WATER SEAL CHEST DRAINAGE

WATER SEAL CHEST DRAINAGE – Indications, Objectives, Mechanism, Factors Affecting the Chest Drainage, Water Seal Drainage System, Types of Chest Drainage

Water seal chest drainage means that a column of water in a bottle seals off the atmospheric air preventing from entering the chest drainage tube and thereby in the pleural sac

Water seal drainage system or so called “closed chest drainage” is indented to allow air and flew to escape from the pleural space with each exhalation and to prevent that return flow with each inhalation

Water seal acts as a one way valve, permitting the unit directional flow of air and fluid out of the pleural space, but permitting none to enter from the drainage system

INDICATIONS

• After thoracic or thoracoabdominal surgeries
• Chest injuries involving the pleura
• Spontaneous pneumothorax

OBJECTIVES

• To remove air and fluid from the pleural space
• To re-establish normal negative pressure in the pleural space
• To promote re-expansion of the lungs which apposition and cohesion of the parietal and visceral pleura
• To restore the normal pulmonary ventilation
• To prevent the reflex (return flow) of air and fluid back into the pleural space from the drainage apparatus
• To prevent shifting of the mediastinum and collapse of the lung tissue by equalizing pressure on both sides

MECHANISM

• In a thoracic surgery the parietal pleura is incised and pleural space is opened
• Atmospheric air rushes into the pleural space and the lungs collapse
• When the chest wall is closed, the air is enclosed in the pleural space thus causing to have a pneumothorax in the operated site
• Additional air may continue to leak into the pleural space through the openings in the pulmonary pleural incision
• Trauma of surgery causes serosanguineous fluid to collect in the patient’s chest until healing occurs
• Negative pressure has been lost inside the space owing to pneumothorax
• The body’s ability to absorb air from the pleural cavity is limited
• Therefore, a closed drainage must be established to remove the collecting fluid and air from the pleural cavity and to prevent additional air and fluid entering the pleural cavity
• A closed drainage system is used postoperatively to remove air and serosanguineous fluid form the pleural cavity

FACTOR AFFECTING THE CHEST DRAINAGE

• Proper placement of chest catheters – usually two catheters are placed in the chest, one of them is placed anteriorly through the second intercostals space to permit the escape of air rising in the pleural space. The lower catheter is placed posteriorly through the eighth or ninth intercostals space in the maxillary line to drain off serosanguineous fluid accumulating in the lower portion of the pleural space
• Proper placement of drainage apparatus – the drainage apparatus for closed chest drainage must always locate at a level lower than the patient’s chest. Thus, this helps drainage by gravity. At the same it prevents backflow of air and fluid in pleural space
• Length of the drainage tubing – drainage tubing which connect the chest catheters to the drainage apparatus should be neither too long nor too short. It should fall in a straight line to the drainage apparatus with no dependent loops. Dependent loops of the tubing, that contain fluids obstruct the flow of air and water into the drainage bottle and create back pressure thus impairing the drainage of air or fluid

WATER SEAL DRAINAGE SYSTEM

• Maintaining the patency of the drainage tubing: patency of the drainage tubing and the chest catheter are checked frequently. Kinks and pressure on the tubing will cause obstruction in the flow of drainage. Observe the amount of drainage per hour to make sure that the tube is not internally plugged with pus or blood clots. Milking the tube helps to dislodge any clot that is formed in the drainage tubes
• Maintenance of an air tight drainage system. Closed drainage system must be maintained air-tight. The bottles are sealed with tight stoppers and all connection of the tubes is taped to ensure its air tightness
• Position of the patient: the patient is placed in a Fowler’s position. This position helps to locate the fluid in the lower portion of the pleural space and drainage thorough the chest tubes, which are placed in the lower chest
• Activity of the patient: the movement of the patient in bed helps to drain the chest. Coughing and deep breathing exercises help the patient to promote lung expansion and expulsion of air and fluid from the pleural space by increasing the intrapulmonic and intrapleural pressure.
• Application of mechanical suction on the water and drainage system

