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A Peggy Kirkwood, RN, MSN, CS-ACNP, replies: ______
Chest tubes are placed in the pleural or the mediastinal space to evacuate an abnormal collection of air or fluid that collects as a result of injury, disease, or surgical procedures. Three primary objectives in caring for the patient with chest tubes are the following:
Keep the system patent. Maintain sterility of the system to avoid introducing bacteria into the intrapleural space. Keep the system airtight. Although some form of chest drainage has been used for centuries, there is still much to learn about many aspects of chest tube management. Research has concentrated on the amount of suction needed for chest tube drainage systems, the effects of that suction, and the practice of milking and stripping chest tubes. Unfortunately, there has been limited research in other areas of chest tube management, such as irrigation and suctioning.
The amount of suction placed to a chest tube drainage system has been discussed in the literature for a number of years. In a review of the literature, Gordon et al1 recommend a low level of suction (–10 to –20 cm H2O) to chest tube drainage systems. Research has shown that higher levels may cause persistent pleural air leaks, lung tissue entrapment, and reexpansion pulmonary edema, and should therefore be avoided.
Chest tube manipulation to keep tubes patent has also been extensively studied. It has been shown in several studies2–5 that milking or stripping of chest tubes increases the negative pressure in the intrathoracic cavity to –100 to –400 cm H2O Several studies reported no significant difference in mediastinal output when chest tubes were routinely milked , stripped, or had neither (control group).4,5 In one study,2 patients whose chest tubes were routinely stripped had a significantly higher drainage amount 4 to16 hours after surgery. Chest tubes remained patent in all groups in each study. Therefore, it seems that milking or stripping of chest tubes on a routine basis should be avoided.
Other techniques to manage chest tube drainage have been used; however, no research literature was found to support them. Practices such as suctioning and/or irrigating chest tubes to free blood clots, either pleural or mediastinal, are described in the literature. Even though there is no research to support this practice, Munnell7 states that irrigation of a chest catheter or drainage tube occasionally must bed one if blockage from a blood clot is suspected or when performing pleurodesis. However, because of the possibility of infection being introduced because of repeated opening of a sterile system, this practice should be discouraged.
If sterile suctioning is to take place, one technique described by Halejian et al8 is to use a sterile cap to provide protection from infection. The procedure described is to clamp the chest tube closed to the patient, disconnect the tube from suction, clean the end of the chest tube with povidone and iodine solution, attach a sterile cap, and use a sterile respiratory suction catheter to remove blood and debris. No literature was found on the frequency this practice should be done, or any support for nurses performing this procedure.
Tattersall et al9 describe a procedure used to irrigate a chest tube when dealing with empyema. Recommendations are to flush with 10 to 100 mL of isotonic sodium chloride every 6 hours to maintain patency using a small-bore catheter attached to a 3-way tap to allow aspiration, flushing, or suction without introducing air. With out the 3 - way tap , repeated disconnections are needed, increasing the risk of pneumothorax or infection. No mention was made of this process being used to clear blood clots. In further support of these recommendations, Bojar10 states that aggressive stripping may actually increase bleeding and that suctioning of clotted chest tubes with endotracheal suction catheters should be discouraged because it may introduce infection.
Given the drawbacks described regarding any chest tube clearance procedure, it seems most important that the nurse should observe the patient and the chest tube before any chest tube manipulation is considered. Pierce et al5 report that the incidence of cardiac tamponade is low regardless of the type of chest tube clearance protocol performed, and visible drainage in chest tubes did not cause a lack of patency. Therefore, the nurse does not always need to manipulate the chest tube when bloody drainage is identified. If, after careful assessment, some manipulation is needed to keep the chest tube patent, it should be done only when visible clot or other obstructing drainage is present in the tubing. In that case, gentle, manual squeezing and releasing of small segments of the chest tubing between the fingers (milking) is recommended over stripping.
One widely recommended practice that also deserves mention is to keep the drainage tubing free of dependent loops. This practice will help prevent obstruction in the collecting system and increased pressure within the lung. Although this recommendation has not been studied through research, experts state that dependent loops have a negative effect on the drainage of fluid and evacuation of air from the chest, and should be avoided.1,6 These negative effects include:
increased pressure in tubing, impeding drainage; higher intrapleural pressures required for drainage to occur; back pressure created, obstructing flow; and reaccumulation of fluid in the pleural cavity. In summary, recommendations from the literature to ensure patency of chest tubes include: Milking or stripping chest tubes on a routine basis is not indicated. If clots are visible in chest tubes and patency is threatened, chest tubes should be gently milked only. Stripping of chest tubes is unsupported by researc hand should only be done if a physician specifically orders. Irrigation and suctioning of the chest tubes for clearance of clots is unsupported by research and should be avoided. Dependent loops in the tubing should be avoided. References
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