Safe insertion, maintenance and removal of chest tube: what every health-care professional must know

Neha Tiwari; Mohan Venkatesh Pulle; Arvind Kumar

doi:10.4103/ijcn.ijcn_55_22

CONTINUING EDUCATION SERIES NO. 43

Year : 2022 | Volume : 23 | Issue : 2 | Page : 134-144

Safe insertion, maintenance and removal of chest tube: what every health-care professional must know

Neha Tiwari¹, Mohan Venkatesh Pulle², Arvind Kumar³
¹ Nurse Co-Ordinator, Institute of Chest Surgery, Medanta – The Medicity, Gurugram, India
² Associate Consultant, Institute of Chest Surgery, Medanta – The Medicity, Gurugram, India
³ Chairman & Senior Consultant, Institute of Chest Surgery, Medanta – The Medicity, Gurugram, India

Date of Submission	14-Jun-2022
Date of Decision	02-Sep-2022
Date of Acceptance	26-Dec-2022
Date of Web Publication	04-Jan-2023

Correspondence Address:
Ms. Neha Tiwari
Room No. 12, 4th Floor, OPD Block, Medanta – The Medicity, Sector – 38, Gurugram - 122 001, Haryana
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijcn.ijcn_55_22

Abstract

Chest tube insertion is a vital, often life-saving procedure which may be required for any patient. A comprehensive knowledge about safe insertion, maintenance and removal of the chest tube is vital for every health-care professional. This article describes essential components of chest tube management such as type of chest tubes, drainage systems, how to perform safe insertion, connecting to the drainage system, fixation of chest tube, precautions during initial drainage, monitoring of patient, daily measurement and emptying of bottle, pain relief, chest physiotherapy, patient transport, method of collecting pleural fluid sample and steps of safe removal.

Keywords: Chest tube insertion, drains and catheters, maintenance and removal of chest tube

How to cite this article:
Tiwari N, Pulle MV, Kumar A. Safe insertion, maintenance and removal of chest tube: what every health-care professional must know. Indian J Cont Nsg Edn 2022;23:134-44

How to cite this URL:
Tiwari N, Pulle MV, Kumar A. Safe insertion, maintenance and removal of chest tube: what every health-care professional must know. Indian J Cont Nsg Edn [serial online] 2022 [cited 2023 May 31];23:134-44. Available from: https://www.ijcne.org/text.asp?2022/23/2/134/367098

Introduction

The first description of the chest tube starts with Hippocrates.^[1] Later on, many clinicians used this procedure, mainly for the management of chest trauma to drain haemothorax.^[2] Although the use of completely closed intercostal drainage system was first described by Hewett,^[3] this was popularised only during World War II in the treatment of injured patients.^[4]Chest tubes are flexible drainage tubes inserted to drain abnormal collection of air or fluid from the pleural space. These tubes are connected to 'underwater seal' drainage systems, which prevent backflow of air/fluid into pleural space. This enables restoration of negative intrapleural pressure and assists in complete lung expansion.^[5] This procedure can be performed as an emergency life-saving procedure or as an elective procedure for specific indications. Hence, a detailed knowledge of all these aspects is essential for all health-care professionals, which will enhance the quality of care being provided to patients with chest tube.^[6]

This article aims at describing the evidence based, practice-oriented aspects of chest tubes, drainage systems, method of safe insertion and maintenance and removal of chest tubes.

Definitions

The definition of various lung conditions which may require a chest tube are given below [Figure 1]:

Figure 1: Chest X Rays – Various lung conditions

Click here to view

Pleural effusion: Collection of fluid in the pleural cavity
Pneumothorax: Collection of air in the pleural cavity
Haemothorax: Collection of blood in the pleural cavity
Hydropneumothorax: Collection of fluid and air in the pleural cavity
Haemopneumothorax: Collection of blood and air in the pleural cavity (the chest X-ray will look similar to hydropneumothorax)
Pyopneumothorax: Collection of pus and air in the pleural cavity (the chest X-ray will look similar to hydropneumothorax)
Empyema: Collection of pus in the pleural cavity
Chylothorax: Collection of lymph fluid in the pleural space (the chest X-ray will look similar to pleural effusion)
Tension pneumothorax: Collection of air under pressure in the pleural cavity causing ipsilateral lung collapse, mediastinal shift, and then pressure on the contralateral lung and, ultimately, its collapse, leading to life-threatening hypoxia, which may even be fatal, if not drained instantly. This is a life-threatening emergency situation.^[7]

