Word: Chest Tube: Assisting With Insertion

CHEST TUBE: ASSISTING WITH INSERTION

DOCUMENT TYPE: PROCEDURE

Site Applicability

Applicable site-wide at BC Childrens Hospital (BCCH), excluding Sunny Hill Health Center (SHHC).Note: Chest tube insertion is generally done in Interventional Radiology, the Operating Room or in the Emergency Department; however, it may be done at the bedside in critical care or inpatient areas.

Practice Level/Competencies

Chest tube insertion is an advanced skill and is completed by a physician.Nurse Practitioners, Registered Nurses, and Respiratory Therapists in acute care at BCCH have foundational skills to aid with the insertion of chest tubes and to care for and monitor patients with chest tubes.

Equipment & Supplies

PPE Sterile gown and gloves Sterile drapes x 2 Sterile split 4x4 gauze or gauze sponges Disposable scalpel Suture material determined by prescribing clinician Sterile scissors Sterile procedure tray Chest tube type to be determined by prescribing clinician Sterile disposable chest tube drainage system (Atrium for Argyle or pigtail chest tubes only or a bulb for Blake chest tubes only) Local anaesthetic such as Lidocaine 1% (requires a prescribing clinicians order) 10 mL syringe and 25 gauge needle Chlorhexidine 2% with 70% alcohol solution (Povidone-Iodine swab sticks may be used if patient allergic to chlorhexidine) Dry sterile occlusive dressing as per prescribers orders (such as Tegaderm , Tegaderm Absorbent, Mepilex or Jelonet covered with gauze and occlusive dressing) Universal securement device (Stat-Lok or Grip-Lok) Securement of chest tube to chest drainage system (Banding gun and zap straps) Wall suction regulator Suction tubing Tube adaptor (Argyle 5-in-1 Barbed Connector) Three way stop cock and 12 inch extension tubing (required for pigtail drain only) Waterproof tape Cardiorespiratory and pulse oximetry monitoring device Chest X-Ray Requisition Chest Tube Emergency Equipment Dry sterile occlusive dressing (such as Tegaderm or Tegaderm Absorbent) Non-grooved occluding clamps per chest tube x 2 Chlorhexidine 2% with 70% Alcohol pads x 2

Procedure

The purpose of a chest drainage device is to help to remove excess air and/or fluid in a closed, one-way fashion. This reduces collection of air and/or fluid in the thoracic cavity and optimizes expansion of the lung and respiratory function. The insertion of a chest tube may be indicated if a patient has a pneumothorax, hemothorax, chylothorax, or pleural effusion. A chest tube may also be indicated post cardiac surgery or thoracotomy. Chest tubes are contraindicated if there is need for immediate thoracotomy. The purpose of this practice support document is to provide guidance regarding the insertion of a chest tube inserted into the pleural, mediastinal or pericardial cavity.

