Chest drainage

Chapter 14 Chest drainage



Michaela Dixon



CHAPTER CONTENTS


Introduction 163
Learning outcomes 163

Rationale 163

Pathophysiology 164

Pneumothorax 164

Haemothorax 164

Pleural effusion/empyema 164
Factors to note 164

Chest drainage 165
Equipment 165

Method 166

Observations and complications 166

Care of the child 166

Care of the equipment 167

Removing the drain 168

Nursing considerations 168
Dos and don’ts 169


INTRODUCTION


Chest drainage may be observed in several practice placement areas, including intensive care, the neonatal unit and the emergency department, as well as the general paediatric ward. It is a relatively common practice that requires a thorough knowledge of research-based principles and pathophysiology to assist with clinical decision-making, to manage effectively and prevent complications (Lehwaldt & Timmins 2007).



LEARNING OUTCOMES


By the end of this section you should be able to:


• Explain why chest drainage is used

• Understand how chest drainage is set up

• Understand how the patient is assessed and the drainage monitored

• Explain why some traditional practices are controversial

• Know of complications that may occur.


RATIONALE


A systematic review of the nursing management of chest drains in 2001 found that there was lack of rigorous research in all areas of chest drain management, particularly in the under 18s (Charnock 2001). This review also noted that practices varied according to individual institutions and that there were often no written protocols to guide practice. After searching the Cochrane library and other relevant sources, it is evident that to date there has not been any further systematic review of the area of practice undertaken. As a consequence of this lack of evidence, most of the information in this chapter remains based upon adult studies.



PATHOPHYSIOLOGY


Before learning about chest drainage, it is important to remember some key points relating to the anatomy and physiology of the chest:


• The lungs maintain expansion through diaphragmatic and intercostal contraction during inspiration, causing air to be drawn into the lungs by negative pressure, followed by expiration and elastic recoil of the lungs to their original state (Tortora & Derrickson 2009)

• The heart is positioned in the mediastinum. If blood builds up around the heart, or the lung is pushed over to the wrong side of the chest, the heart will become restricted and its function compromised. This is known as cardiac tamponade (Allibone 2003)

• The pleural cavity is a potential space, lying between the visceral and parietal pleura, the diaphragm and mediastinum. Pressure in the space is normally negative (−4 to −10 mmHg) (Ward et al 2002)

• A small amount of fluid is secreted into the space and acts as a lubricant to reduce possible shearing forces being exerted on each other by the pleura (Coughlin & Parchinsky 2006)

• Any injury, disease or surgical intervention that may cause accumulation of air or fluid in the pleural cavity may impair ventilation, through first reducing elastic recoil of the lung and second, by compression of the lung (Lazzara 2002, Allibone 2003).

The following conditions require chest drainage.



PNEUMOTHORAX


Air is present in the pleural space which limits the ability of the lung to expand during inspiration. A pneumothorax may be termed spontaneous (frequent in neonates who aspirate stomach contents, causing alveolar rupture); tension (the alveoli rupture and leak air into the pleural space – this may occur in critically ill children requiring positive pressure ventilation); or open (through trauma) (Lazzara 2002).


A tension pneumothorax is a life-threatening emergency, which requires immediate intervention.



HAEMOTHORAX


Blood is present in the pleural space and mediastinum. This can occur after chest surgery such as thoracotomy or sternotomy for repair of congenital heart lesions or as a consequence of trauma. If there is a mix of blood and air present in the pleural space then this is termed a haemopneumothorax.



PLEURAL EFFUSION/EMPYEMA


Secretions such as fluid or chyle from the thoracic lymph duct (chylothorax) fill the pleural space, often as a complication of surgery, or a pre-existing illness (e.g. cystic fibrosis, heart failure or oncological conditions). The collection of purulent material (pus) in the pleural space is known as an empyema and usually occurs as a consequence of infection such as pneumonia.



FACTORS TO NOTE


Insertion of a chest drain may be performed as an emergency by the doctor. If this is the case, there is little time to alert and prepare parents or the child for the procedure, but simple, brief explanations should be given. If the parents are not present, it is not usually possible to wait to gain their consent, as a delay could be life-threatening, but every effort should be made to contact them and inform them of the situation. If chest drains are expected as a result of surgery, children can be prepared through play, with verbal and visual explanation suitable for their conceptual understanding. There will be more time to give parents and the child fuller information.


The procedure is painful and distressing. Co-operation is likely only in the older child; therefore, if time allows, sedation and analgesia should be given, usually by intravenous injection. Local anaesthesia is normally used around the puncture site. If the child is ventilated, breathing against the ventilator may worsen the condition, therefore the use of muscle relaxants may be indicated. It is important to ensure that the ventilator settings are adjusted, e.g. rate increased, to take into account a child who has received a dose of muscle relaxant.


Full monitoring of the child’s respiratory rate and effort, heart rate and oxygen saturations should be in place prior to and for the duration of the procedure.


Resuscitation equipment including Ambu bag or T-piece bagging circuit, appropriately sized face mask, airway adjuncts (e.g. Guedel airway), suction equipment and oxygen must be available.


The child should have an intravenous line, although in an emergency the insertion of the chest tube may have higher priority (APLS 2005).



CHEST DRAINAGE



EQUIPMENT



Chest drain


The doctor will specify the size and type of drain dependent on whether air or serous matter needs draining.


For a child with suspected pneumothorax in a resuscitation situation, needle thoracocentesis may be performed using a large intravenous cannula and a 20 mL syringe – this is an emergency procedure and the child will require formal chest drain placement after the initial resolution of the pneumothorax (APLS 2005).


There are a number of proprietary chest drains available, ranging from 8 to 32 French gauge (Fg). These chest drains consist of a PVC catheter, with drainage eyes and radio-opaque markings (for visualisation on X-ray), and may include a trocar. Some are specifically designed for neonatal or emergency use. The use of a trocar when inserting chest drains in children is not recommended and indeed in adult practice it is also seen as no longer necessary, due to the potential for secondary trauma within the chest cavity (Tang et al 2002).

Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. Radiography
  2. Aseptic non-touch technique
  3. Stoma care
  4. Key concepts

Stay updated, free articles. Join our Telegram channel
Tags:
Mar 7, 2017 | Posted by in NURSING | Comments Off on Chest drainage

Full access? Get Clinical Tree
Get Clinical Tree app for offline access