Type of Chest Tubes

A chest tube, also known as a thoracic catheter, is a sterile, flexible and thin plastic rubber tube with several drainage holes. The chest tubes are of different types, each available in different sizes. The types are -
Simple tube: Which can be straight or angled [Figure 2]
Trocar chest tube: Simple tube with a trocar inside [Figure 2]
Malecot's catheter: Straight tube with a flower at distal end, which makes it self-retaining (can be red rubber or plastic) [Figure 2]
Pigtail catheter: A self-retaining small-bore tube, commonly used for localised collections [Figure 2].

Figure 2: Type of chest tubes

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The internal diameter of the chest tube determines the amount of air or liquid flowing through it. The size of a chest tube refers to its outer diameter and is measured in French (Fr) (1 Fr = 0.33 mm). Thus, a 12F tube is 4 mm in diameter. Commercially available chest tube sizes in India range from 8 Fr to 36 Fr. The size of the chest tube used depends on the age of the patient and the pathology.

Type of Drainage Systems

These can be classified into (1) traditional underwater seal systems (a plastic bag or bottle) and (2) commercially made 'chest drainage units'.

Traditional 'underwater seal systems'

A chest tube drainage system is a sterile, disposable system to remove air or fluid from the chest and prevent its return back into the patient. It can be in the form of a plastic bag or a bottle
Chest tube drainage bags can be differentiated from abdominal/urobag by noticing a long tube passing till the bottom of the bag^[8] [Figure 3], where underwater seal can be achieved. Chest tube drainage bag is easy to manage as patient can do routine activities by tucking it under clothes. However, there is a higher risk of toppling.
Chest drainage bottles have the advantages of lesser risk of toppling and spillage. In olden times, saline glass bottles were modified by putting a cork with a long and a short straight glass tube to create an underwater seal system. These were sterilised and reused. They were cumbersome. Nowadays, sterilised, disposable (single-patient use) plastic bottles, which can be single chambered (500 ml capacity) or double chambered (2000 ml capacity), are available and routinely used [Figure 3].

Figure 3: Chest drainage bag and bottles

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Commercially made 'Chest drainage units'

Usually, these drainage systems consist of three chambers: (1) a collection chamber for the collection to accumulate, (2) sealing chamber – to provide sealing and (3) a suction chamber – to create negative pressure, which can be transmitted to the chest cavity.^[9]

Based on the method of sealing (water seal or dry seal) and mode of suction (wet suction or dry suction), these devices can be classified into three generations.^[10]

First generation – Water seal, wet suction systems

Sterile water is used to fill the water-seal chamber to the specified level, as it acts as a one-way valve to allow air to pass out of the pleural cavity.

These systems also use water in the suction mechanism, where sterile water or normal saline solution will be filled in the suction control chamber to the prescribed level (usually 10–20 cm of water). This chamber will be connected to a wall mount negative suction through short tubing. In a wet suction system, suction is typically controlled by the level of water in the suction control chamber and is typically set at 20 cm on the suction control chamber for adults. If there is less water, there is less suction. The amount of suction may vary depending on the patient and is controlled by the chest drainage system, not by the suction source.

Examples: Atrium Ocean™, PLEUR-EVAC A-7000 series™ [Figure 4].

Figure 4: Commercial chest drainage units

Click here to view

Second generation – Water seal, dry suction systems

These devices also use sterile water in the water-seal chamber as a sealing mechanism. However, these systems do not use a water column as a suction mechanism. Instead, the negative pressure is controlled by the unit's design – a self-compensating mechanical regulator. The dial in the suction setting can be rotated and set at − 10, −20, −30 or − 40 cm of water to achieve the prescribed suction level.

Examples: Atrium Oasis™, PLEUR-EVAC A-6000 series™ [Figure 4].

Third generation – Dry-seal, dry suction systems

These are the latest generation of drainage systems which work on dry seal and dry suction mechanism. The dry seal is achieved by the 'one-way mechanical valves' and negative pressure is controlled by the unit's design – a self-compensating mechanical regulator.

Examples: Atrium Express™, PLUER-EVAC S-1100 Sahara^® Series, SINAPI chest drain systems [Figure 4].

In few devices, there is an option of digitally calibrating the amount of air leak and the drainage. These are called 'Digital Negative Suction Devices'. They display accurate and real-time negative pressure and air leak. The amount of suction in the chamber is regulated by the suction control, depending on patient's requirement. These are small, easy to carry, electrically operated, with a battery backup that allows suction to be maintained even when the patient is moving about. These devices help in lung expansion and are a great help in the recovery of chest surgery patients. Examples: Thopaz Medela™, Atomos™ [Figure 5].

Figure 5: Digital negative suction device

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Safe Insertion of a Chest Tube

Chest tube insertion is a basic, yet life-saving surgical procedure. Although this is a simple procedure, there is a need to standardise it so that patients get an optimum outcome and complications are kept down to minimum. Therefore, in-detail knowledge about various aspects of chest tube insertion is of utmost essential for all health-care professionals.

Indications

Pleural effusion
Empyema
Haemothorax
Chylothorax
Pneumothorax
Tension pneumothorax
Hydropneumothorax
Pyopneumothorax
Haemopneumothorax – traumatic or secondary
Post-operative – after pulmonary/pleural/mediastinal/cardiac/oesophageal surgery.

Contraindications

The published literature states that if the procedure is required as a life-saving measure, there are truly no absolute contraindication.^[11]

However, the relative contraindications in an elective setting include – uncorrected coagulopathy, active infection at the insertion site and multiple pleural adhesions. Attempt should be made to correct coagulopathy by infusing various blood products. In cases of active local infection, those sites should be avoided by choosing the alternative insertion site.

Checklist

Informed consent
Explain the procedural details to the patient: it helps tremendously in allaying the anxiety and gets cooperation from the patient during the procedure and makes the procedure less traumatic for the patient/family
Secure an intravenous line
Pre-medication (IV sedation) in selected cases: advisable
Pulse oximeter should be in place and even if oxygen levels are normal, it is a good idea to have oxygen on the flow
Imaging of the patient (chest X-ray or CT scan chest) should be available for viewing before insertion.

Setup

Sterile drapes (4–6 in number)
10% betadine solution
2% chlorhexidine gluconate + 70% isopropanol alcohol solution
Chest tube of appropriate size (with a spare tube also, if possible)
Drainage system
Chest tube insertion set containing sterile gauze pieces, sponge holder, two long artery forceps, surgical scalpel, No. 15 blade, tissue forceps, needle holder, No. 1 silk reverse cutting needle and suture cutting scissors.

Technique

It is important for health-care professionals to be aware of the crucial steps in the insertion of the chest tube. It will allow them to improve patient safety.

The steps in insertion are as follows: [Figure 6] and [Figure 7]

Figure 6: Steps in chest tube insertion (A) Aseptic precautions (B) supine position with ipsilateral side elevated and arm hyperextended or (C) Sitting position with patient's arms supported on cardiac trolley (D) Skin preparation: (E) Draping: Sterile drapes are placed around the site of insertion of the tube, (F) Local anaesthesia adminstration

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Figure 7: Steps in chest tube insertion (A) Planning & creating the sub-cutaneous tunnel (B) Skin incision (C) Chest wall puncture(D) Dilating the tract (E) Grasping the chest tube (F) Inserting and guiding the tube

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Aseptic precautions
Patient position
Skin preparation
Draping
Infiltration of local anaesthesia^[12]
Skin incision
Planning and creating the subcutaneous tunnel
Chest wall puncture
Dilating the tract
Grasping the chest tube
Inserting and guiding the tube.

Connecting to drainage system

Chest tube is connected to an underwater seal system, which can be in the form of a chest tube bag or single-chamber bottle or double-chamber bottle. Usually, a single-chamber device is used for pneumothorax, minimal haemothorax or mild effusions. However, double-chamber bottles are used for massive pleural effusion/massive haemothorax. All of the underwater seal systems have inbuilt, very long connecting tubes. Establishing an appropriate length of the connecting tube is of critical concern at this step. If the length of the connecting tube is longer, it forms a loop over the floor, which forms a pressure head/resistance through which air/fluid has to come out. If the length of the connecting tube is too short, it can cause undue pull over the chest tube, which can interfere with daily activities of the patient. Therefore, the connecting tube should be of just adequate length [Figure 8].

Figure 8: (A) Connecting chest tube to underwater seal bottle (B) A snugly fitting suture applied around the chest tube

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Fixation of chest tube

After chest tube insertion, a purse-string suture is taken, which should fit snugly around the tube, and should not allow chest tube movement in and out through the skin incision. This is the most important step to prevent peri-drain leakage. If, one purse string is not sufficient to close the bigger skin incision, one/two interrupted sutures can be placed to approximate the skin defect [Figure 8].

Chest tube dressing

A tincture benzoin-soaked cotton wick is placed around the chest tube at the entry point, which forms a protective layer upon drying. This is followed by placing a water-impermeable sterile dressing, which helps to seal the area in a sterile manner. Then, a sterile gauze piece is placed and rolled around the chest tube, which is anchored to the skin by adhesive plaster dressing. At a location close to the lateral waist, chest tube is refixed with adhesive plaster dressing. This secondary strapping helps to avoid inadvertent removal of the chest tube due to accidental pull over the chest tube while sleeping, walking and other activities [Figure 9].

Figure 9: (A) Cotton wick (Tincture benzoin soaked) around Chest tube, (B) Water-impermeable sterile dressing over cotton wick to seal chest tube surrounding, (C) A gauze piece is placed and rolled around the chest tube, (D) Adhesive plaster dressing over gauze piece, should be 2 cm bigger than gauze piece for proper sticking of plaster, (E) Primary fixation, (F) Secondary fixation

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Management of Chest Drain

Precautions during initial drainage

In case of massive pleural effusion, the fluid should be drained slowly. Not more than 1 L should be drained in the first go, after which the tube should be clamped for an hour and then drained at intervals of every 1 or 2 h, about 300 ml at a time, with the tube clamped in between. This is necessary to prevent re-expansion pulmonary oedema
If the collection bottle gets filled with drained blood or fluid, it should be emptied, after clamping the tube and it is to be done in a completely sterile manner.

Monitoring of patient

After shifting the patient from the operating room/other site to the room/bed, vital signs are carefully monitored with a special focus on the respiratory function. The respiratory examination includes checking the respiratory rate, monitoring the oxygen saturation, inspection of bilateral chest movements and auscultation of the chest to assess the intensity of breath sounds bilaterally. Chest X-ray is done for two reasons, (1) to assess the exact position of chest drain and (2) to evaluate the status of underlying lung expansion. Any alterations in the patient's haemodynamics and respiratory mechanics should be monitored for appropriate management.

Daily measurement/emptying of the bottle

The amount of drainage, consistency and colour of fluid should be checked at regular intervals. However, in patients with bleeding and massive pleural effusion, hourly monitoring may be needed
It is essential to empty drainage bottles at regular intervals (every 24-h) as excessive fluid accumulation causes resistance to drainage of pleural fluid.
In case of any air leak, the intensity of bubbling of air through the underwater seal should be monitored
The drainage bottle should always be kept below chest level, which prevents fluid re-entering the chest. The movement of the fluid column with each breath should be carefully looked for
Emptying the water bottle should also be carried out in the utmost aseptic manner, without touching the mouth of the bottle. The drainage tube should be temporarily clamped while emptying the bottle to ensure that no air is sucked into the chest cavity [Figure 10].

Figure 10: Emptying the chest drainage bottle in a sterile manner (a) Opening the mouth of chest tube bottle while clamping the tube, (b) Emptying the drainage bottle without touching bottle mouth, (c) Rinse bottle with normal saline, (d) Fill bottle with fresh normal saline till initial level

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Pain relief

Pain relief is a vital component of patient care after chest tube insertion, as inadequate analgesia leads to restricted chest movement, which delays recovery.^[13] Usually, injectable non-steroidal anti-inflammatory drugs (NSAIDs) and/or oral paracetamol and/or local application of NSAID gel are used to control the pain. In patients with multiple rib fractures in chest trauma and patients who underwent thoracotomy, it is a good practice to insert an epidural catheter through which fentanyl with or without bupivacaine can be administered as bolus or through an infusion pump or patient-controlled analgesia pumps for effective pain relief.^[14]

Chest physiotherapy

Patients should be encouraged to ambulate as soon as possible. Deep breathing and breath-holding exercises should be initiated as soon as possible after chest tube insertion.^[15] This facilitates effective lung expansion and drainage of fluid.

