who are going to insert, remove or care for patients with chest drains must be competent in the management of chest drains.
It is important to take an evidence-based approach to chest drain care.
Best Practice StatementAreas in which patients with chest drains are to be cared for should have standard chest drain observation proformas
Rationale: Risk Reduction
Source of Evidence: NPSA
Procedural Guidelines: Chest Drain Management
In the initial hours after a chest drain has been inserted checks should be performed and documented every 30 minutes. When checking a chest drain it is important to always complete the following, which should be recorded on a standard chest drain proforma. A Procedural Checklist can be found at Appendix E. This will be of use to you during the simulated practice session
Wash hands, wear apron and non-sterile gloves Check Patient
o Observations (ideally record on early warning observation chart to highlight changes in physiology and potential deterioration early)
Temperature Pulse
Blood Pressure Respiratory rate Oxygen Saturations
o Check patient positioning for comfort and any analgesia requirements
Check drain
o Record volume and amount of any drainage. Record whether drain bubbling or swinging o Check all connections to make sure they are intact
o Check underwater seal system and make sure either 3cm of water or to the marked level as per manufacturers recommendations
o Check wound to ensure drain still secure and no signs of infection o Check underwater seal system is below level of chest
o Check tubing to ensure it is not looped or kinked
Trouble shooting and Pitfalls
The following are some hints and tips to avoid the common problems associated with chest drains and to know what actions to take when problems do occur;
Drain not bubbling or swinging- could be either blocked, clamped or have inadvertently fallen out-check patient, drain, connections, tubing, GET SENIOR HELP
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Leakage from drain site – check wound, send swab Drain bubbling ++- could be either leak from chest drain connections or persistent air leak within the lung, check patient, drain, connections, tubing, GET SENIOR HELP
Sudden increased blood or fluid losses in drain – GET SENIOR HELP as patient may need surgery(>1500ml stat of blood or 200ml/hour indicates need for thoracotomy)
Best Practice StatementNever milk or strip chest drains
Rationale: This can lead to underlying damage to the lung
Source of Evidence: Marsden
Never clamp a chest drain unless changing the bottle or the tubing has become disconnected (using thumb and forefinger rather than clamp avoids inadvertently leaving it on), or unless under direct supervision of a senior respiratory physician in an appropriate specialised clinical environment. An exception is that when draining a large effusion, the drain may be clamped for one hour after 1.5 L has drained to minimise risks of flash re-expansion pulmonary oedema.
Drainage bottles and tubing should be replaced every 48-72 hours or when volume of drainage in the bottle exceeds 500-600 mls.
In some specialised environments such as respiratory wards it may be necessary to apply suction to a drain, if for example a pneumothorax is failing to respond. Again this should be ordered and supervised by a
respiratory physician. High volume, low pressure suction must be used, not standard wall suction as they are high pressure.
Activity
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Procedural Guidelines: Removing a Chest Drain
Chest drains should only be removed by a practitioner who is trained in the procedure. An assistant must be present to help with wound closure. The decision to remove a chest drain should only be made by a senior doctor. A Procedural Checklist can be found at Appendix F.This will be of use to you during the simulated practice session
Introduce yourself to the patient. Ensure that you have the correct patient by checking name, date of birth and CHI against name band and notes
Explain the procedure to the patient and obtain informed consent.
Get patient to practise Valsalva manoeuvre (3 deep breaths in and out and then hold the breath at the end of the 4th inspiration)
Gather appropriate equipment and open dressing pack
Ensure patient is lying comfortably with the arm on the side of the drain behind the head
Administration of oral or intravenous analgesia if not contraindicated (ideally 15 minutes before the procedure)
Wash hands and put on gloves and apron
Remove dressing and identify ‘stay’ and ‘close’ sutures Isolate ‘close’ suture ready to tie once drain removed
Clean wound with antiseptic skin preparation such as chlorhexidine Cut the ‘stay’ suture
Ask the patient to perform the Valsalva manoeuvre and firmly pull out the chest drain and get your assistant to apply pressure over the wound to prevent an air leak
Clean wound with antiseptic skin preparation such as chlorhexidine
Tie suture to close wound, not too tightly, apply a few steristrips if necessary Apply occlusive dressing
Perform repeat chest x-ray to make sure that original pathology has not recurred (normally after 1 hour)
Record procedure, including any complications in the patient’s notes
Regularly check patient’s observations and drain site in the hours after chest drain removal
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Purse-string sutures should not be used to secure drains any more
Rationale: Closing the wound with a purse-string suture after the drain has been removed can result in unsightly scarring
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Risk Factors of Chest Drain Management
As discussed there are risks associated with the management and of chest drains. Practitioners need to be able to assess the risk and decide if the benefits outweigh the risks, to reduce risks where possible and
to be able to troubleshoot when things do not go to plan. The table below is not exhaustive, but highlights some of the risks and problems.
