What is the proper management of an Ogilvie's (chest tube)?

Management of Chest Tubes: Best Practices for Maintaining Patency

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 This is the primary intervention for maintaining chest tube function when drainage issues arise.

Identifying Chest Tube Blockage

Signs that indicate a chest tube may be blocked include:

• Sudden cessation of fluid drainage
• Poor drainage despite presence of pleural fluid
• Visible clots or debris in the tube
• Loss of normal respiratory swing in fluid level

Proper Flushing Technique

1. Preparation:

   • Use sterile technique
   • Prepare 20-50 ml of sterile normal saline
   • Ensure aseptic conditions throughout the procedure 1

2. Flushing Procedure:

   • Gently flush the chest tube with saline solution
   • Monitor for restoration of drainage
   • Document the amount and character of drainage 2, 1

3. Post-Flushing Assessment:

   • Observe for improved drainage
   • Monitor vital signs for any adverse reactions
   • Ensure proper functioning of the underwater seal drainage system 1

Management of Persistent Blockage

If poor drainage persists after flushing:

1. Imaging Assessment:

   • Perform chest radiograph or CT scan to check tube position
   • Evaluate for tube distortion and identify undrained locules
   • Contrast-enhanced CT scanning is most useful for providing anatomical detail 2, 1

2. Interventions for Persistent Blockage:

   • Reposition the tube if kinked, especially with smaller tubes which are more prone to kinking at the skin 2
   • Use commercial dressings designed to secure small drains and reduce kinking 2
   • If permanently blocked, remove the tube and insert a new one if indicated 2

Special Considerations for Small Chest Tubes

Small chest tubes require particular attention as they:

• Are more prone to blockage than larger tubes
• May require more frequent flushing
• Can develop kinks at the skin entry point that require repositioning and redressing 1

Critical Safety Precautions

• Never clamp a bubbling chest tube as this risks a tension pneumothorax 1
• If a chest tube is clamped, immediately unclamp it if the patient develops breathlessness or chest pain 1
• Always ensure the drainage system remains below the level of the patient's chest 1

Maintenance of Drainage System

• Keep the underwater seal bottle below the level of the insertion site at all times
• Keep the bottle upright with adequate water to cover the end of the tube
• Document daily reassessment of drainage amount, bubbling, and respiratory swing 2

Patient and Staff Education

• Patients with chest drains should be managed on specialist wards by staff trained in chest drain management 2
• Educate patients and their families about chest tube care
• Encourage patients to take responsibility for their chest tube and drainage system
• Instruct patients to keep the underwater seal bottle below chest level and report any problems 2

By following these evidence-based guidelines for chest tube management, clinicians can effectively maintain tube patency, ensure proper drainage, and minimize complications associated with chest tube blockage.