Patient transport

During transportation, the chest tube bottle/bag should always be kept lower than the chest level
It is important 'not' to clamp the chest tube, as continuous drainage is the safest approach.^[16]
In cases where there is an air leak from the lung surface, clamping the tube will lead to the accumulation of air in the pleural cavity, causing lung collapse and, sometimes, the risk of developing tension pneumothorax.

Specimen collection

Drainage fluid is often sent for various microbiological and pathological investigations in the diagnostic workup. Therefore, collecting the pleural fluid samples aseptically and appropriately should be known to every health-care professional. The method to collect pleural fluid samples varies according to the drainage system that is applied to the chest tube.

In underwater seal system, pleural fluid is collected directly from the tip of the tube, which is passing till the bottom of the bottle. During this process, a transient clamping of the chest tube should be done to prevent air entering the chest cavity.

In commercially made 'chest drain units', one/two sampling port(s) are designed for the sampling process, where a sterile syringe can be used to aspirate and collect the samples.

Equipment required

Specimen container
Alcohol swab
10 ml syringe
Sterile gloves.

Procedure

Wait for the fluid to collect in a loop of the tubing
Perform hand hygiene, then wear gloves
Clean the sampling port with an alcohol wipe and leave it to dry for 20 s
Connect a 10 ml lock syringe to the sampling port and aspirate the fluid out of the tubing
Place fluid in the sterile specimen container
Once the syringe is disconnected, remove all clamps and kinks.

Safe Removal

Indications

The set-up required for removal of chest tube includes,^[17]

The lung should be fully expanded
There should be no air leak
No fresh or altered blood or pus should be draining from the chest tube
The last 24-h drainage should be <100–150 ml.

Set up

Before removing the chest tube, the nurse assistant should be ready with the following set up:

Dressing set with sterile gauze pieces and artery forceps
Sterile water impermeable adhesive wound dressing/adhesive tight dressing.

Technique

The process of removal of the chest tube should be explained to patient by nurse and his/her cooperation is sought. In the ideal scenario, two persons are recommended for safe chest tube removal.^[18]

The importance of taking a deep breath and holding it at the end of inspiration should be carefully explained and rehearsed multiple times. At the peak of deep inspiration, chest tube should be pulled out gently. While one person pulls out the chest tube, the other one should be ready to tighten the purse string suture to prevent any air entering the chest [Figure 11]. A water-impermeable occlusive dressing is applied at the site of insertion, which is removed after 48 h.

Figure 11: Safe removal of a chest tube (a) Purse string suture positioned, (b) Assistant removing the chest tube at the end of deep inspiration

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Post-chest tube removal monitoring

The chest should be examined clinically after the removal of chest tube, whether there is adequate air entry bilaterally present or not. Pain relief measures should be continued, they should be encouraged to do slowly increasing level of physical activity and physiotherapy and dietary advice should be reinforced. A chest X-ray must be done to look for pneumothorax or any other abnormality. Patient also needs to be advised for treatment of the primary disease which needed chest tube insertion.

Complications and troubleshooting

The following complications has to be checked and managed^[19]

If the post chest tube removal X-ray shows a pneumothorax, the further action depends on the amount of pneumothorax and the patient's symptoms
An asymptomatic patient with minimal pneumothorax should be kept under close observation, and chest X-ray to be repeated after 24 h
A patient who develops respiratory distress or has large pneumothorax, should have a new chest tube re-inserted immediately (at an adjacent site, not there at the same site).

Conclusion

Chest tube insertion is a vital, often life-saving procedure which may be needed for any patient, in any ward, at any time and in any part of the country. Although a simple procedure, a large number of patients still suffer avoidable complications due to lack of adequate knowledge. This article provides a simple, step-by-step and practice-oriented guidance of critical steps of chest tube management. Adherence to the principles described herein will definitely make chest tube insertion and maintenance safer for our patients. We owe it to our patients!