STEPSRATIONALEPERFORM hand hygiene and DON appropriate PPE.Reduces the transmission of microorganisms.IDENTIFY patient using two patient identifiers.Ensures identification mechanism is present to prevent treatments, medications, and procedures to wrong child.ENSURE patient and family are informed of the following:the need for a chest tube to be insertedwhat a chest tube iswhat the procedure and aftercare of a chest tube entailsplan for sedation and/or analgesiaapproximate duration of procedureapproximate duration the chest tube will be insituany other questions or concernsENSURE informed consent has been obtained by physician performing the chest tube insertion.Reduces anxiety regarding procedure and fills any gaps of understanding. Ensures legal steps have been taken for procedureCONDUCT a baseline cardiopulmonary and neurological assessment. CONDUCT a full set of vital signs (Heart Rate, Respiratory Rate, Blood Pressure, Oxygen Saturations, and Temperature) per Nursing Assessment of Pediatric Patients and Related Documentation: Inpatient Units. PLACE on continuous oxygen saturation monitoring.Note: Chest tube insertion may need to be done emergently. Follow steps below as able without delaying procedure.Obtaining patients baseline is essential to monitoring and care.For example, a tension pneumothorax is a life-threatening emergency that requires immediate decompression. Signs and symptoms include sudden onset of sharp chest pain, shortness of breath, tachycardia, tachypnea, hypotension, diminished breath sounds and increased work of breathing.CONSIDER patients history of bleeding disorders, anticoagulant or antiplatelet therapy. ASSESS recent laboratory results, including CBC, platelets, PT and aPTT.Ensures appropriate measures are taken if patient at risk for bleeding.VERIFY patient has functional IV access. If not, OBTAIN IV access.IV access may be necessary for sedation, analgesia, and/or fluid replacement.FOLLOW fasting guidelines, per Pre Anesthesia and Procedural Sedation FastingGuidelines and COMPLETE Pre-Op Checklist if procedure occurring in Procedures or the Operating room per Pre and Post-Operative Care Procedure, as able.This decreases risk of aspiration. Sedation may need to be delayed or the procedure performed with airway protection is guidelines not followed.This ensures all information is available for the team inserting the chest drain for the safety of the patient.In emergent cases, the urgency to insert the chest tube will take precedence.CONSIDER environment prior to insertion such as treatment procedure room.This aids in ensuring the patient room is a safe and therapeutic space. ENSURE emergency equipment and supplies are checked and readily available:appropriate and functioning suctioning equipment including: adult and pediatric size oral Yankauer suction catheters as required suction regulator, canister, and tubing set up correctlyappropriate and functioning oxygen equipment including:appropriate size oxygen mask, tubingoxygen regulator cardiorespiratory and pulse oximetry monitoring device (i.e. oxygen saturation, cardiac, respiratory)Immediate interventions can be provided in case of deterioration in patients condition.All patients with chest tubes require oxygen saturation monitoring, at minimum. Ensure patient has been admitted and is on appropriate profile.ADMINISTER pre-procedural sedation and/or analgesia, as prescribed. Refer to Procedural Sedation: Non-Critical Care Areas and follow and complete Procedural Safety Checklist. MONITOR and RECORD full set of vital signs, level of consciousness and arousal score per policy.PAGE Respiratory Therapist (RT) to notify regarding upcoming procedural sedation, as necessary.Ensures patient comfort as chest drains are invasive and likely to be uncomfortable and restrict movement. The presence of pain when breathing will prevent the child breathing deeply and coughing which may decrease the ventilation of the alveoli, impede good oxygenation, and impair lung expansion. Consider patients underlying diagnosis before selecting appropriate sedative and/or analgesia. This must be discussed with the Attending Physician as it may worsen the patients condition. Ensures RT available for procedure, as needed.PREPARE equipment using aseptic non-touch technique (ANTT) technique:pediatric chest drainage insertion tray/emergency procedure tray indicated size and type of chest tube(s)prescribed local anesthetic Chlorhexidine 2% with 70% alcohol solution For patients allergic to chlorhexidine, substitute with an iodophore-based preparation or 70% alcohol For patients with non-intact skin or allergic to all antiseptic agents, sterile normal saline may be substitutedsuction regulator (for continuous suction only) sterile disposable chest drainage unit zap straps and banding guntwo non-grooved occluding clamps per chest tube suction tubing universal securement device (Stat-lok or Grip-lok)sterile dry occlusive dressing gauze and occlusive transparent dressing ENSURE the following supplies remain at the bedside at all times: sterile semi-permeable occlusive transparent dressing of appropriate size two non-grooved occluding clamps per chest tube500 ml bottle of sterile waterANTT technique will prevent spread of microorganisms and decrease infection risk. Preparing all equipment will aid in ease of insertion without unnecessary delay.There is little evidence for the need for petroleum gauze dressings. However, historically this has been standard practice. Occlusive dry sterile dressings have been found to be as effective in preventing air leaks and wound infections. It is the prescribers preference as to which dressing will be used.Emergency chest tube supplies are necessary in case of accidental removal, disconnection or persistent air leak (see Chest Tube: Troubleshooting Unexpected Guidelines).Occluding clamps are also necessary if the drain has to be moved above the patients chest level.PREPARE the drainage collection chamber.FILL water seal to 2 cm line with 45 mL sterile water.If suction is ordered, ENSURE appropriate suction is set on dry suction regulator as per prescribers order. Dry suction regulator can be adjusted from -10 cmH2O to -40 cmH2O. To change the setting, adjust rotary dial located on side of collection chamber. CONNECT to wall suction but do not turn on.ENSURE sterility is maintained to distal end of tubing that connects to the chest tube. The water seal acts as a one way valve and prevents air and/or fluid from going back into the pleural space.The least amount of suction to maintain full expansion of the lung is recommended. Too high of suction may delay pleural healing. When lowering regulator setting, temporarily depress the vent located on top of the drain to reduce excess vacuum pressure. When setting up suction, attach suction tubing to collection canister, not directly to wall suction, to avoid any accidental fluid from entering the medical vacuum system.REASSESS patients pain status and address as necessary.This ensures appropriate sedation and/or analgesia has been administered, allowing for reassessment and need for further time for onset of medication or need for further medication.PROVIDE non-pharmacologic pain management, through support, distraction, and other techniques. ENGAGE Child Life as able.To keep patient as comfortable as possible.PERFORM a time-out to verify correct patient, correct site (left/right upper, mid or lower lobe), and correct procedure.This is performed immediately prior to the start of a procedure and is the final safety stop before the procedure is begun. All staff present are to STOP what they are doing and participate in the time out. The physician performing the procedure leads the time-out.POSITION patient as directed by the physician. Generally the patient will be supine with the affected side arm above the head, or if patient has a pneumothorax, with the affected side upright.To ensure patient comfort, ease of chest drain placement, and to reduce the risk of infection through contamination.Physician to DON sterile PPE and set up sterile field. Nurse to ASSIST as needed.To prevent infection.Physician CLEANSE and prepare skin for procedure with chlorhexidine gluconate 2-4% solution, unless otherwise indicated.To prevent infection.Physician to INSERT chest tube. Nurse to ASSIST with insertion as required. To facilitate ease of insertion and minimize risk of infection, unintentional injury, etc. ATTACH patient to chest drainage unit. ESTABLISH suction using wall regulator as prescribed. Suction bellows will expand to the mark or beyond when suction is connected and operating at a regulator setting of -20 cmH2O or higher. If the bellows is expanded but less than the mark, increase the wall suction to -80 mmHg or higher. For regulator settings less than -20 cmH2O, any visible bellows expansion in bellows