Continuous and gentle cough and respirations are too weak to force the air and fluid out of the pleural space through the chest catheters

In the treatment of empyema thoracic in which the drainage is too thick to drain

In those patients where air is leaking into the pleural space faster than it can be removing by a water seal apparatus and or to speed up the removal of air or fluid out of the pleural space

TYPES OF CHEST DRAINAGE

The One-Bottle Water-Seal System

The end of the drainage tube from the patient’s chest is covered by a layer of water which permits drainage and prevents lung collapse by sealing out the atmosphere. Functionally, drainage depends on gravity, on the mechanics of respiration and, if desired, on suction by the addition of controlled vacuum

The tube from the patient extends approximately 2.5 cm below the level of the water in the container. There is a vent for the escape of any air that might be leaking from the lung. The water level fluctuates as the patient exhales. At the end of the drainage tube, bubbling may or may not be visible. Bubbling can mean either persistent leakage of air from the lung or other tissues or a leak in the system

The Two-Bottle Water-seal System

The two bottle system consists of the same water seal chamber plus a fluid-collection bottle. Drainage is similar to that of a single unit, except that when pleural fluid drains, the underwater seal system in not affected by the volume of drainage

Effective drainage depends on gravity or on the amount of suction added to the system. When vacuum is added to the system from a vacuum source, such as wall suction, the connection is made at the vent stem of the underwater-seal bottle. The amount of suction applied to the system is regulated to the wall gauge

The Three-Bottle Water-seal System

This system is similar in all respect to the two-bottle system, except for the addition of a third bottle to control the amount of suction applied. The amount of suction is determined by the depth to which the tip of the venting glass tube is submerged. In the three-bottle system, drainage depends on gravity or the amount of suction applied. The amount of suction in the system is controlled by the manometer bottle. The mechanical suction motor or wall suction creates and maintains a negative pressure throughout the entire closed drainage system

The manometer bottle regulates the amount of the vacuum in the system. This bottle contains three tubes:

• A short tube above the water level comes from the water seal bottle
• Another short tube leads to the vacuum or suction motor or wall suction
• The third tube is a long tube which extends below the water level in the bottle and which is open to the atmosphere outside the bottle. This is in the tube that regulates the amount of vacuum in the system. This is regulated by the depth to which this tube is submerged the usual depth is 20 cm

When the vacuum in the system becomes greater than the depth to which the tube is submerged, outside air is sucked into the system. This result in constant bubbling in the manometer bottle, which indicates that the systems is functioning properly

COMMMERCIALLY PREPARED DISPOSAL DRAINAGE SYSTEMS

Combine drainage collection, water seal and suction control in one unit. These systems ensure patient safety with positive and negative pressure relief valves and have a prominent air leak indicator. Some systems produce no bubbling sound. System allows air and fluid to escape from the pleural cavity but does not allow the air to re-enter. The system may include one, two or three bottles to collect drainage, create a water seal, and control suction. Or it may be a self-contained disposable system. That combines the features of a multi bottle system in a compact, one piece unit

Equipment: thoracic drainage system which can function as gravity drainage systems to be connected to suction to enhance chest drainage

PREPARATION OF THE EQUIPMENT

Check the doctor’s order to determine the type of drainage system to be used and specific procedural details. If appropriate, request the drainage system and suction system from the central supply department. Collect the appropriate equipment and take it to the patient’s bedside

Implementation

• Explain the procedure to the patient and wash your hands
• Maintain sterile technique throughout the entire procedure and whenever you make changes in the system or alter any of the connections to avoid introducing pathogens into the pleural space

