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Policies,Clinical,UWHC Clinical,Department Specific,Nursing Patient Care,Pulmonary

Closed Chest Tube Drainage System (Adult and Pediatric) (7.12AP)

Closed Chest Tube Drainage System (Adult and Pediatric) (7.12AP) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Pulmonary

7.12AP

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
May 29, 2015

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 7.12 AP

Original
Revision

Page
1
of 9

Title: Closed Chest Tube Drainage System
(Adult and Pediatric)


I. PURPOSE

To provide guidelines and procedures for the safe use and management of closed
chest drainage using the Atrium Oasis® disposable unit (Adult, Pediatric and
Autotransfusion), Atrium Express™ Mini 500, PleurX®, and Aspira®. Closed chest
drainage is intended to facilitate re-expansion of the lung after surgery, trauma or
spontaneous pneumothorax by removing air and fluid from the thoracic cavity.

II. POLICY

A. Prior to the chest tube insertion, refer to Hospital Administrative Policy 8.48,
Operative, Invasive, & Other Procedures, to complete universal protocol
requirements and document in clinical record. When performing moderate
sedation for chest tube insertion, refer to UWHC Hospital Administrative Policy
8.38, Adult Sedation Policy and UWHC Hospital Administrative Policy 8.56,
Pediatric Sedation Policy.
B. Pneumonectomy: Suction should never be applied to the drainage system of a
patient who has undergone a pneumonectomy. Only the balanced
pneumonectomy drainage system should be used for these patients.


III. EQUIPMENT: Atrium Oasis® Procedure

A. Atrium Oasis® disposable unit from Central Services (CS) – adult single (CS #
1216245) or dual chamber (CS # 1216246), pediatric (CS # 4012266) (for use in
neonates with a small amount of drainage suspected), and autotransfusion (CS
#4012244)
B. Sterile suction canister with tubing (unit stock)
C. Personal protective equipment (mask, gloves, gown, eye protection)
D. Suction gauge
E. Banding gun (available from units that for commonly care for patients with chest
tubes)
F. Chest tube bands (available from CS)

IV. PROCEDURE: Atrium Oasis®

Sterility of the drainage system during setup, insertion and maintenance is key to
prevent any potential complications.
A. Atrium Oasis®


Page 2 of 11

1. Setup
a. Perform hand hygiene according to UWHC Hospital
Administrative Policy 13.08, Hand Hygiene.
b. Remove outer wrapper from Atrium Oasis® unit and then sterile
paper wrapper. The sterile paper wrapper may be used as a sterile
work area.
i. The single Atrium Oasis® drainage unit consists of two
functionally different (water seal, and collection) chambers
in a single plastic unit with one inlet and one outlet. The
inlet is connected to drainage tubing for direct connection
to the patient's chest tube catheter. The outlet is the small
blue port on top of the Atrium Oasis® and is connected to
suction using sterile connecting tubing.
ii. A dial on the side of the drainage unit is how the suction
level is regulated.
iii. A double drainage system Atrium Oasis® for two chest
tubes is also available for B4/5 (Cardiac and Thoracic
Surgery, Heart and Lung Transplant Unit) and TLC
(Trauma and Life Support Center) only, as well as a
pediatric unit and an autotransfusion unit.
ξ If a double drainage system ends up on a unit that is
NOT B4/5 or TLC, switch the double drainage system
to two single drainage systems.
iv. If initiated in the Operating Room, the Atrium Oasis® is
handled by the scrubbed person as a sterile unit.
c. Fill the water seal chamber with the pre-filled syringe attached to
the back of the drainage system. The syringe gets emptied into the
blue suction port which will fill the water seal chamber to the “2
cm level” (this is identified by the dashed lines or the 0 level in the
water seal chamber). The water will turn blue for increased
visibility. The sterile suction tubing is connected to the blue port if
suction is needed.
d. Connect the chest tube from the patient to the six-foot rubber tube
at the top of the drainage collection chamber, with the large
straight plastic connector. Once this connection is made, the water
seal is established. Water seal promotes drainage by gravity;
therefore the collection chamber must be positioned below the
level of the chest.
e. Tightly secure all connections using a banding gun and zip ties.
Tape is not an appropriate method to secure connections.
f. Check with physician to determine if suction is indicated. Negative
pressure obtained by suction is used to facilitate drainage of the
chest cavity and re-expansion of the lung.
g. The amount of suction is regulated by turning the dial on the side
of the drainage system. Each drainage system is preset at -20 cm
H2O suction. If more or less suction is ordered simply turn the dial
until the orange line touches the number for the amount of
prescribed suction.