Risks Associated with the on-going management of chest drains
Risk Cause Practitioner’s Action
Chest drain displacement Poor skin suture technique
Failure of patient to protect drain enough to slightly indent drain. Tell the Make sure skin suture is knotted tightly patient to protect the drain and to avoid
pulling it.
Infection Poor Aseptic technique
Re-inserting chest drain through initial incision
Toxic Shock Syndrome
Correct aseptic technique. Wash hands, sterile gloves, mask, and gown. Always make a fresh incision if a drain is to be
re-inserted. Examine wound sites daily to check for signs of infection Blockage of chest drain Small bore chest drains being used to
drain either -Blood -Or pus
Chest drain clamped inappropriately Chest drain kinked
Use large bore chest drains in these circumstances
Chest drains should NEVER be clamped except in very specific circumstances Regular monitoring of drains to makes sure
that they are still working Aspiration of chest bottle water
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Section 3
Theoretical Assessment
Chest Drains
Guidance notes for the theoretical assessment are available on the mobile unit or from the Clinical Skills Managed Educational Network office (email [email protected]) to enable your assessor to give you feedback on your work. Practitioners should cover key points for each question. Practitioners who have not considered key points in their answers should be guided by their assessor to further reading, before
attempting to answer the questions again.
Question One
All practitioners have a responsibility to keep up to date and prevent skill fade. Explain what actions you can take to keep up to date with chest drain insertion and prevent skill fade.
Question two
List the indications for both small and large bore chest drain insertion
Question Three
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Case Scenario
James Smith is a 24-year-old patient who has been stabbed to the left side of the chest. He is brought into A&E and despite the fact that he is haemodynamically normal a chest x-ray shows a moderate sized left pneumothorax. You decide to insert a large bore chest drain
Question Four
Following assessment, it appears that Mr Smith has had a chest drain inserted before and found it to be a very unpleasant experience. How would you attempt to improve his experience of the procedure this time?
Question Five
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Question Six
What equipment would you choose for the procedure, giving a rationale for your choice?
Question Seven
Why should a trained assistant be present during this procedure and what is their role?
Question Eight
Several hours later the drain stops bubbling and Mr Smith becomes very breathless. What actions will you take?
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Question Eight
Mr Smith’s chest drain was inadvertently clamped and the patient nearly dies as a consequence. Discuss what you may learn from this incident?
Question Nine
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Question Ten
Regarding chest drains identify areas where you can further improve your practice and learning. Explain what possible sources you may obtain further information from.
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Assessment of Skill Acquisition-Large Bore Chest Drain Insertion
Assessor: ____________________ Status: _____________________ Practitioner: _________________ Status: _____________________ Clinical Skill: ________________ Date: ______________________ Number of Supervised Evaluations: ______
Practitioners should be assessed until competence is achieved in all domains or if competence is achieved on first attempt they must undergo a minimum of 3 observations. Competence is achievement when all criteria are met in all domains. Assessors should indicate if competence has been achieved in each domain by circling ‘YES’ or ‘NOT YET.’ Feedback should be entered in each remarks box, identifying criteria to be achieved or demonstrated.
Competence Achieved YES/NOT YET 1. Professionalism Criteria
- applies ethical principles to inform decision making - involves patient in decision making process
- practices in accordance with professional code - demonstrates autonomy and initiative
- maintains accurate record keeping
Competence Achieved YES/NOT YET
2. Patient Assessment Criteria
- assesses patient suitability for the procedure - selects equipment (providing rationale for choice) - discusses the potential psychological impact with the patient
- critically analyses potential risks
Competence Achieved YES/NOT YET 3. Knowledge and Application Criteria
- demonstrates knowledge of relevant A&P - provides appropriate patient information
- discusses indication and contraindications with patient - seeks information from appropriate sources when necessary
Competence Achieved YES/NOT YET 4. Communication Criteria
- skill explained to patient/significant others to obtain informed consent
- practitioner demonstrates accurate and legible documentation of skill
5. Organisational Criteria Competence Achieved YES/NOT YET - correct equipment is prepared and checked
- skill is carried out in a timely, logical sequence - responds appropriately to any complications
Remarks: Remarks: Remarks: Remarks: Remarks:
