Chest Tube Securement Techniques
The chest drain must be well secured after insertion using a non-absorbable suture to narrow the linear incision around the edge of the chest drain, followed by a stay suture placed through the skin and then criss-crossed up the drain to prevent accidental dislodgment. 1
Primary Securement Methods
Suture Techniques
- Initial Incision Closure: Use a non-absorbable suture to narrow the linear incision around the edge of the chest tube 1
- Stay Suture Method: Place a suture through the skin and then criss-cross it up the drain in a "Roman sandal" pattern 1
- Ensure the suture is not too tight as it can occlude a soft drain
- This is particularly important for preventing accidental dislodgment which can lead to pneumothorax or fluid reaccumulation
Alternative Securement Options
- Special Dressings/Fixation Devices: Commercial devices designed specifically for chest tube securement 1
- Adhesive Options:
- Steristrips can be useful as additional security
- Transparent adhesive dressings allow inspection of the drain site
- "Omental tag" of tape can be used to allow the tube to lie away from the chest wall, preventing tube kinking and tension at insertion site 1
Important Considerations
Purse String Controversy
- Controversial Technique: Some guidelines note that purse string sutures should not be used as they convert a linear wound to a circular one 1
- May cause more pain
- Can leave an unsightly scar
- Alternative View: Some clinicians believe purse string sutures provide the best security for a drain 1
Tube Size Considerations
- For smaller drains (≤14F), the initial incision closure may not be necessary 1
- Smaller tubes require particularly careful securement as they are more prone to dislodgment 2
Post-Securement Management
- Connect the tube to a unidirectional flow drainage system (underwater seal bottle) 1
- Ensure the drainage system remains below the level of the patient's chest at all times 1
- Perform a chest radiograph after insertion to confirm proper tube position 1, 3
Special Populations
COVID-19 Patients
- For COVID-19 patients, consider additional securement methods to minimize the risk of accidental disconnection 1
- Use disposable inner cannulas when applicable to avoid risks from cleaning and handling reusable components 1
- Consider Xeroform dressings, custom tubes with stoma seals, or Silflex silicone pads to improve the seal around the tube and decrease aerosolized viral particles 1
Neonatal Patients
- Subcutaneously anchored sutureless systems have been reported as effective in preventing dislodgment in premature neonates 4
- These devices may be easier to insert and remove while causing less discomfort in fragile patients 4
Avoiding Common Pitfalls
- Avoid Excessive Tape: Large amounts of tape and padding may restrict chest wall movement and increase moisture collection 1
- Prevent Tube Kinking: Use proper positioning techniques to prevent kinking that can obstruct drainage 1
- Regular Inspection: Use transparent dressings to allow for regular inspection of the insertion site 1
- Never Clamp a Bubbling Chest Tube: This can lead to tension pneumothorax 1
- Staged Removal: When removing chest tubes, use a staged approach to ensure air leaks have resolved 1
By following these evidence-based securement techniques, you can minimize the risk of chest tube dislodgment and associated complications, ultimately improving patient outcomes related to morbidity and mortality.