Page 3 of 11

i. For patients on suction:
ξ Connect tube from suction source to the blue port at
the top of the water seal chamber.
ξ Make sure the chest drainage system is set to the
prescribed suction level (pre-set at -20 cm H20) and
adjust using the side dial if needed.
ξ Turn on the wall suction and increase until the orange
bellow in the suction window is at or past the ▲ mark
(typically -80 cm H20 of wall suction will accomplish
this).
ξ For patients on water seal only (no suction), the suction
tubing should be left disconnected.

2. Patient Care - Maintenance
a. Atrium Oasis® unit should always be lower than the patient's chest
to promote drainage and prevent siphoning of fluid into the chest
cavity.
i. To maintain the water seal and calibrated drainage, the unit
must be kept in an upright position at all times.
ii. The Atrium Oasis® unit can hang from an Operating Room
(OR) table, stretcher or patient’s bed using two plastic or
metal hangers, or it may be set upright on the floor with the
perpendicular stand located at the bottom of the collection
unit.
iii. Avoid dependent loops, obstructions and kinks in the
drainage tubing to maximize drainage flowing freely to the
Atrium Oasis®.
iv. For pediatric patients, secure the Atrium Oasis® unit to the
floor with tape.
b. Assess for and document presence of an air leak (bubbling in the
water seal chamber) on the flowsheet at least every 8 hours.
Document the presence and location of any crepitus and notify the
provider if present. Crepitus is assessed by palpating around the
area where the chest tube is and feeling for “snap, crackle and pop”
sensation under the patient’s skin.
c. Assess and document color, quantity and character of drainage.
Indicate amount of drainage and time interval on the marking strip
on the collection chamber as ordered.
i. Total daily drainage, for each time frame (i.e., every 1 hr,
every 2 hrs or every 8 hrs) according to physician order, is
recorded as output in the patient’s clinical record.
ii. The collection chamber is NEVER emptied; if it becomes
filled, a new unit is prepared and attached to the terminal
end of the chest tube tubing.
d. Record in the clinical record the time that drainage or suction was
established, amount and type of drainage, and patient's response to
treatment.


Page 4 of 11

e. For pediatric patients, chest tube drainage will be marked and
recorded with vital signs and as needed in the patient’s clinical
record.
i. Physician will be notified of chest tube drainage greater
than 3 mL/kg/hr for 3 hours or chest tube drainage of
greater than 5 mL/kg/hr for 1 hour.
ii. Drainage amount will be documented as hourly output (in
mL)/total daily chest tube output (in mL).
f. Specimens are drawn using a needless luer lock syringe and
attaching it to the luer port on the patient tube connector. Fluid
samples can also be taken directly from the patient tube by forming
a temporary dependent loop and inserting a 20 gauge needle at an
oblique angle. Always clean the luer port or the patient tubing with
alcohol swab prior to obtaining sample.
g. Clamping of the Atrium Oasis® is allowed only for, identifying
the location of the air leak, changing the Atrium Oasis® and by
physician order to check for the possibility of removing the
chest tube.
h. The chest tube will be sutured in place by the physician and should
be covered with a dressing that encompasses the entire site.
i. Dressing:
i. Adult Patients Only:
ξ Dressing should be changed every 24 hours or as
needed. Clean the site using ChloraPrep. Place 4x4
drain sponges around the tube at the insertion site.
Apply 4x4 gauze on top of the drain sponge and
secure with either Medipore or paper tape. The
dressing does NOT need to be occlusive when the
chest tube is in place. Use only the amount of tape
needed to secure the gauze to the patient.
ξ Vaseline gauze and antibiotic ointment are not
recommended while the tube is in place, as
maceration of the skin can occur and well as
destruction to the sutures.
ii. Pediatric Patients:
ξ Additional securement of chest tube tubing to bed to
prevent dislodgement and a provider order is
required to change the dressing.
j. Stripping:
i. Adult Patients:
ξ DO NOT strip the drainage tubing. Stripping can
cause negative pressure levels of 300-400 cm,
which is damaging to tissues. If clots are present,
milk outer sections of tubing by gently pinching the
tubing where clots are present.
ii. Pediatric Patients:


