Atrium TM Express Chest Drainage Collection Chamber Philip Woodrow, 2013
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1 Atrium TM Express Chest Drainage Collection Chamber Philip Woodrow, 2013 Philip Woodrow Practice Development Nurse, Critical Care
2 Introduction this session: trouble-shooting for caring for the patient with an Atrium Express TM chest drain collection chamber relevant aspects from the half-day course Caring for Patients with Intrapleural Chest Drains key resources: company literature, national guidelines (BTS, 2010), Trust guidelines 2
3 terminology drain collection chamber 3
4 evidence first described 1876; wide use with influenza epidemic Davies HE, Davies RJO, Davies CWH, BTS Pleural Disease Guideline Group Management of pleural infection in adults: British Thoracic Society pleural disease guideline Thorax. 65 (Supplement 2): ii41-ii53. much medical literature, especially about insertion few adequate studies; little new knowledge MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline Thorax. 65 (Supplement 2): ii18-ii31. nursing evidence limited Charnock Y, Evans D Nursing management of chest drains: a systematic review. Australian Critical Care. 14 (4): Fremlin G, Baker R, Walters G, Fletcher T Thinking outside the lung: improving the safety of pleural procedures. P34 Are nursing staff sufficiently educated and competent in managing patients with a chest drain? Thorax. 66 (Supplement 4): A81. and much literature anecdotal Godden J, Hiley C Managing the patient with a chest drain: a review. Nursing Standard. 12 (32):
5 BTS 2010 Guidelines some key points should be managed on wards familiar with chest drains & their management check daily for - wound infection - drainage volumes - documentation whether bubbling Havelock T, Teoh R, Laws D, Gleeson F, BTS Pleural Disease Guideline Group Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline Thorax. 65 (Supplement 2): ii61-ii76. 5
6 Set Up 6
7 step 1: connect tube to patient before initiating suction 7
8 step 2: connect suction to patient company literature refers only to use with suction one-way valve (Heimlich) prevents drainage or air re-entering pleural space anecdotally, Atrium Express TM effective with gravity drainage (suction vs no suction discussed later; easier if wall suction not used, and promotes patient mobility) 8
9 step 3: turn suction source on increase suction source to -80 mmhg or higher but we use kilopascals (kpa) 1 kpa = 7.4 mmhg; so 80 mmhg = 10.8 kpa suction regulator (labelled A) set to -20 cmh 2 O; adjust as required (range -10 to -40) vacuum indicator (labelled B) shows tick (no tick = no vacuum) 10 cmh 2 O = (approx) 1 kpa so 20 cmh 2 O = 2 kpa nb Thoracic (low) suction unit if vigorous bubbling, reduce suction pressure 9
10 step 4: fill air leak monitor to fill line air leak monitor labelled C3 inject sterile water through bung (on back) to level of blue arrow (= 0 atmospheric pressure) water will turn blue each vertical mark = 1 cmh 2 O; indicates patient s negative intrathoracic pressure ~ 10
11 samples sampling port on tubing clinell wipe; needleless port 11
12 Changing collection chambers changing may introduce infection, so change only when full Durai R, Hoque H, Davies TW Managing a chest tube and drainage system. AORN. 91 (2): to change: clamp tubing disconnect tubing between closed clamp & container (press and pull) 12
13 What to Check During Use 13
14 Is Suction Present (if intended to be used) check bellows expanded arrow marker = -20 cmh 2 O 14
15 Changing Suction Pressures suction regulator preset to -20 cmh 2 O 15
16 Increasing Vacuum if bellows not expanded to arrow, increase negative pressure 16
17 Manual High Negativity Vent if pressure too negative, release by pressing manual negativity vent (on top, behind surface of chamber) do not use if suction not in use 17
18 Automatic High Negativity Release if pressure reaches approximately -50 cmh 2 O, automatic valve opens to release additional negative pressure 18
19 Placement of Unit unit must always be below patient s chest hang system with built-in hanger (to prevent system being knocked over) if standing on floor, use stand 19
20 Vacuum Indicator (for wall suction) 20
21 Positive Pressure Relief Protection top left, behind face of chamber do not occlude 21
22 Graduated Air Leak Monitor check fluid level check bubbling (right to left): 1 (low) to 5 (high) continuous bubbling = persistent leak intermittent bubbling = intermittent leak no bubbling = no air leak (lung re-expanded or drainage blocked) record (using numbers) ~ 22
23 Recording Drainage Volume collection chamber labelled D dry system ie NO water in system, so numbers represent total ml drained can write on plastic (eg level, date, time) record drainage in notes/fluid chart colour/type (blood, plasma, pus) 23
24 Observations (S, B, D) Suction Swinging only if suction not used Bubbling Draining + respiratory observations check insertion site for audible sucking noise; if present, one or more eyelets dislodged from pleural cavity Gallon A Pneumothorax. Nursing Standard. 13 (10): or 24
25 Swinging if suction not used, drainage in tube should swing with breathing (negative pressure) if swinging appears with suction, check suction (eg may not be turned on) 25
