Underwater Seal Drainage

Nursing Management of Underwater Seal Drainage

Monitoring Drainage:
- Volume, Color, and Consistency: Nurses should regularly assess the amount, color, and nature of the drainage. Blood, pus, or fluid that appears abnormal may indicate complications.
- Air Leaks: Continuous bubbling in the water seal chamber indicates an air leak, which may suggest a persistent pneumothorax or an issue with the tubing or chest wall connection.
Maintaining the Drainage System:
- Ensure Patency: Check that the tubing is not kinked or clamped unnecessarily, which could impede drainage or cause pressure buildup.
- Keep the Drainage System Below Chest Level: This prevents backflow of air or fluid into the chest.
- Securing the Chest Tube: Ensure that the chest tube is well-secured to the patient to avoid dislodgement or accidental removal.
Observing Respiratory Status:
- Breathing Pattern: Monitor the patient's respiratory effort, rate, and depth. Difficulty breathing, cyanosis, or use of accessory muscles may indicate complications.
- Lung Expansion: Auscultate lung sounds to assess the effectiveness of re-expansion and detect any signs of pneumothorax.
Assessing for Complications:
- Infection: Inspect the insertion site for signs of infection (redness, swelling, discharge).
- Chest Tube Dislodgement: If the tube is accidentally removed, immediate intervention is required to prevent pneumothorax or reaccumulation of air/fluid.
- Subcutaneous Emphysema: Monitor for the presence of air trapped under the skin around the insertion site, which can indicate a leak.
Managing Pain:
- Analgesia: Provide appropriate pain relief to ensure patient comfort, as chest tubes can be uncomfortable, particularly during movement or deep breathing.
Documentation:
- Record all findings, including the amount and type of drainage, presence of air leaks, patient's respiratory status, and any interventions carried out.
Chest Tube Removal:
- When the patient's lung has sufficiently re-expanded and drainage has ceased, the chest tube can be removed. The nurse's role includes preparing the patient, assisting with removal, and monitoring for complications post-removal (e.g., recurrent pneumothorax).

Underwater seal drainage is crucial in ensuring optimal recovery in chest surgery patients, and proper nursing care is vital for preventing complications and promoting healing.

## ASSESSMENT OF CHEST DRAINS

**TUBE POSITIONING**

* The aim is to ensure the chest tube connects to the correct space, e.g. pleural space, mediastinum

* If a tube is in the wrong position it will not ensure adequate drainage

* If the tube is malpositioned it may stay in place for extended periods.

**CHEST TUBE OUTPUT**

* Most important measurement when chest drain is in place

* Should be documented regularly (hourly in the first stage)

* If there is a large amount of drainage the chest tube may need to be changed to prevent blockage.

* It is essential to note the colour, consistency and volume of drainage.

**TOALING RESPIRATORY INTERVENTIONS**

* Toaling indicates that the lung is partially inflated

* If toaling is observed the first intervention is a chest drain

* The chest drain is used to remove the fluid that is preventing the lung from expanding.

* It is important for assessing the quantity of fluid that has been drained and the rate of drainage

* Toaling is used to measure the rate of fluctuation of the fluid in the tube when the patient breathes.

**AIR LEAK**

* An air leak is a release of air that is found in the chest cavity

* Can be measured by observing air bubbles with the water seal

* An air leak can occur if there is a tear in the lung.

* An air leak can be a sign of a pneumothorax

* If there is an air leak, the chest tube should be clamped

* The amount of air leakage is measured in cm H20, the higher the reading the bigger the leak or hole in the lung.

**SUCTION**

* Suction is connected to the chest tube

* The suction is designed to control the amount of negative pressure within the chest cavity

* The amount of suction used depends on the situation.

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**ASSESSMENT OF CHEST DRAINS**

*Chest tubes are used for:*

* To remove air from the pleural space (pneumothorax)

* To remove fluid from the pleural space (pleural effusion)

* To drain blood from the pleural space (haemothorax)

* To prevent air from entering the pleural space (pneumothorax)

* To prevent fluid from entering the pleural space (pleural effusion)

*The chest tube should be attached to a drainage system. The functionality of the drainage system will depend on the purpose of the tube.*

**Chest Tube Systems & Procedures**

* **One way valve for internal suction**

* - Allows air to escape from the chest

* - Prevents air from entering the chest

* - Provides gentle suction to remove fluids

* - Must be connected to a suction source

* - May have a water seal to prevent air from entering the chest

* - Can be used for pneumothorax and haemothorax

* **Drainage Bottle**

* - Collects fluid from the chest

* - Allows fluid to escape from the chest

* - Prevents air from entering the chest

* - Used to measure the amount of fluid drained

* **Water Seal**

* - Prevents air from entering the chest

* - Allows air to escape from the chest

* - Should bubble gently when the patient breathes

* - Should have a minimum of 2 cm H20 water level in the bottle

* - Should be free of air bubbles

* - Will detect an air leak

* **Pressure Regulator**

* - Controls the amount of suction applied to the chest

* - May be used for both pneumothorax and haemothorax

* - Will assist in the drainage of air from the chest

*The drainage system allows fluid to drain from the chest while keeping the chest cavity sealed and preventing air from entering the chest.*

**WEAKING A CHEST TUBE**

* If there is no air leak and the tube is no longer necessary, the chest tube can be clamped.