Page 5 of 11

ξ Chest tubes may be stripped for postoperative
cardiac surgery patients to maintain patency.
3. Removal of Chest Tubes
a. Adults: When a chest tube is discontinued by the physician, cover
the site with Vaseline gauze, then a gauze dressing on top of the
Vaseline gauze, then an occlusive tape (either a Tegaderm or foam
tape). Upon removal of chest tube, date and time the dressing and
write the date in the clinical record. The occlusive dressing should
remain on for 48 hours. If the dressing becomes soiled within the
48 hours, the dressing should be reinforced. After the 48 hour time
frame, the site can be open to air if there is no drainage. If there is
drainage, a dry clean dressing should be applied and changed daily
until there is no drainage. Document condition of stab sites once
occlusive dressing is removed.
b. Pediatrics: Dressing style will depend upon the type of closure and
the service providing care. Dressing choices may consist of either
gauze and occlusive tape or Vaseline gauze and occlusive tape. For
either dressing type, if dressing should become loose or saturated,
reinforce and contact service providing care.
c. If the patient is connected to a DUAL Atrium Oasis® and only one
chest tube is being removed:
i. Clamp the Atrium Oasis® tubing for the tube being
removed and clamp the tubing for the tube being left in.
ii. Once the chest tube is removed leave the clamp on the
connection to the Atrium Oasis® of the tube that was
removed. For the tube that is remaining, remove the clamp.
iii. Change the Atrium Oasis® as soon as possible to a single
system to prevent a potential for pneumothorax.
d. Disposal of full or discontinued units:
i. Suction connecting tubing may be removed and discarded.
ii. Remove any reusable hemostats.
iii. Place the unit in the large red bin located in the soiled
utility areas, Do NOT try to empty the collection box.
B. PleurX® Catheter: (HFFY #5813)
1. Purpose: PleurX® catheter is a long-term tunneled
catheter placed to drain more chronic pleural
effusions and facilitate the patient’s management of
pleural effusions at home.
2. The physician will order the frequency with which
the catheter is to be drained.
3. The PleurX® catheter is left capped under a sterile
dressing until it is to be drained.
4. Set Up
a. Obtain a PleurX® drainage kit (includes the drainage bottle and
dressing kit).
b. Set up a clean, clear workspace on a table or counter.
c. Perform hand hygiene according to UWHC Hospital
Administrative Policy 13.08, Hand Hygiene.


