Steps

Rationale/Points of Emphasis

1 Gather the necessary supplies, and perform hand hygiene.

Promotes efficient time management and provides an organized approach to the procedure. Reduces transmission of microorganisms.

2 Open single-use sterile chest drainage unit. Fill the water-sealed chamber to the specified level according to the manufacturer’s instructions, using sterile water (Figure 29-1).

Figure 29-1 Left: Infant/pediatric-sized dry chest drainage system. Note lack of water-sealed chamber to be filled. Right: Large child, adolescent, or adult-sized dry chest drainage system.

The water-sealed chamber acts as a one-way valve to allow air to pass out of the lung, down through a narrow channel, and bubble out through the bottom of the water seal. Because air must not return to the child, a water seal is considered one of the safest means for protecting the child.

3 Maintain sterile patient connection tube, with cap in place, and set aside.

Allows for later connection of chest tube catheter to chest tube drainage system collection device.

4 Fill the suction-control chamber with sterile water to 20 cm of water or as ordered by the healthcare prescriber. If using a dry-suction chest drainage system, this step will not be necessary (Figure 29-2).

Figure 29-2 Components of a water seal chest tube drainage system.

The addition of suction (10-20 cm of water) increases the negative intrapleural pressure and helps overcome air leakage by improving the rate of airflow out of the child as well as improving fluid removal. Normal saline cannot be used because it crystallizes and becomes frothy under suction pressure. The dry-suction systems use a bellows device and suction wheel to adjust amount of suction and do not require the addition of water to a suction control chamber.

The chest drain must be connected to the child first, before initiating suction. (Refer to following procedure for Chest Tube Insertion.)

5 After chest tube drainage system has been connected to child’s chest tube, connect the short end of the drainage collection system to the suction source and apply wall regulator chamber suction-to-suction outlet until gentle bubbling appears in the suction control chamber.

Connects the suction source to the water seal and activates suction.

6 Place the chest tube drainage collection device at the bedside, at least 1 ft (30 cm) below the child’s chest in the upright position (Figure 29-3).

Placement of the device below the chest allows for gravity in addition to negative pressure to drain the tube for optimum results.

caREminder

Avoid accidental knockover of the device by hanging the system on the crib or bed frame with the hangers provided or by securing the base of the collection device to the floor with tape.

Figure 29-3 Place the chest tube device below the chest to allow gravity, in addition to negative pressure, to drain the tube for optimum results.

Steps

Rationale/Points of Emphasis

1 Gather the necessary supplies, and perform hand hygiene.

The healthcare prescriber may select to use ultrasound to guide drain placement. Verify preference with the healthcare prescriber and ensure equipment available if requested.

Promotes efficient time management and provides an organized approach to the procedure. Reduces transmission of microorganisms.

2 Obtain baseline data (i.e., vital signs; respiratory rate, pattern, and effort; skin color; perfusion; level of consciousness; oxygen requirements; hemodynamic stability) of child.

This helps to identify and document any acute changes in child during and after procedure.

3 Administer sedation/pain medication per healthcare prescriber’s orders.

General anesthesia is the preferred option for noncooperative children. Moderate sedation is recommended for more cooperative children to reduce pain and help the child remain calm.

4 Don sterile attire, including eyewear.

Standard precautions for surgical sterile procedure.

5 Position the child for chest tube access by the healthcare prescriber, while maintaining sterile access for the healthcare prescriber.

Ease of access facilitates placement of a chest tube.

caREminder

Generally, the healthcare prescriber places the chest tube in the midaxillary to anterior axillary line.

To expose the preferred site for chest tube placement, it is easiest to lay the child supine, using rolled towels/blanket to slightly rotate the upper body in a side lying position, with the arm of the affected side raised above head.

6 Restrain child’s limbs as necessary to ensure sterility of procedure.

Keeps child from breaking sterile field required for chest tube placement.

