Post-procedural Care

Patient

Confirm your patient is well; indeed their clinical parameters should improve.

Analgesia

Is there a need for top-up analgesia for your patient? There is some evidence that directing bupivacaine into the pleural cavity via the chest drain is beneficial [5].

Chest x-ray

Request a chest x-ray before the patient leaves the ED to indicate tube position and changing pathology. Note the chest x-ray may mislead you into thinking the drain is in the pleural cavity, when in fact it is in the chest wall. Fogging and swinging, confirm placement within the pleural cavity.

Further, check that the proximal hole of the tube (as demarcated by a break in the tube’s radiopaque linear line) lies medial to the lateral rib border on the chest x-ray (click on the x-ray to enlarge).

Chest drain position

What if the drain points upwards for the haemothorax, or conversely downwards for pneumothorax?

It actually does not matter. It is likely to be effective and should not be repositioned solely because of the x-ray position. [4,6]

Clamping and suctioning

Potential modifications to chest drain management include clamping the tube and suctioning.

Avoid both – the former in particular might lead to a tension pneumothorax. Leave these decisions to a senior thoracic surgeon when your patient is on a surgical ward.

Underwater seal

Note the underwater seal needs to remain below the insertion site at all times otherwise the contents start to empty into the chest. It is also vulnerable to being knocked over. Nursing staff, junior doctors and the patient need clear instructions to prevent them knocking over the underwater seal.

Sharps

Dispose of your sharps correctly – your responsibility.

Key Points

In addition to the fogging of the drain, confirm the drain lies within the chest by noting swinging with respiration. Do not clamp the chest tube or apply suction. The underwater seal needs to remain below the insertion site at all times.