Page 6 of 11

d. Put on non-sterile gloves. Remove the patient’s old dressing. Be
careful not to tug on the catheter. The stitch should be intact.
e. Remove gloves and perform hand hygiene again.
f. Open the drainage kit bag and remove the procedure pack pouch.
Set the adhesive dressing to the side (this will be used at the very
end).
g. Set the blue Procedure Pack pouch on your workspace with the flat
side up. Carefully unfold the blue wrapping (be careful not to
touch the inside of the pouch or the items inside it with ungloved
hands or other non-sterile items).
h. Remove the drainage bottle, uncoil the drainage line from the
bottle, remove the plastic cover from the tip of the drainage line
(make sure you do not touch the white tip with your hands). Place
the white tip on the sterile part of the blue wrapping of the
procedure pack.
i. Using sterile technique put on the sterile gloves found in the
procedure pack (they are designed to fit both hands)
j. Open the pouch containing the valve cap and let the cap fall onto
the blue wrapping.
k. Open the three alcohol pads, but do not remove them from the
wrapping.
5. Connecting the Bottle
a. Squeeze the white clamp on the drainage bottle so that the line is
closed.
b. Hold the drainage line of the patient near the access tip and remove
the white cap at the end by twisting it off.
c. Clean around the base of the patient’s catheter with one of the
alcohol pads. Be sure you do not insert the alcohol wipe inside of
the patient’s catheter.
d. Pick up the drainage line near the access tip and securely insert it
into the catheter valve on the patient’s catheter. You should feel
and hear a click when they are locked together.
6. Draining Process
a. Remove the white support clip on the top of the drainage bottle by
grasping the upper part of the support clip and pulling outward.
(This insures that the vacuum bottle is intact before you start
draining).
b. Hold the bottle steady with one hand and push the white “T”
plunger down, to activate the vacuum in the bottle.
c. Release the white pinch clamp on the drainage line to allow fluid
to flow into the bottle. The flow of fluid may slow when the fluid
is almost completely drained. You can manually slow the flow of
fluid by squeezing the white pinch clamp on the drainage line (this
may help decrease pain associated with draining).
i. To drain a second bottle: repeat steps in section 5 and 6.
You do not need to clean the valve on the patient’s catheter
between bottles.
7. Placing a New Dressing


Page 7 of 11

a. When draining is complete, pull the access tip out of the valve in a
firm smooth motion. Set the used drainage line down (not on the
blue paper).
b. Clean the catheter valve with the second alcohol wipe and place
the new cap (on the blue paper) by turning it clockwise until it
snaps and is locked in place.
c. Take the third alcohol wipe and clean around the insertion site on
the patient.
d. Place the foam split dressing around the catheter. Wind the
catheter into loops and place the cap on top of the foam dressing
(keep pressure off of the skin).
e. Place the gauze pads over the catheter and foam pad.
f. Remove gloves.
g. Apply the self-adhering dressing.
i. Peel away the larger of the two white pieces of paper
backing from the dressing. Place the dressing over the
gauze pads and press down.
ii. Remove the clear shiny plastic covering the top of the
dressing. Start at one of the corners where the white paper
backing remains; bend the shiny plastic coving back while
pinching the corner of the white paper to separate the shiny
plastic covering from the clear wound dressing.
iii. Remove the remaining white paper backing from the clear
wound dressing pressing down to ensure an occlusive seal
is made.
h. Emptying the bottle
i. Record the volume drained in the patient’s clinical record.
ii. Hold the bottle steady with one hand and push down on the
“t” plunger and move it in a circle to make a larger opening
in the foil seal.
iii. The drainage line is attached with a flexible cap. Grasp the
cap and pull it away from the bottle to remove the drainage
line. Empty the bottle into the toilet. Place the bottle into a
red biohazard bag to discard.
8. Discharge: Staff nurses order the patient bridge drainage kits (CS Item
Number #4005152 – maximum of 3) from Central Services upon
discharge. Send these kits home with the patient. Case Management,
Social Work, or nursing can complete the implant and insurance forms (in
the insertion kit) and fax to the company. A provider must sign the form
before it can be faxed to the company.

C. Aspira® (HFFY # 7707)
1. The Aspira® drainage system is used for home
management of pleural effusions (much like the
PleurX®). To drain the Aspira® you will need to
make sure you have both the drainage kit and the
dressing kit (found in CS).
2. Set Up