* The chest tube should be clamped for 24 hours to allow the lung to re-expand and seal.

* If the lung does not re-expand after 24 hours, the chest tube should be removed.

* Clamping a chest tube is a non-invasive procedure that can help to prevent air from entering the chest and promote lung re-expansion.

* If the patient is stable and the chest tube is not needed, the chest tube can be removed safely.

**$$ \text{Volume of drainage} = \text{Volume of fluid in drainage bottle} $$**

ASSESSMENT OF CHEST DRAINS

BY Prof Jones H. Munang'andu.

TUBE POSITIONING

The aim is to ensure the chest tube is correctly positioned in the intended space, such as the pleural space or mediastinum.
A tube placed in the wrong position will not allow for adequate drainage.
Malpositioned tubes may remain in place for extended periods without serving their purpose.

CHEST TUBE OUTPUT

Chest tube output is the most critical measurement when the chest drain is in place.
Output should be documented regularly, especially hourly during the initial stages of insertion.
A large amount of drainage may indicate the need for a chest tube change to prevent blockage.
It is essential to note the color, consistency, and volume of the drainage.

TOALING RESPIRATORY INTERVENTIONS

Toaling refers to partial lung inflation.
If toaling is observed, the initial intervention involves a chest drain.
The chest drain helps remove fluid that is preventing lung expansion.
Toaling also assists in assessing the quantity of drained fluid and the rate of drainage.
It measures the rate of fluctuation of fluid within the chest tube during the patient’s breathing cycle.

AIR LEAK

An air leak is a release of air within the chest cavity.
It can be measured by observing air bubbles in the water seal chamber.
Air leaks can occur due to a tear in the lung and are often a sign of a pneumothorax.
If an air leak is detected, the chest tube should be clamped to prevent further air escape.
The severity of the leak is measured in cm H2O; a higher reading indicates a larger leak or tear in the lung.

SUCTION

Suction may be connected to the chest tube.
Its purpose is to control the amount of negative pressure within the chest cavity.
The level of suction applied depends on the patient’s condition and needs.

ASSESSMENT OF CHEST DRAINS

Chest tubes are used for:

Removing air from the pleural space (pneumothorax).
Removing fluid from the pleural space (pleural effusion).
Draining blood from the pleural space (haemothorax).
Preventing air from re-entering the pleural space (pneumothorax).
Preventing fluid accumulation in the pleural space (pleural effusion).

The chest tube should be connected to an appropriate drainage system based on the purpose of the tube.

CHEST TUBE SYSTEMS & PROCEDURES

One-Way Valve for Internal Suction:
- Allows air to escape from the chest while preventing its re-entry.
- Provides gentle suction to remove fluids.
- Must be connected to a suction source and may include a water seal to prevent air re-entry.
- Suitable for conditions like pneumothorax and haemothorax.
Drainage Bottle:
- Collects fluid from the chest cavity.
- Prevents air from entering while allowing fluid to escape.
- Used to measure the amount of fluid drained.
Water Seal:
- Prevents air from entering the chest while allowing its escape.
- Should gently bubble when the patient breathes.
- A minimum water level of 2 cm H2O is required in the bottle.
- Helps detect air leaks, which should be free of excessive bubbles.
Pressure Regulator:
- Controls the amount of suction applied to the chest cavity.
- Used for both pneumothorax and haemothorax.
- Assists in draining air from the chest.

WEANING A CHEST TUBE

If there is no air leak and the tube is no longer necessary, it may be clamped.
The tube should be clamped for 24 hours to allow the lung to re-expand and seal.
If the lung does not re-expand within 24 hours, the chest tube should be removed.
Clamping is a non-invasive method to prevent air from entering the chest and promote lung re-expansion.
When the patient is stable and the chest tube is no longer needed, it can be removed safely.