window will confirm suction operation. If STRAIGHT OR GRAVITY DRAINAGE is ordered, do not have suction on and leave suction port uncapped and free of obstruction.Establish connection with chest tube drainage system and patient that follows infection control measures. Amount of wall suction needed will vary patient to patient due to other factors (such as amount and consistency of fluid) and must be set individually and checked routinely per patient. This should be reviewed daily by the medical team and the decision documented.Leaving suction port free of obstruction allows air to exit and minimizes chance of tension pneumothorax.Physician to SUTURE the chest tube in place. Nurse to ASSIST and SECURE chest tube to chest wall using a universal securement device (Stat-lok or Grip-lok)To prevent chest tube displacement.APPLY split 4x4 gauze or sponge gauze around chest tube, cover with 4x4 gauze and an occlusive transparent dressing, such as Tegaderm.This allows for proper assessment of the chest tube insertion site, including bleeding or infection, and prevents air from reentering the pleural space. It may be necessary to add dry gauze between the occlusive dressing and drain for comfort.ENSURE chest drainage system is kept below the patients chest level. COIL excess tubing on bedside do not allow tubing to hang below the bed and coil on the floor. To avoid accidental knock over, open the floor stand for secure placement on the floor or hang the system bedside with the hangers provided. AVOID taping to the floor.To prevent fluid or gas re-entering the pleural space. Prevent dependent loops and pressure changes, and accidental occlusion of tubing.Avoiding taping to the floor promotes ambulation and prevents accidental removal.SECURE all connections from the insertion site to the chest drainage unit using zap straps and banding gun.To prevent accidental disconnection. COLLECT specimens as ordered using aseptic non-touch technique (ANTT): SWAB needleless cap with chlorhexidine 2% and alcohol 70% pad for 30 seconds and allow to dry for 60 seconds.ATTACH syringe directly onto needleless cap and WITHDRAW required amount as per eLab handbook.PLACE aspirate into specimen container. LABEL container and send to lab with appropriate requisition.ENSURE amount of fluid removed is documented on BCCH Daily Flowsheet.To assess lab values and treat appropriately (i.e. PRBC if hemoglobin low or change in antibiotics due to C&S results).POSITION patient comfortably with head of bed at minimum of 30-45 degree angle, or as prescribed.To facilitate drainage of air and/or fluids from the pleural space.PERFORM a site to source check as per Chest Tube: Care and Management procedure. COMPLETE a cardiorespiratory assessment OBTAIN a full set of vital signs and RECORD PEWS. ESCLATE care as necessary. If patient has a Blake Chest Tube, see Blake Chest Tube Maintenance and Removal policy.If patient was off the ward for procedure, receive handover from PACU RN, provide care per the Pre and Post-Operative Care procedure. PERFORM a full assessment, including a full chest tube site to source, and set of vital signs together. RECORD PEWS. ESCALATE care as necessary. INVOLVE family if present.In obtaining the patients new baseline assessment with the chest tube and a set of vital signs, recognition, mitigation, notification, and appropriate response to their needs and risk of deterioration can occur. Follow the PEWS Escalation Aid as necessary.OBTAIN chest imaging as prescribed.This should be done within one hour of insertion or arrival to ward to assess that the tube is in the correct position to enable the drain to function.COLLECT specimen as ordered. See Chest Tube: Care and Management.AP and lateral chest x-rays are typically preferred.DISCARD supplies and PPE. PERFORM hand hygiene.To prevent the spread of infection.ADMINISTER regular analgesia for the first 24 hours. RECORD pain using appropriate pain scale.This will minimize patient discomfort and allow for review of efficacy of prescribed analgesia. Consider need for intravenous analgesia as chest tube insertion is a painful procedure and control of this pain may need specialist advice for a multi-modal approach.INVOLVE and EDUCATE patient and family regarding chest tube management and emergency care. ANSWER questions as they arise.This reassures the patient and family about the procedure and the aftercare the patient will be receiving.