Page 8 of 11

a. Prepare a clean work space and place supplies, drainage kit and
dressing kit (if the dressing needs to be changed) on the cleaned
area.
b. Wash hands with soap and water.
3. Draining Procedure
a. Open the drainage kit pouch and set aside.
b. Remove and discard the valve cap from the patient’s catheter line.
c. Wipe the end of the patient’s drainage line (catheter valve) with
one of the alcohol pads.
d. Connect the drainage line of the drainage system to the patient’s
catheter. You should hear or feel a click when secure.
e. Place the drainage bag below the level of the chest.
f. Squeeze the pump one time (to initiate suction). Let the fluid drain
until the bag is full or the fluid stops. If the patient has pain with
draining, disconnect the drainage line from the patient’s drainage
catheter (to remove the suction). When you reconnect it again, do
not squeeze the pump. (This will allow for more of a gravity
assisted drainage as well as patient assisted drainage with each
breath they take).
g. When fluid stops or the bag fills to 1,000 mL, disconnect the
drainage line from the catheter.
h. Wipe the catheter valve on the patient with the second alcohol
wipe. Place the new valve cap on the end of the patient line.
4. Dressing Procedure
a. With the Aspira®, you do not need to change the dressing with
each drainage. The dressing should only be changed if it is soiled,
coming loose and/or every 7 days.
b. Peel open the dressing kit and remove the gloves. Put them on
using sterile technique.
c. Remove the sterile sheet from the pouch and place it on the
cleaned work area.
d. Lay the sheet flat so you can see dressing supplies,
e. Clean the skin around the catheter exit site with the alcohol pad.
Place the split gauze on the skin around the catheter. Place the 4x4
gauze on top of that. Place the transparent dressing over the gauze
leaving the end of the catheter outside of the dressing. Coil the
catheter tubing and tape the exposed catheter to the skin using the
tape provided.
5. Discarding Fluid
a. Cut the corner of the drainage bag and empty fluid into the toilet.
b. Discard the drainage bag and used supplies in the red biohazard
trash.
c. Wash hands.
6. Discharge: Staff nurses order the patient bridge drainage kits (Bag
Drainage Chest 1000ML Aspira #4013810 order 3 and Kit Dressing
Drainage Chest Aspira #4881503 order 1) from Central Services upon
discharge. Send these kits home with the patient. Case Management,
Social Work, or nursing can complete the implant and insurance forms (in


Page 9 of 11

the insertion kit) and fax to the company. A provider must sign the form
before it can be faxed to the company.

V. PROCEDURE: Atrium Express™ Mini 500

ξ Sterility of the drainage system during setup,
insertion and maintenance is essential to prevent any
potential complications.
ξ Dressings for the chest tubes with the following drain
systems should follow section IV, A, 2, i.,
(Maintenance for Atrium Oasis®)

A. Atrium Express™ Mini 500 Chest Tube System
(HFFY# 6603)
1. Purpose: Drain fluid and air from the patient’s chest and promote
increased mobility.
2. Atrium Express™ 500 is a closed, dry suction chest drainage system that
is dry seal on initial setup but can be primed only to (-20) cm suction.
Patients may be left attached until drainage exceeds 300-400 mL with 500
mL being the volume limit. Patients may be discharged on this system.
3. Setting up the Atrium Express™ Mini 500 Chest tube system
a. Perform hand hygiene according to UWHC Hospital
Administrative Policy 13.08, Hand Hygiene.
b. Open the Atrium Express™ 500 sterile package.
c. Clamp the patient’s Atrium Oasis® chest tube using the blue slide
clamp.
d. Disconnect the patient’s chest tube from the Atrium Oasis® by
pressing on the clear plastic tab and pulling the patient tubing out
from the Atrium Oasis®.
e. Remove the red cap from the Atrium Express™ 500 and insert the
patient’s chest tube connector into the Atrium Express™ 500 until
you hear a click.
f. Unclamp the blue slide clip on the patient’s chest tube to allow for
air and fluid drainage
g. To prime suction to -20 cm H2O, hook the Mini 500 to wall suction
attaching suction tubing to the top white port on the Mini 500 until
you see a  in the vacuum indicator window. You know that -20
cm H2O suction is being maintained when the  remains in the
window once the Atrium Express™ 500 has been disconnected
from wall suction.
h. Vacuum can be applied to the system and is verified by the
presence of a  in the “C” section of the system.
i. Keep the system upright and below chest level at all times
including when the patient is laying down.
B. Monitor the drainage amounts, color and consistency and document in the clinical
record.


