BLUE BUBBLING OR BLUE SWINGING??

Hello people! Jo’s turn

It’s my first blog entry so please be kind!

I was asked by someone to put together an idiot’s guide to chest drains….

Firstly none of you are idiots but I know how daunting it can be when you are presented with a new piece of equipment and I am happy to help in any way. Please feel free to collar any of us surgical nurse specialists if/when you have a query… a problem shared is a problem halved!

So Chest drains…. AKA nurses achilles heel!

I think the main reason people struggle with caring for chest drains is due to the fact we do not have lots of them and when we do they are only in for a few days so you could potentially miss caring for one for months! We tend to see more chest drains in the winter months when children have empyemas (pus) and pleural effusions (fluid). We have the occasional tall slim male that gets a spontaneous pneumothorax (air) which is treated with a chest drain and then some of our elective surgeries including lobectomys will have one post op. There are more reasons but for this blog I have chosen the most common ones we see.

It is vital we use these drains correctly as if not it can cause a variety of issues including pnuemothorax (excess air in pleural space) and tension pneumothorax (mediastinal shift due to excess air in pleural space). Or in fact we could just not be treating the true reason why we put the drain in in the first place.

Scenario time:

You are looking after a patient with a chest drain….

  1. Check your safety equipment!
  • Thoracic suction on the wall (low vacuum/green)
  • Appropriate chest drain is in use (aquaseal)
  • Continuous sats monitoring
  • Plastic clamps available by bedside (look like green plastic scissors)
  1. Check the insertion site! (once a shift as minimum)
  • Look for leakage on the dressing
  • Listen for any obvious air leaks
  • Check it is securely dressed
  • Try not to pin tubing to clothing
  1. Assess the chest drain bottle
  • Bottle should be below the height of the patient’s chest at all times!!!
  • Ensure the bottle will not get knocked over (use the hooks)
  • Ensure tubing is not kinked
  • Water level of suction (far right chamber) should be checked 8 hourly and should be at 20cmH20

SWINGING AND BUBBLING
underwater-seal

YOU ARE LOOKING FOR BUBBLING AND SWINGING IN THE BLUE CHAMBER ONLY!!!!!!

please see videos on the facebook group for examples of bubbling and swinging

The most common mistake that is made by people is recording that the chest drain is bubbling as they have looked at the far right chamber which is where the suction attaches. Doctors get extremely anxious about this mistake and it can be avoided by just looking at the blue chamber only!

If you have bubbling that means that there is air coming out of the chest… which is great if your patient has a pneumothorax but unexpected if your child has an empyema! Please inform a doctor if your chest drain is unexpectedly bubbling! and vice versa if your chest drain should be bubbling and it has stopped also contact a doctor!

Swinging occurs when the patients breaths in and out this is a good sign that your drain is working! You can also see swinging in the tubing if there is liquid in it. Small children may have very minimal swinging due to the size of their lungs. If there is no swinging temporarily switching off the suction may help determine if there is swinging present. If a drain was swinging and is now not swinging please inform a doctor as the drain could be blocked.

SUCTION

The suction chamber does not need to bubble ferociously  a gentle bubble does the same job. The level of the water should be checked 8 hourly and should be at 20cmH2O unless documented by a doctor.

No matter what the reading is on the suction monitor on the wall the patient will still only be receiving the same level of suction as the level of the water determines the power.

The black stick opens and closes the suction port. Please ensure it is open at all times!!

CHARTING

PLEASE REMEMBER TO CHECK THE BLUE CHAMBER FOR BUBBLING AND SWINGING

chart

You should be doing hourly observations including heart rate, oxygen saturations and respiration rate and also hourly readings of the chest drain.

  • Tick or cross for swinging/bubbling
  • Write level of suction (cmH20), not what the wall unit reads.
  • Write levels of drainage (Consider if this volume should be on the IV fluid chart as an output?)
  • Every 8 hours tick to say the level of the suction water has been assessed and topped up if needed to 20cmH2O.

CLAMPING

clamping

It is imperative we do not unintentionally clamp a chest drain as it could cause a pneumothorax. Therefore, if suction is turned off you must disconnect the tubing.

ONGOING CARE

Urokinase is an enzyme which can be instilled into the chest drain to break down the fluid/pus that is present. It is given by a doctor/outreach nurses/surgical nurse specialist over the course of 15 minutes. It stays in the pleural space for 4 hours, the drain is clamped + the suction turned off. When the chest drain is unclamped the suction needs to be turned back on. The normal regimen is 6 doses given 12 hours apart (aiming for 10am + 10pm) this may be dependent upon the response.

PAIN RELIEF

Chest drains are painful! Especially when put on suction. Please ensure that your patient has adequate regular pain relief- this can include morphine infusions if deemed necessary. If the patient is in severe pain they will not take deep breaths and this will prolong their recovery; as well as being distressing for families and the child!

PHYSIOTHERAPY

Children and families should be encouraged to move around once the urokinase is instilled. It may be appropriate for them to be seen by the chest physios. Exercises should include:

  • Encouraged deep breathing.
  • Bubble blowing.
  • Incentive spirometry, if > five years old.
  • Blow cotton wool balls through a goal post made of straws.
  • Singing.

FURTHERMORE…..

There is a chest drain policy on staffnet and it is worth a read if you are caring for a child with a chest drain it includes further reading and more information about changing a chest drain bottle etc.

Congratulations you have made it to the end!

Jo

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