Documentation

DOCUMENT in appropriate record(s): Date, time, length of procedure Name of physician performing procedure Chest tube brand/model, size, lot number, location and depth of placementPatient assessment pre/post insertion (breath sounds, signs of oxygenation, ventilation, pain) Amount, colour, consistency of drainage Amount negative pressure suction Site assessment Dressing type Comfort assessment and any specific interventions Patient/family education Unexpected outcomes and related treatmentTransfer documentation via SHARED form, if applicable

Related Documents

Atrium Oasis Wall ChartA Personal Guide to Managing Chest DrainageRelated BCCH Documents: Blake Chest Tube Maintenance and RemovalChest Tube: Care and ManagementChest Tube: Dressing ChangeChest Tube: RemovalChest Tube: Troubleshooting Unexpected OutcomesClinical Skill Validation: Chest TubesPEWS Escalation AidPre and Post-Operative CareProcedural Sedation: Non-Critical Care AreasProtocol for the Management of Pleural Effusions in Previously Healthy Pediatric Patients

References

American Association of Critical Care Nurses. (2007). Procedure Manual for Pediatric Acute and Critical Care. St. Louis: Elsevier.Atrium Med. (n.d). Oasis Dry Suction Water Seal Drain. Retrieved from http://www.atriummed.com/EN/chest_drainage/oasis.asp Carol, P. (2013). Evidence-Based Care of Patients with Chest Tubes. American Association of Critical-Care Nurses National Teaching Institute. Boston, MA.Crawford, D., (2011). Care and management if a child with a chest drain. Nursing Children and Young Curley, MAQ and Thompson, JE. (2001). Oxygenation and Ventilation in Critical Care Nursing of Infants and Children 2nd edition. Curley, MAQ and Moloney-Harmon, PA (ed). Saunders: Philadelphia.Durai, R., Hoque, H., & Davies, T. (2010). Managing a chest tube and drainage system. AORN Journal, 91(2), 275-283. doi:10.1016/j.aorn.2009.09.026Elsevier. (2018). Chest Tube Insertion (Pediatric). Retrieved from http://point-of-care.elsevierperformancemanager.com/#/skills/705/extended-text?skillId=CCP_033 Gan, K. L. J., & Tan, M. (2015). Evidence-based management of patients with chest tube drainage system to reduce complications in cardiothoracic vascular surgery wards. International Journal of Evidence-Based Healthcare, 13(2), 58.Gogakos, A., Barbetakis, N., Lazaridis, G., Papaiwannou, A., Karavergou, A., Lampaki, S., Baka, S., Mpoukovinas, I., Karavasilis, V., Kioumis, I., Pitsiou, G., Katsikogiannis, N., Tsakiridis, K., Rapti, A., Trakada, G., Zissimopoulos, A., Tsirgogianni, K., Zarogoulidis, K., Zarogoulidis, P. (2015). Heimlich valve and pneumothorax. Annals of translational medicine, 3(4), 54.Great Ormond Street Hospital for Children. (2016). Chest drain management. Retrieved from https://www.gosh.nhs.uk/health-professionals/clinical-guidelines/chest-drain-management#Rationale Jeffries, M. (2017). Research for Practice. Evidence to Support the Use of Occlusive Dry Sterile Dressings for Chest Tubes. MEDSURG Nursing, 26(3), 171174. Lippincott. (2015). Lippincott Nursing Procedures (Vol. 7th). [N.p.]: Wolters Kluwer Health. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=e680sww&AN=1473216&site=ehost-live Perry, A.G., Potter, P.A., Ostendorf, W.R. [Eds.] [2018]. Clinical nursing skills & techniques [9th ed.]. St. Louis: Elsevier. Retrieved from http://point-of-care.elsevierperformancemanager.com/#/skills/743/quick-sheet?skillId=CCP_036 SickKids. (2017). General Care of a Chest Tube Policy. Toronto, ON.SickKids. (2017). Setting Up and Changing a Chest Drainage System. Toronto, ON.The Royal Childrens Hospital Melbourne. (2016). Clinical Guideline (Nursing): Chest Drain Management. Retrieved from http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/chest_drain_management/UpToDate. (2018). Placement and management of thoracostomy tubes. https://www.uptodate.com/contents/placement-and-management-of-thoracostomy-tubes?search=chest%20tube&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Definitions

Pleural Chest Tube: A drainage tube located in the pleural space between the visceral and parietal pleurae. It is used to remove air and/or fluid from the pleural space.Mediastinal Chest Tube: A drainage tube in the mediastinal cavity, which includes part of the thoracic cavity that contains a group of structures (the esophagus, trachea, heart, thymus, thoracic duct). It is used to evacuate air and/or fluid. Post cardiac surgery, this tube might also drain the pleural space to evacuate any pooling of blood which left might cause cardiac distress or tamponade.Pericardial chest tube: Drainage tube located in the pericardial sac of the heart.Argyle chest tube: A clear PVC single lumen catheter that is inserted using a sharp trocar. The catheter has numerical depth marks at 2 cm increments and once inserted and position it is typically sutured in place.Pigtail chest tube: A flexible single lumen catheter designed to allow the distal end to coil when a string is pulled at the proximal end. It can be used for the purpose of drainage or introducing fluids. The coil end helps to hold the catheter in place and can slow the flow of fluids injected through the catheter. Pigtail catheters are often used in medical imaging studies or for patients with a pleural effusion. Typically they are held in place with a universal securement device (Stat lok or Grip-lok) and are not always sutured into place. A pigtail drain often has extension tubing and a three way stop cock.Blake chest tube: A white radiopaque silicone drain with four channels along the sides with a solid core center. Typically it is sutured in place using a purse-string suture. The Blake is attached to a reservoir bulb with a mechanical one way valve instead of a water seal chamber. Used when patient requires drainage only (not suction to re-expand lung). Chest Tube Drainage System: A device used to collect air and/or fluid from a chest tube. Atrium: Disposable water seal drainage system that separates the functions of fluid collection, suction control and water seal.Water Seal: Water in a chamber that serves as a simple one way valve. Dry Suction: The dry suction control regulator works by balancing the forces of suction and atmosphere to deliver reliable suction to the patient. The standard default setting is typically -20cmH2O. However, this can be adjusted using the rotary dial on the side of the Atrium as per doctor order.

Version History

DATE

DOCUMENT NUMBER and TITLE

ACTION TAKEN

06-Feb-2019

C-05-12-60107 Chest Tube: Assisting With Insertion

Approved at: BCCH Best Practice Committee

Disclaimer

This document is intended for usewithinBC Childrens and BC Womens Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document.This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.

C-05-12-60107 Published Date: 11-Feb-2019

Page 1 of 9 Review Date: 11-Feb-2022

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