How should a chest drain be assessed?

Chest Drain Assessment Protocol

A chest drain should be assessed systematically by checking drain position via chest radiograph, monitoring drainage characteristics, evaluating the underwater seal system for air leaks and respiratory swing, ensuring proper drain security, and regularly assessing for complications. 1

Initial Assessment After Insertion

• A chest radiograph must be performed after insertion to:

  • Confirm proper drain position
  • Rule out iatrogenic pneumothorax
  • Establish baseline for subsequent assessments 1

• Note: An effectively functioning drain should not be repositioned solely based on radiographic appearance 1

Daily Assessment of Drain Function

Drainage System Inspection

• Ensure the underwater seal bottle remains below patient's chest level at all times 1
• Check for respiratory swing in the fluid level (indicates tube patency) 1
• Monitor for bubbling:
  • Continuous bubbling suggests ongoing air leak from lung
  • Absence of bubbling in pneumothorax may indicate resolution 1
• Assess drainage characteristics:
  • Volume
  • Color
  • Consistency
  • Presence of blood clots 2

Insertion Site Assessment

• Inspect for:
  • Signs of infection (redness, swelling, purulent discharge)
  • Air leakage around the insertion site
  • Proper dressing integrity
  • Secure anchoring of the drain 1, 2

Management of Drainage Issues

If Drainage Suddenly Stops

• Check for obstruction:
  • Inspect entire visible length for kinking
  • Assess for external compression
  • Check for clots blocking the lumen 2
• If blockage is suspected:
  • Flush with normal saline using aseptic technique (typically 10ml for small bore drains)
  • Never use excessive force when flushing 2

For Persistent Blockage

• Consider imaging (ultrasound or CT) to assess remaining fluid and drain position 2
• If significant fluid remains and drain cannot be unblocked:
  • Remove and replace the drain 1
• If minimal fluid remains and clinical resolution has occurred:
  • Consider drain removal 1, 2

Suction Management

• If suction is used:
  • Maintain pressure at 5-10 cm H₂O
  • Ensure appropriately trained nursing staff supervise 1
• Suction can be briefly disconnected for patient mobility or procedures 1
• There is limited evidence that suction improves drainage in pleural infection 1

Critical Safety Points

• NEVER clamp a bubbling chest drain (risk of tension pneumothorax) 1
• If a drain is clamped and patient develops breathlessness or chest pain:
  • Immediately unclamp the drain
  • Seek urgent medical advice 1
• For large volume drainage:
  • Clamp drain for 1 hour after initial 10ml/kg removal to prevent re-expansion pulmonary edema 1
• Patients with chest drains should be managed on specialized wards by properly trained staff 1

Criteria for Drain Removal

• Clinical resolution of underlying condition
• Cessation of air leak (if pneumothorax)
• Minimal drainage (<50-100ml/24hrs, depending on indication)
• Radiographic improvement 1

Documentation Requirements

• Daily assessment of:
  • Drainage volume and characteristics
  • Air leak status
  • Patient's respiratory status
  • Pain levels
  • Insertion site condition 2, 3

Using a systematic checklist for chest drain assessment has been shown to prevent adverse events and enhance the safety of patient care 3.