7a The healthcare prescriber will prepare a sterile field using sterile drapes. The healthcare prescriber will also complete a sterile prep of the child, using sterile towels and chlorhexidine swab stick to cleanse the insertion site.

Identifies access site. Reduces the risk for infection from microorganisms.

7b A local anesthetic is injected at the site.

In infants younger than 2 months of age, ensure that cleansing solution is removed with sterile water to prevent tissue damage. Reduces pain.

8 Healthcare prescriber makes a skin incision about 1 inch long and then inserts a hemostat through the opening to enter the pleural space. Using his or her finger, the prescriber creates a track for the chest tube. Then the prescriber clamps the tube with the hemostat and inserts the tube (size per healthcare prescriber choice), generally through the second intercostal space at the midclavicular line for pneumothoraces or the fifth to seventh intercostal space at the midaxillary line for fluid removal. Assist as needed while continually assessing child for any vital sign changes.

Air tends to collect in the apexes of the lung when the child is in a supine position, thus the high insertion point in the midclavicular line, whereas gravity pools fluid, warranting a lower insertion site. A drain of appropriate size in any position in the pleural cavity will restore negative pressure and allow for reexpansion of the lung, expelling excess pleural contents. The proximal end of the tube has several eyelets (small holes) to drain the air and fluid and prevent catheter occlusion. Prompt identification of any acute change in status can therefore be treated.

KidKare Ask the child to take a deep breath just before tube insertion if age appropriate and child is able to cooperate. This displaces the diaphragm downward, minimizing risk for injury.

9 When chest tube insertion is completed and secured into place with suture material, assist the healthcare prescriber in attaching the disposable sterile chest drainage unit to the chest tube, using a 5-in-1 connector or, if more than one chest tube is placed, a Y connector.

Creates the drainage collection system.

Drain large effusions slowly. Rapid removal during the first 30 minutes after insertion may cause postthoracentesis pulmonary edema.

10 Healthcare prescriber may now request sterile petrolatum gauze to be placed over the entrance site.

This seals insertion site from any air entry or escape.

11 Assist in applying a gauze with a split over the tube and anchored to the chest. Place a semipermeable transparent dressing over the wound site.

Protects site from microorganisms. Allows the wound site to be easily inspected for leakage or infection.

caREminder

Time and date the dressing for change, if indicated.

12 Tab-tape all connections with adhesive tape and ensure that all clamps are open.

Secures any loose connections and allows for sure flow of drainage.

13 Secure the chest tube and drainage tube so that there is no tension pulling on the insertion site.

Prevents accidental dislodgment of chest tube.

14 Ensure that the drainage tubing has a straight flow to chest tube drainage collection device and has no dependent loops or kinks. Connect chest tube drainage system to suction regulator as in step 5 of preprocedure device setup.

Do not routinely “strip” (i.e., occlude the chest tube with one hand while quickly squeezing and moving the other hand down the tube to move fluid down the tube into the drainage chamber) a chest drain because intraluminal pressures can rise dangerously high, potentially converting simple pneumothoraces to life-threatening pneumothoraces and causing tissue trauma and unnecessary additional discomfort. Only in special circumstances, such as hemorrhaging, should the chest tube be stripped to maintain patency.

If fluid collects in a loop in the tubing between the child and the collection device at a height greater than the suction control limit, the tube will be effectively sealed. This can lead to lung collapse as air and fluid again collect in the pleural space.

15 Reassess child after the procedure. Obtain vital signs; respiratory rate, pattern and effort; skin color; perfusion; level of consciousness; oxygen requirements; hemodynamic stability; and comfort level/pain reassessment.

This will identify child’s tolerance of procedure and response to chest tube placement.

16 Consult with the healthcare prescriber regarding an order for an X-ray, if necessary, after chest tube placement.

Chest tubes are normally radiopaque and should be visualized to ensure that they do not go further than the pleural space.

17 Dispose of equipment and waste in appropriate receptacle. Perform hand hygiene.

Standard precautions. Reduces transmission of microorganisms.