What are the key considerations when noting a patient with a chest connected to suction?

Key Considerations When Noting a Patient with a Chest Connected to Suction

When documenting a patient with a chest tube connected to suction, it is essential to note the drainage system type, suction pressure settings (typically 5-10 cm H2O), drainage characteristics, and respiratory swing in the chest tube to ensure proper management and prevent complications. 1, 2

Documentation Requirements

Drainage System Details

• Type of drainage system (underwater seal, digital system)
• Suction pressure setting (5-10 cm H2O if used)
• Position of drainage system (must be kept below patient's chest level)
• Presence of respiratory swing in fluid (indicates tube patency)

Drainage Assessment

• Color and consistency of drainage
• Volume of drainage (note if >10 ml/kg was removed initially)
• Presence of air leak (bubbling in underwater seal)
  • Continuous bubbling indicates ongoing visceral pleural air leak
  • Note if bubbling increases with coughing or respiration

Tube Assessment

• Size of chest tube (16F-22F for stable patients, 24F-28F for unstable patients)
• Insertion site appearance (signs of infection, subcutaneous emphysema)
• Tube security method (stay suture, fixation device, dressing type)
• Tube patency (kinking, obstruction)

Critical Management Points

Suction Management

• Document if suction is being used and at what pressure (5-10 cm H2O recommended)
• Note any temporary disconnection from suction (for mobility, radiographs)
• Record nursing supervision of suction as required 1
• Document patient response to suction application or removal

Safety Precautions

• Never clamp a bubbling chest drain (risk of tension pneumothorax) 1
• Document any clamping periods (e.g., after fibrinolytic agent administration)
• Note standing instructions for immediate unclamping if patient develops:
  • Breathlessness
  • Chest pain
  • Clinical deterioration

Monitoring Parameters

• Vital signs (respiratory rate, heart rate, blood pressure, oxygen saturation)
• Pain assessment
• Lung expansion status (via physical exam and radiographic findings)
• Air leak assessment (presence, absence, or changes)

Removal Criteria Documentation

Document progress toward meeting chest tube removal criteria:

• Resolution of air leak
• Lung re-expansion confirmed by chest radiograph
• Clinical stability
• Trial period without suction (typically 5-12 hours of observation) 2
• Drainage volume below threshold (typically <150-200 mL/24h)

Common Pitfalls to Avoid

1. Failing to note drainage bottle position: The underwater seal bottle must always be kept below the level of the patient's chest to prevent fluid backflow 1

2. Inadequate documentation of air leaks: Air leaks must be carefully assessed and documented as they guide management decisions

3. Improper clamping: Document clear instructions that bubbling chest drains should never be clamped due to risk of tension pneumothorax 1

4. Missing drainage volume limits: Note if large volumes were drained initially (>10 ml/kg) as this requires temporary clamping to prevent re-expansion pulmonary edema 1

5. Failing to document patient mobility: Note if suction was temporarily disconnected for mobility and instructions provided to staff regarding keeping the drainage system below chest level

By following this structured approach to documentation, clinicians can ensure proper management of patients with chest tubes connected to suction, potentially reducing complications and improving outcomes.