Under water seal drainage

Factors Affecting Water Seal Drainage

Several factors can influence how well a water seal drainage system works. Knowing these factors is key for effective nursing care and management.

1. Proper Placement of Chest Catheter (Chest Tube): Rationale: Correct placement is key for effective drainage. As discussed earlier, tubes placed high are for air, and tubes placed low are for fluid.

Considerations:

• Intercostal Space: Using the correct intercostal space (e.g., 2nd for air, 8th-9th for fluid).
• Anterior/Posterior: Anterior for air, posterior for fluid in surgical cases with two tubes.
• Single Tube: If only one tube is used, it’s often placed lower for general drainage of both air and fluid, although its effectiveness for air drainage alone might be less optimal than a higher placed tube in pneumothorax.
• Separate Bottles: If multiple tubes are placed, they should be connected to separate drainage bottles to manage drainage from different areas effectively.

2. Proper Placement of Chest Drainage Apparatus: Rationale: Gravity is key. The drainage system must be lower than the chest for drainage to occur effectively and to prevent backflow.

Considerations:

• Below Chest Level: Always ensure the drainage unit is consistently below the patient’s chest level, whether the patient is in bed, sitting, or walking.
• Gravity Assist: This helps gravity to pull drainage from the pleural space into the collection system.
• Prevent Backflow: Keeping it low prevents fluid in the drainage system from flowing back into the pleural space, which could cause infection or other complications.
• During Transfer: When moving the patient (e.g., to another bed or for transport), the drainage unit should be held or placed carefully below chest level. It’s also advisable to briefly clamp the tubing (as instructed by protocol or physician order) during transfer to prevent accidental spillage or backflow, but clamping should be brief and tubing must be unclamped immediately after.

3. Length of Drainage Tubing: Rationale: Tubing length affects drainage efficiency and patient mobility.

Considerations:

• Not Too Short: Tubing that is too short can restrict patient movement, potentially dislodge the chest tube, or cause tension on the insertion site.
• Not Too Long: Tubing that is too long can create loops that impede drainage flow due to increased resistance and potential fluid collection in loops.
• Straight Line: Tubing should ideally run in a relatively straight line from the chest to the drainage system, avoiding kinks or dependent loops.
• No Loops: Avoid creating loops in the tubing, as these can trap fluid and air, obstructing drainage.

4. Patency of Chest Tubing: Rationale: The chest tube must be open and clear for drainage to flow.

Considerations:

• Frequent Checks: Regularly check the tubing for kinks, clamps, or pressure points that might obstruct flow.
• No Kinks or Pressure: Ensure the patient is not lying on the tubing, and that bedding or clothing is not pressing on it.
• Mucus Plugs/Clots: Clots or mucus plugs inside the tubing can block drainage.
• Milking the Tube: If clots or plugs are suspected, gently “milking” or stripping the tubing (following hospital protocol and physician orders) can help to dislodge them and maintain patency. However, routine stripping/milking is generally discouraged as it can create excessive negative pressure and potentially damage lung tissue. Gentle manipulation to maintain patency is preferred.
• Avoid Clamping: Never clamp the chest tubing routinely, as this can lead to tension pneumothorax if air is still leaking into the pleural space. Clamping is generally only done briefly in specific situations, such as changing the drainage system, assessing for air leaks, or prior to removal, and should be done per physician order or hospital protocol.

5. Maintenance of Air Tight Drainage System: Rationale: The system must be airtight to maintain the water seal and suction (if used) and prevent air from entering the pleural space.

Considerations:

• Air Tight Seals: Ensure all connections in the drainage system (tubing connections, bottle stoppers, connections to the chest tube at the insertion site) are airtight.
• Taping Connections: Tape all tubing connections securely to prevent accidental disconnections and air leaks.
• Stoppers and Seals: Make sure bottle stoppers (if using bottle systems) are firmly in place and that any seals in modern systems are intact.
• Check for Leaks: Regularly check the system for air leaks. Continuous bubbling in the water seal bottle (when not expected) may indicate an air leak in the system rather than from the patient. To check for system leaks, briefly and sequentially clamp sections of the tubing starting close to the patient. If bubbling stops when you clamp a certain section, the leak is likely in that section or closer to the patient. If bubbling continues even when clamped near the patient, the leak is likely from the patient (e.g., lung air leak) or the chest tube insertion site.

6. Position of the Client: Rationale: Patient position can affect drainage, especially fluid drainage.

Considerations:

• Fowler’s Position (Semi- or High-Fowler’s): Elevating the head of the bed (Fowler’s position) is often recommended.
• Fluid Localization: Fowler’s position helps to localize fluid in the lower pleural space, making it easier to drain through a lower placed chest tube.
• Lung Expansion: It can also improve lung expansion and breathing mechanics.
• Regular Repositioning: Encourage the patient to change position regularly (within activity limitations) to promote drainage from different areas of the pleural space and prevent fluid from settling in one area.

7. Application of Mechanical Suction: Rationale: Suction, when used appropriately, can enhance drainage but must be applied correctly.

Considerations:

• Continuous and Gentle: Suction should be continuous and gentle, not intermittent or high pressure.

When to Use Suction: Suction is typically used when:

• Gravity drainage alone is not enough (e.g., persistent air leak, slow lung re-expansion).
• The patient’s respiratory effort and cough are weak.
• There’s a fast or significant air leak into the pleural space.
• Speedier removal of air or fluid from the pleural space is needed.

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• Physician Order: Suction should always be applied based on a physician’s order.
• Proper Setting: Ensure the suction is set to the prescribed level (often indicated by the water level in the suction control bottle or the setting on a modern drainage unit).
• Bubbling in Suction Chamber: Gentle, continuous bubbling in the suction control chamber (Manometer Bottle) is a sign that suction is being applied correctly. Vigorous bubbling is usually unnecessary and can increase water evaporation and noise.

8. Activity of the Client: Rationale: Patient activity can promote drainage and lung function.

Considerations:

• Movement on Bed: Encourage gentle movement in bed (turning side to side, repositioning). Movement helps to shift fluid and air within the pleural space, promoting drainage.
• Coughing and Deep Breathing: Encourage the patient to cough and deep breathe regularly.
• Intrapleural and Intrapulmonary Pressure: Coughing and deep breathing help to increase intrapleural and intrapulmonary pressure, which can assist in expelling air and fluid from the pleural space and promote lung expansion.
• Walking (if appropriate): If medically appropriate and ordered by the physician, ambulation (walking) can also be beneficial, as it encourages deeper breathing and overall lung function.