Nursing practice often involves undertaking procedures about which there is debate or uncertainty. In Practice Questions we ask experts to determine how nurses should approach these procedures
Q. What is the correct way to remove a chest drain – on inhalation or exhalation, or does it not matter?
Inserting a chest drain, or performing a tube thoracostomy, involves the placement of a plastic tube into the thoracic cavity to remove air or fluid from the pleural space.
The tube is usually inserted into the fifth intercostal space in the mid axillary line (Mattox and Allen, 1986). This position is usually used to ensure minimal damage to surrounding chest structures, such as muscle and breast tissue, and to avoid perforation of the mammary artery (Laws et al, 2003).
The tube is secured to the skin with sutures to ensure correct placement is maintained. The free end of the tube is normally attached to a closed drainage system, often with an underwater seal to prevent air from re-entering the pleural space (Durai et al, 2010).
Indications for chest drain insertion
Chest drains are used frequently in both medical and surgical settings and for a broad range of different indications.
On surgical wards, they are often used in cases of thoracic trauma, or used post operatively after thoracic surgery. On medical wards, drains tend to be used to drain effusions, most commonly in patients with an underlying infective or malignant pathology. In the acute setting, chest drains are used in patients with tension pneumothoraces to create a one way valve for air to escape from the chest cavity (Miller and Sahn, 1987)
Safe removal of chest drains
The timing for drain removal depends on both the initial indication for drain insertion and the patient response to therapy.
Generally drains are still functioning if the fluid level is swinging in association with respiratory movements (Miller and Sahn, 1987). If pneumothorax was the original indication for chest drain insertion, the drain should remain in place until bubbling has ceased and chest imaging provides evidence of resolution (Laws et al, 2003).
Drains should not remain in situ unnecessarily, as the risk of introducing infection at the insertion site increases over time.
Removal method is also a crucial factor in patient recovery. The technique employed needs to involve drain removal while preventing the accumulation of thoracic air, which potentially could cause new or worsening pneumothoraces and increase patient morbidity.
A discussion during preparation to remove a chest drain highlighted the uncertainty and inconsistency between colleagues, even on the same ward at Gloucestershire Royal Hospital. A survey was conducted in order to establish the extent of this discrepancy across a range of medical, surgical and acute wards.
A total of 22 nursing staff and 18 doctors of varying grades were asked whether they would remove a chest drain on inhalation or exhalation. The results were very interesting.
Seventy per cent of nursing staff would remove the chest drain on inspiration; the logic behind this being that if the lungs are at full expansion there will be little space for air to enter the chest cavity. This would imply, however, that there is a negative intra pleural pressure, which may result in entrainment of air on removal of the drain. Other nursing staff used a technique in which the patient would inhale and hold their breath, similar to performing a valsalva manoeuvre. By contrast, 70% of doctors questioned would remove the chest drain on expiration.
Interestingly, these findings, which show discrepancies in technique, arealso apparent in nursing guidelines (Mallett and Dougherty, 2001) and medical training. The British Thoracic Society suggests removal of chest drain either during expiration or via valsalva manoeuvre (Laws et al, 2003).
Nursing literature recognises a lack of national standardised guidelines for chest drain management (Sullivan, 2008). An audit in a cardiothoracic specialist centre discussed the need for standardisation of guidelines for physicians, but did not consider differences between healthcare specialties (Tang et al, 1999).
Positional complications, in particular post removal pneumothoraces, have long been recognised although evidence to support use of one specific removal technique remains limited (Bailey, 2000).
Guidelines for nurses and doctors on chest drain removal should be standardised.
There appears to be limited literature available as to whether favouring drain removal on inhalation or exhalation actually makes a difference with regard to the risk of complications. Perhaps the relationship between removal technique and incidence of complications post removal need to be identified with an appropriately designed clinical trial.
AUTHORS Nicola Hannaway, BSc, MBChB, is foundation doctor; Donna Brown, MBBS, is foundation doctor; Simon Monkhouse, MA, MBBChir, MRCS, is specialist registrar; all at Gloucestershire Royal Hospital
Bailey RC (2000) Complications of tube thoracostomy in trauma. Journal of Accident and Emergency Medicine;17: 111-114.
Durai R et al (2010) Managing a chest tube and drainage system. AORN Journal; 91: 2, 275-280.
Laws D et al (2003) BTS Guidelines for the insertion of a chest drain. Thorax; 58: 53-59.
Mallett J, Dougherty L (2001) The Royal Marsden Manual of Clinical Nursing Procedures (5th edn). Oxford: Blackwell Science.
Mattox KL, Allen MK (1986) Systematic approach to pneumothorax, haemothorax, pneumomediastinum and subcutaneous emphysema. Injury; 17: 309-312.
Miller KS, Sahn SA (1987) Chest tubes. Indications, technique, management and complications. Chest; 91: 2, 258-264.
Sullivan B (2008) Nursing management of patients with a chest drain. British Journal of Nursing; 17: 6, 388-393.
Tang A et al (1999) A regional survey of chest drains: evidence-based practice? Postgraduate Medical Journal; 75: 886: 471-474.