SETTING UP A COMMERCIALLY PREPARED DISPOSABLE SYSTEM

• Open the packaged system and place it on the floor in the rack supplied by the manufacture to avoid accidental knocking it over or dislodging the components. After the system is prepared, it may be hung from the side of the patient’s bed
• Remove the plastic connector from the short tube that is attached to the water-seal chamber. Using a 50 ml catheter tip syringe instill sterile distilled water into the water-seal chamber
• If suction is ordered, remove the cap on the suction-control chamber to open the vent. Next instill sterile distilled water until it reaches the 20 cm mark or the ordered level and recap the suction-control chamber
• Using the long tubes connect the patient’s chest tube to the closed drainage system to the suction source, and turn on the suction. Gentle bubbling should begin in the suction chamber, indicating that the correct suction level has been reached

MANAGING CLOSED CHEST UNDERWATER-SEAL DRAINAGE

• Repeatedly note the character, consistency and amount of drainage collection chamber
• Mark the drainage level in the drainage collection chamber by noting the time and date at the drainage level on the chamber every 8 hours
• Check the water level in the water-seal chamber every 8 hours, if necessary, carefully add sterile distilled water until level reaches the 2 cm mark indicated on the water-seal chamber of the commercial system
• Check for fluctuation in the water-seal chamber as the patient breathes. To check for fluctuation when a suction system is being used, momentary disconnect the suction system
• Check the water level in the suction-control chamber. Detach the chamber from the suction chamber when the bubbling ceases, observe the water level. If necessary add sterile distilled water to bring the level to the 20 cm line or as ordered
• Check the gentle bubbling in the suction control chamber because it indicates that the proper suction level has been reached
• Periodically check that the air vent in the system is working properly. Occlusion of the air vent results in a build-up of pressure in the system that could cause the patient to develop a tension pneumothorax
• Coil the systems tubing and secure it to the edge of the bed with a rubber band or tape and a safety pin. Avoid creating dependent loops, kinks or pressure on the tubing
• Be sure to keep two rubbers tipped clamps at the bedside to clamp the chest tube if a bottle breaks or the commercially prepared system cracks or to locate an air leak in the system
• Encourage the patient to cough frequently and breathe deeply to help drain the pleural space and expand the lungs
• Check the rate and quality of the patient’s respirations and auscultate his lungs periodically to assess air exchange in the affected lung
• Tell the patient to report any breathing difficulty immediately. Notify the doctor immediately if the patient develops cyanosis rapid or shallow breathing, sub-cutaneous emphysema chest pain or excessive bleeding
• When clots are visible you may be able to strip the tubing depending on your facility policy. This is a controversial procedure because it creates high negative pressure that could suck viable lung tissue into the drainage
• Check the chest tube dressing at least every 8 hours. Palpate the area surrounding that dressing for crepitus or subcutaneous emphysema, which indicates that air is leaking into the subcutaneous tissue surrounding the insertion site
• Encourage active or passive range of motion (ROM) exercises for the patient’s arm or the affected side if he has been splint his arm to decrease his discomfort
• Remind the ambulatory patient to keep the drainage system below chest level and to be careful not to disconnect the tubing to maintain the water seal

ASSESSMENT OF PROPER FUNCTIONING

• Observing the oscillating movements of the fluid up and down in the water-sealed tube
• Observing the intermittent bubbling in the water seal bottle
• Observing the collection of drainage in the water seal or drainage bottles
• Observing the periodic emptying of the suction control tube and bubbling in the suction control bottle when a mechanical suction is attached to the under-water seal drainage system
• Ascertain the status of the patient by assessing vital signs and the appearance frequently

PRECAUTIONS TO BE TAKEN WHILE REPLACING CHEST DRAINAGE BOTTLES

• Assemble the bottle with tight stopper and tubes and check for their proper functioning
• Double clamp the chest catheters close to the patient’s chest to prevent entry of air into the pleural cavity
• Clamps are applied at the end of a full inspiration to prevent the air being sucked into the pleural space
• Disconnect the bottle to be replaced along with the drainage tubing and attach to new set, taking care not to contaminate the end of the chest catheters
• Be certain that the bottle is placed well before the chest level and is fixed safely to prevent falling or being kicked over accidentally
• Unclamp the patient’s chest catheter and make certain that the system is functioning properly before leaving the patient
• Watch the patient’s vital signs for few minutes to see any changes in the general conditions