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

CE Test No. 43- Questions

1. What is Pneumothorax ?

Collection of blood in the pleural cavity
Collection of air in the pleural cavity
Collection of Pus in the pleural cavity
Collection of spinal fluid in the pleural cavity

2. What is Hydro-pneumothorax ?

Collection of blood in the pleural cavity
Collection of fluid and air in the pleural cavity
Collection of blood and air in the pleural cavity
Collection of pus and air in the pleural cavity

3. Which of the following is NOT an indication for Chest Tube insertion?

Pneumothorax
Haemothorax
Fibrothorax
Chylothorax

4. The size of a chest tube refers to its outer diameter and is measured in French (Fr).

One Fr is equal to how many millimetres?

0.22
0.33
0.44
0.55

5. Chest tube drainage bags can be differentiated from abdominal/Uro-bag by noticing

Two connecting tubes passing to the bottom of the bag
A long tube passing till the bottom of the bag
A three-way stopcock at the exit valve in the bag
100 ml of saline at the bottom of the bag

6. Which of the following is “necessary” for safe insertion of a chest tube:

An operation theatre with laminar airflow
An operation theatre without laminar airflow
An operation theatre with thoracotomy set ready
A clean or sterile area where asepsis can be maintained.

7. Which of the following instruments is NOT a part of the chest tube insertion set:

A curved artery forceps
A toothed forceps
A vascular forceps
A suture cutting scissors

8. Use of which of the following devices improves the safety of chest tube insertion:

X-Ray screening
Ultrasound
C T Scan of the chest
PET Scan

9. Which of the following liquids is commonly used in underwater seal for chest tube:

Tap water
Distilled water
Savlon solution
Normal saline

10. Why is it necessary to have an underwater seal while connecting chest tube to a bottle or a chest tube bag:

It prevents ascending infection from bottle /bag into the chest cavity
It sucks air /fluid from inside the chest, leading to faster clearance
It prevents aspiration of air into the pleural cavity
It allows you to measure the amount of fluid drainage

11. Which of the following prevents peri-tubal fluid leakage at chest tube insertion site:

a purse- string suture snugly fitting around the chest tube at insertion site
Skin sutures for 2 cms on either side of the chest tube
Skin sutures for upto 5 cms on either side of the chest tube
Heavy pad dressing around the chest tube

12. After chest tube insertion, which of the following needs regular monitoring:

Respiratory rate
Oxygen saturation level
Heart rate
All of the above

13. Which of the following can cause re-expansion pulmonary edema after chest tube insertion:

Injury to the lung parenchyma due to the chest tube
Sudden expansion of lung due to drainage of huge amount of fluid
Lung injury due to hypoxia caused by the disease
Fluid overload during chest tube insertion

14. Following insertion of a chest tube, which of the following should be monitored by the nurse on duty:

Amount of drainage from the chest tube
Consistency and color of drainage fluid
Any air leak present
All of the above

15. Pain relief is an important measure after chest tube insertion. Which of the following methods is NOT routinely used for pain relief:

Oral analgesics
Parenteral analgesics
Epidural analgesia
Local application of analgesic gels

16. Emptying of the chest tube bottle is an important step in the maintenance of the chest tube. It should be performed by:

Treating unit doctors
Qualified and trained nurses attached to the unit
Nursing students attached to the treating unit
Ward boys attached to the unit

17. Which of the following is NOT an important step in the maintenance of the chest tube:

The chest tube bottle should be emptied regularly under strict asepsis
The amount and nature of drainage should be carefully observed and noted
CT scan of the chest should be done frequently to check for lung expansion
Patient should be auscultated at regular intervals to check for adequate air entry.

18. In patients who are having air leak from the chest tube, which of the following should NOT be done:

Deep breathing exercises
Local application of analgesic gels
Clamping of the chest tube during transport of the patient
Epidural analgesics for pain relief

19. Which of the following is a contraindication for removal of the chest tube:

Daily drainage is still between 50-100 ml
Pain at the insertion site is not yet relieved
Chest x ray still shows fracture in the ribs
Air leak is still present in the chest tube

20. After removal of the chest tube, which of the following steps is NOT necessary:

Auscultate the patient carefully to check for air entry
Order a chest X-Ray to check that the lung is fully expanded
Order an Ultrasound of the chest for further treatment
Give advice regarding physiotherapy, pain relief and nutrition.

CE Test No: 43

Safe Chest Tube Insertion, Maintenance & Removal: What Every Nurse Must Know

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