26 Suction historically, thought to increase drainage no evidence for or against benefit of suction Havelock T, Teoh R, Laws D, Gleeson F, BTS Pleural Disease Guideline Group Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline Thorax. 65 (Supplement 2): ii61-ii76. should not be routinely employed; may cause pulmonary oedema MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline Thorax. 65 (Supplement 2): ii18-ii31. check pressure (often -20 cmh 2 O) 26
27 Bubbling will only bubble if air draining if not bubbling: leak closed or tube blocked ask patient to take deep breath & cough Gallon A Pneumothorax. Nursing Standard. 13 (10):
28 Draining (already covered) 28
29 Oxygen may be needed for hypoxia high concentration oxygen increases absorption of air from pleural cavity (so aim SpO 2 100%) BTS BTS guideline for emergency oxygen use in adult patients. Thorax. 63 (Supplement VI): vi1 68. MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline Thorax. 65 (Supplement 2): ii18-ii31. 29
30 Dressing dry dressing pad around insertion site, cover with occlusive dressing Jones SKB Chest Tube Dressings: A Comparison of Different Methods. PhD Thesis. University of Oklahoma/Proquest. Ann Arbor, Michigan. eg keyhole dressing ± Mefix TM check connections secure & dressings intact at least once each shift change dressings only when soiled or when specifically indicated avoid heavy strapping (restricts breathing) Roskelly L, Smith AP Respiratory Care. in Dougherty L, Lister S (eds). The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8 th edition. Oxford. Wiley-Blackwell
31 NO-NOs 31
32 Milking/Stripping never milk - can create negative pressures of 100 to 400 cmh 2 O, drawing tissue into drain Roskelly L, Smith AP Respiratory Care. in Dougherty L, Lister S (eds). The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8 th edition. Oxford. Wiley-Blackwell if occluded, replace tube Roskelly ibid. 32
33 Clamping only indications for clamping disconnection rapid drainage (>500 ml can cause re-expansion pulmonary oedema) Roskelly L, Smith AP Respiratory Care. in Dougherty L, Lister S (eds). The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8 th edition. Oxford. Wiley-Blackwell maximum initial drainage 1500 ml Havelock T, Teoh R, Laws D, Gleeson F, BTS Pleural Disease Guideline Group Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline Thorax. 65 (Supplement 2): ii61-ii76. changing collection unit Roskelly ibid. moving containers over bed (avoid if possible) Gallon A Pneumothorax. Nursing Standard. 13 (10): briefly, following sclerosant instillation (1 hour) Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ, BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline Thorax. 65 (Supplement 2): ii32-ii40.
34 Clamping otherwise, never clamp a bubbling drain Havelock T, Teoh R, Laws D, Gleeson F, BTS Pleural Disease Guideline Group Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline Thorax. 65 (Supplement 2): ii61-ii76. Roskelly L, Smith AP Respiratory Care. in Dougherty L, Lister S (eds). The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8 th edition. Oxford. Wiley-Blackwell may convert simple pneumothorax into life-threatening tension pneumothorax release ASAP; never leave chest drains clamped O Hanlon-Nichols ibid. no evidence that clamping before removal beneficial (if requested, ensure documented) Havelock ibid. 34
35 Clamping clamped drains should be closely supervised by nursing staff familiar with management of chest drains unclamp if clinical deterioration (eg dyspnoea, colour) Havelock T, Teoh R, Laws D, Gleeson F, BTS Pleural Disease Guideline Group Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline Thorax. 65 (Supplement 2): ii61-ii76. 35
36 other risks if above chest, contents siphoned into pleural cavity Gallon A Pneumothorax. Nursing Standard. 13 (10): make patient/family aware of this disconnection 36
37 Removing Chest Drains 37
38 Mattress Sutures Rashid MA, Wilkström T, Örtenwall P A simple technique for anchoring chest drains. European Respiratory Journal. 12 (4): cut sutures A+B just above knots; leave sutures in cut suture C ( mattress stitch ) below knot pull 3 suture ends to close wound (prevent air entry) during removal: Valsalva manoeuvre (or hold breath out) remove tube tie suture to close wound 38
39 Removing drains remove only on medical instructions analgesia cover before procedure, allow sufficient time to work before removing drain turn off suction ask patient to take deep breaths before removal most drains not sutured, but if they are... mattress sutures: need 2 people (historically: purse-string suture, but these should not be used) ~ Havelock T, Teoh R, Laws D, Gleeson F, BTS Pleural Disease Guideline Group Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline Thorax. 65 (Supplement 2): ii61-ii76.
40 after removal cover site with occlusive dressing (eg Duoderm TM ) ensure chest X-ray requested respiratory observations (rate, depth, oxygen saturation) at least 4 hourly for first 24 hours 40
41 Resources Trust Guidelines (nb Express, not Ocean) British Thoracic Society ( including: BTS Pleural Disease Guideline A Quick Reference Guide. Havelock T, Teoh R, Laws D, Gleeson F, BTS Pleural Disease Guideline Group Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline Thorax. 65 (Suppl 2): ii61-ii76. MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline Thorax. 65 (Supplement 2): ii18-ii31. Dougherty L, Lister S (eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8 th edition. Oxford. Wiley-Blackwell
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