CHEST CATHETER REMOVAL

• The chest catheter is removed only on the return order of the physician, and is removed by the physician
• Usually the chest catheters are removed in two or three days, provided the remaining lung tissue is well expanded, the air leaks are absent and fluid drainage is less than 75 ml per day
• A chest X-ray may be taken before the chest catheters are removed to make sure that the lungs are fully expanded
• After removal of the chest catheters, the wound is covered with sterile petrolatum gauze and a firm dressing is applied over the wound which is secured with wide strips of adhesive tapes
• After removal of the catheters the patient is observed closely for the development of respiratory distress

DISCHARGE TEACHING

The following advice is given to these patients on discharge from the hospital

• To have deep breathing and coughing exercise
• To maintain good nutrition
• To maintain good hygiene especially oral hygiene
• To avoid activities or environment that can cause irritation of trachea bronchial tree
• They are advised not to smoke, to avoid dusty place and to avoid exposure to the persons having respiratory infections
• To consult the physician if symptoms of upper respiratory infections or other ailments develop
• To obtain a fitness certificate before they join their duty

COMMON PROBLEMS AND SUGGESTED ACTIONS

• Lack of drainage

Causes: kinking, looping or pressure on the tubing may cause reflux of fluid into the intrapleural space or may impede drainage, causing blocking of the intrapleural drain

Nursing action: check the system and straighten tubing as required. Secure the tubing to prevent a recurrence of the problem

• No fluctuation of fluid in tubing from the underwater seal

Causes – re-expansion of the lung, tubing is obstructed by blood clots fibrin, failure of the suction apparatus

Nursing action: ask medical staff if the drain may be removed following chest X-ray. The purpose of the drain has been fulfilled. Keeping the drain in any longer than necessary may lead to hazards from infection or air re-entry. “milk” the tubing towards the drainage bottle to try to dislodge the obstruction and re-establish potency. Straighten tubing as required. Secure the tubing to prevent a recurrence. Disconnect the suction apparatus and ensure drain is patent

• Constant bubbling of fluid in the drainage

Causes: an air leak in the system

Nursing action: clamp the intrapleural drain momentarily close to the chest wall and establish whether there is a leak in the rest of the system. Clamping the tubing shows whether the leak is below the level of the clamp

• Patient shows signs of rapid shallow breathing, cyanosis, pressure in the chest, subcutaneous emphysema or hemorrhage

Causes: tension pneumothorax, mediastinal shift, postoperative hemorrhage, severe incision pain, pulmonary embolus or cardiac temponade

Nursing action: observe record and report, any of these signs to a doctor immediately

• Incision pain:

Nursing actions: provide analgesia as prescribed to reduce the patient’s discomfort and to enable deep breathing exercises to be performed and mobilization to ensure adequate drainage and to avoid complications

• Accidental disconnection of the drainage tubing from the intrapleural drain:

Nursing action: apply an artery clamp to the drain immediately in order to avoid air entering the pleural space. Re-establish the connection as soon as possible in order to re-establish drainage. If necessary use cleans sterile drainage tube tubing may have been contaminated when it became disconnected

• Patient needs to be moved to another area:

Nursing action: place the drainage bottle below the level of the intrapleural drain as close to the floor as possible in order to prevent reflux of fluid into the pleural space. Do not clamp the drain unless the doctor has ordered it

• Intrapleural brain falls out

Nursing action: pull the purse string suture immediately to close the wound. Cover the wound with an occlusive sterile dressing. Inform a doctor. The objective is to minimize the amount of air entering the pleural space. The drain will probably need reinserting. Reassure the patient with appropriate explanations.