What are the guidelines for managing and troubleshooting chest tubes?

Guidelines for Managing and Troubleshooting Chest Tubes

Small-bore chest tubes (10-14F) should be used initially for most pneumothoraces and pleural effusions, with larger tubes only considered when there is persistent air leak or significant pleural fluid present. 1

Insertion and Securing Techniques

• Chest tubes should be inserted using proper aseptic technique to prevent infection (estimated at 1% after chest tube insertion) 1, 2
• Never use substantial force or trocars during insertion as this risks damage to intrathoracic structures 1
• After insertion, a chest radiograph must be performed to check tube position and ensure proper placement 1
• Secure the chest tube using either a stay suture criss-crossed up the drain, special dressings/fixation devices, or steristrips with transparent adhesive dressing 1
• Connect all chest tubes to a unidirectional flow drainage system (such as an underwater seal bottle) which must be kept below the level of the patient's chest 1

Drainage System Management

• The underwater seal bottle should have a side vent which either allows escape of air or is connected to a suction pump 1
• Respiratory swing in the fluid level of the chest tube confirms position in the pleural cavity and tube patency 1
• For prolonged air leaks, wall suction should be considered to create a closed system 1
• Maintain chest tube patency without breaking the sterile field to prevent retained blood complications 1
• If the chest tube becomes blocked, it may be flushed with 20-50 ml normal saline to ensure patency 3
• If poor drainage persists after flushing, imaging should be performed to check tube position and look for undrained locules 3
• If a chest tube is permanently blocked, it should be removed and a further tube inserted if indicated 3

Critical Safety Considerations

• A bubbling chest tube should NEVER be clamped as this could potentially convert a simple pneumothorax into a life-threatening tension pneumothorax 3, 1
• A chest tube which is not bubbling should not usually be clamped 3, 1
• If a chest tube is clamped (which should be rare), this should only be done under the supervision of a respiratory physician or thoracic surgeon, with the patient managed in a specialist ward with experienced nursing staff 3, 1
• If a patient with a clamped drain becomes breathless or develops subcutaneous emphysema, the drain must be immediately unclamped and medical advice sought 3, 1

Monitoring and Complications

• Watch for development of surgical emphysema, which may occur with malpositioned, kinked, blocked, or clamped tubes 3, 1
• Surgical emphysema is usually of cosmetic importance only but can occasionally lead to respiratory compromise requiring intervention 3
• Monitor for complications including organ injury, hemothorax, infections, and re-expansion pulmonary edema 4
• Electronic chest drainage systems can help standardize postoperative management and facilitate informed decision-making regarding tube removal 5, 4

Referral Guidelines

• Pneumothoraces which fail to respond within 48 hours to treatment should be referred to a respiratory physician 3, 1
• Failure of a pneumothorax to re-expand or a persistent air leak exceeding 48 hours duration should prompt referral to a respiratory specialist 3, 1
• Patients requiring suction should only be managed on lung units where there is specialist medical and nursing experience 3

Suction Management

• Suction should not be applied directly after tube insertion, but can be added after 48 hours for persistent air leak or failure of a pneumothorax to re-expand 3
• When needed, use high volume, low pressure (-10 to -20 cm H₂O) suction systems 3
• For pleural infection cases, contrast enhanced CT scanning is the most useful imaging modality in patients failing chest tube drainage to provide anatomical detail and ensure accurate chest tube placement 3

Pain Management

• Intrapleural local anesthetic given as a bolus and at eight-hourly intervals after chest tube insertion significantly reduces pain 1
• Intercostal nerve blocks provide effective analgesia when pharmacological management is inadequate 1
• NSAIDs should be used as the primary systemic analgesic for chest wall pain 1