What is the recommended protocol for chest tube flushing?

Chest Tube Flushing Protocol

When a chest tube becomes blocked or drainage is inadequate, it should be flushed with 20-50 ml of normal saline to ensure patency. 1

Indications for Chest Tube Flushing

• Blocked chest tube with cessation of drainage
• Poor drainage despite presence of pleural fluid
• Visible clots or debris in the tube
• Cessation of the normal respiratory swing in fluid level

Flushing Technique

Standard Protocol

1. Prepare 20-50 ml of sterile normal saline 1
2. Ensure aseptic technique during the procedure
3. Flush the chest tube with the saline solution
4. Monitor for restoration of drainage
5. If poor drainage persists, proceed to imaging evaluation

Assessment After Flushing

• If drainage improves, continue monitoring
• If drainage remains poor, obtain chest radiograph or CT scan to:
  • Check tube position
  • Evaluate for tube distortion
  • Identify undrained locules 1

Special Considerations

Small-Bore Catheters

• More prone to blockage than larger tubes
• May require more frequent flushing
• Consider repositioning if kinking occurs at the skin 1
• Special dressings are available to secure small drains and reduce kinking 1

Chest Tube Management by Type

• Subcutaneous ports not in active use: Four-weekly flush recommended 1
• Tunneled cuffed catheters and PICC lines: Weekly flush recommended 1
• Active chest tubes: Routine flushing after completion of any infusion or blood sampling 1

When Flushing Fails

If flushing does not restore adequate drainage:

1. Perform imaging (preferably contrast-enhanced CT scan) to assess:

   • Tube position
   • Presence of loculations
   • Pleural thickening 1

2. Consider the following interventions:

   • Repositioning the chest tube if malpositioned
   • Replacing with a new chest tube if permanently blocked 1
   • Adding intrapleural fibrinolytic therapy in cases of pleural infection 1, 2

Cautions and Contraindications

• Never clamp a bubbling chest tube as this may lead to tension pneumothorax 1
• If a chest tube is clamped (e.g., during fibrinolytic administration), it should be immediately unclamped if the patient develops breathlessness or chest pain 1
• Ensure the drainage system remains below the level of the patient's chest at all times 1

Advanced Techniques for Complicated Cases

For complicated parapneumonic effusions or empyemas with thick pus:

• Consider manual saline flushing plus fibrinolytic therapy (e.g., urokinase)
• This combination has shown reduced need for fibrinolytic doses, shorter chest tube duration, and shorter hospital stays compared to fibrinolytics alone 2

Monitoring After Flushing

• Observe for improved drainage
• Monitor vital signs for any adverse reactions
• Document the amount and character of drainage
• Ensure proper functioning of the underwater seal drainage system
• Maintain the drainage system below the level of the patient's chest 1

By following this protocol for chest tube flushing, you can effectively maintain chest tube patency and optimize pleural drainage, potentially reducing complications and length of hospital stay.