Volume of drainage = Volume of fluid in the drainage bottle

UNDERWATER SEAL= 1 BOTTLE SYSTEM

UNDERWATERSEAL + SUCTION CONTROL BOTTLE = 2 BOTTLE SYSTEM

DRAINAGE BOTTLE + UNDERWATER SEAL BOTTLE + SUCTION CONTROL BOTTLE= 3 BOTTLE SYSTEM

UNDERWATER SEAL DRAINAGE INDICATION

The choice of an underwater seal drainage (UWSD) system for chest injury repair depends on the type and severity of the injury, the underlying condition of the pleural cavity, and the desired outcome of the drainage process. Here are the main indications for selecting a particular UWSD system based on different chest injuries:

1. Pneumothorax (Air in the Pleural Space)

Indication: Pneumothorax occurs when air accumulates in the pleural space, preventing the lungs from fully expanding. It can result from trauma, rib fractures, or medical procedures.
System Choice: A simple water seal drainage system without suction is typically used to allow air to escape the pleural space while preventing it from re-entering. If the pneumothorax is large or recurrent, a system with suction may be necessary to create a continuous negative pressure that helps re-expand the lung.
Rationale: The water seal acts as a one-way valve that lets the air exit while preventing it from returning, which promotes lung re-expansion and healing.

2. Hemothorax (Blood in the Pleural Space)

Indication: Hemothorax is the accumulation of blood in the pleural cavity due to trauma (such as blunt or penetrating injuries) or surgical procedures.
System Choice: A water seal system with suction is often recommended to drain blood effectively and prevent further accumulation. A drainage system with a larger bore chest tube is required to allow the blood to drain easily without clot formation.
Rationale: Suction helps maintain negative pressure to ensure blood is continually removed and prevent the build-up of clots, which could block the tube.

3. Hemopneumothorax (Air and Blood in the Pleural Space)

Indication: Hemopneumothorax is a combination of pneumothorax and hemothorax, where both air and blood accumulate in the pleural space following trauma or surgery.
System Choice: A two-chamber system is often required, where one chamber handles fluid drainage (blood) and the other handles air evacuation. Suction may be added to improve drainage efficiency and promote quicker lung re-expansion.
Rationale: The dual-chamber system helps manage both the blood and air components, preventing tension pneumothorax or further compression of the lung due to fluid accumulation.

4. Empyema (Pus in the Pleural Space)

Indication: Empyema is the collection of pus within the pleural cavity, typically as a result of an infection following chest trauma or surgery.
System Choice: A water seal drainage system with suction is often necessary to continuously drain thick fluid or pus from the pleural space. A wide-bore chest tube may be required for viscous drainage.
Rationale: The continuous drainage of pus prevents the formation of abscesses and encourages lung re-expansion, while suction helps keep the pleural cavity free of infection.

5. Chylothorax (Lymphatic Fluid in the Pleural Space)

Indication: Chylothorax is the accumulation of lymphatic fluid (chyle) in the pleural space, which may occur due to trauma to the thoracic duct during surgery or injury.
System Choice: A water seal drainage system with or without suction may be used, depending on the rate of fluid accumulation. In cases of high-output chylothorax, suction is often employed to maintain continuous drainage.
Rationale: The drainage system helps remove the fluid, preventing further respiratory compromise while allowing the injured duct to heal.

6. Postoperative Chest Drainage (Following Thoracic Surgery)

Indication: After chest surgery (e.g., lobectomy, pneumonectomy), a chest tube is placed to drain air, blood, and other fluids that may accumulate in the pleural cavity.
System Choice: A three-chamber system with suction is often employed to ensure thorough drainage. The three chambers include a collection chamber, water seal, and suction control.
Rationale: The three-chamber system allows for careful monitoring of drainage, ensuring no air or fluid buildup post-surgery, and maintaining lung expansion.

7. Traumatic Chest Injury (Blunt or Penetrating)

Indication: Traumatic chest injuries can lead to pneumothorax, hemothorax, or hemopneumothorax, requiring immediate drainage.
System Choice: Depending on the severity of the injury, a two-chamber system or three-chamber system with suction is usually preferred. Larger chest tubes are used for effective blood and air drainage.
Rationale: In trauma cases, managing both air and blood efficiently is critical for lung re-expansion and preventing complications like tension pneumothorax or shock due to massive hemothorax.

Key Considerations for Choosing a UWSD System

Type of Injury: Different chest injuries (air, blood, pus, or fluid accumulation) require specific systems to manage drainage effectively.
Suction Requirement: The need for suction depends on the volume of fluid/air and the rate of accumulation. Suction helps maintain negative pressure, aiding in the rapid re-expansion of the lung.
Chest Tube Size: Larger chest tubes are used for blood drainage (e.g., hemothorax), while smaller tubes may be sufficient for pneumothorax.
Monitoring: Systems that allow for careful monitoring of air leaks, fluid volumes, and rate of drainage are essential for postoperative care or trauma management.

By selecting the appropriate UWSD system, healthcare professionals can ensure effective drainage, promote lung re-expansion, and reduce the risk of complications associated with chest injuries.

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