Page 10 of 11

C. To check for an air leak, lay the system on its side so drainage enters the window
marked “A” at a horizontal level. Bubbles in the window signal an air leak. If
drainage is not sufficient to check for an air leak, clean the syringe port with
alcohol and add 10-20 mL of sterile water through the port.
D. Changing from an Atrium Oasis® system to the Atrium 500 should be performed
only by the medical team or properly trained staff.
E. Changing from Atrium Express™ 500 to a new Atrium Express™ 500
1. Perform hand hygiene according to UWHC Hospital Administrative
Policy 13.08, Hand Hygiene.
2. Open the second Atrium Express™ 500 kit.
3. Don sterile gloves.
4. Clamp the patient’s drainage line.
5. Disconnect the patient’s line and connect to the Atrium Express™ 500. Do
not touch the drainage tube and the connection to the Atrium Express™
500.
6. Unclamp the patient’s drainage line.
7. Document the amount of drainage in the patient’s clinical record.
8. Dispose of the used Atrium Express™ 500 in the ACCO.
F. Emptying the Atrium Express™ 500
1. Perform hand hygiene according to UWHC Hospital Administrative
Policy 13.08, Hand Hygiene.
2. Use an alcohol wipe to swab the port at the front of the Atrium 500 for 15
seconds.
3. Screw a sterile 60 mL luer lock syringe to the port.
4. Pull the plunger back on the syringe to draw the fluid out.
5. Empty the fluid from the syringe into a toilet or sink, making sure not to
touch the end of the syringe to any surface.
6. Repeat as needed until the fluid level is at the 100 cc mark in the Atrium
500.
7. Throw the syringe away and again wipe the port off with an alcohol wipe
for 15 seconds.
8. Record how much fluid you removed and the color of the fluid.
9. Dispose of the 60 mL syringe in the sharps container.

VI. UWHC CROSS REFERENCES


A. Health Facts For You #7707: Caring for Your Aspira® Pleural Drainage System
B. Health Facts For You # 5813: Caring for Your PleurX Pleural Catheter
C. Health Facts For You # 6603: Care after Your Chest Tube is Connected to the
Atrium 500
D. Hospital Administrative Policy 8.38, UWHC Adult Sedation Policy
E. Hospital Administrative Policy 8.48, Operative, Invasive, & Other Procedures
F. Hospital Administrative Policy 8.56, Pediatric Sedation Policy
G. Hospital Administrative Policy 13.08, Hand Hygiene
H. Nursing Patient Care Policy 7.20, Autotransfusion Using the Atrium Chest Tube
I. Respiratory Care Services Policy 3.20, Pulse Oximetry Check & Continuous
Monitoring (Includes Ambulating SPO2)


Page 11 of 11

J. UWHC Nursing Practice Guidelines, Sedation
K. Chest Tube Workspace, located at
https://workspaces.uconnect.wisc.edu/display/ct/Chest+Tubes+Home

VII. REFERENCES

A. Atrium (2013). Oasis Dry Suction Water Seal Chest Drain Instructions for Use.
Retrieved from: http://www.atriummed.com/en/chest_drainage/Documents/Oasis-
IFU-009933.pdf
B. Atrium University (201008). Chest drainage support and education: Atrium
Express™ Mini 500. Retrieved from:
http://www.atriummed.com/Products/Chest_Drains/education.asp
C. Briggs, D. (2010). Nursing care and management of patients with intrapleural
drains. Nursing Standard, 24(21), 47-55.
D. Carroll, P. (2014) Evidence-based Care of Patients with chest tubes. Retrieved
April 27, 2015, from Atrium University, Evidence Center Web site:
http://www.atriummed.com/EN/chest_drainage/Documents/NTI%202014%20Sli
des%20with%20Notes.pdf
E. Crawford, D. (2011). Care and nursing management of a child with a chest drain.
Nursing Children and Young People, 23(10) 27-33.
F. Durai, R., Hoque, H., & Davies, T. (2010). Managing a Chest Tube and Drainage
System. AORN Journal, 91(2), 275-283.
G. Frazer, C. (2012). Managing Chest Tubes. Academy of Medical-Surgical Nurses,
21(1), 9-12)
H. Patient Guide (2014). Aspira® Drainage System. Retrieved from:
http://myaspira.com/assets/pdfs/0728009_Aspira_Patient_Guide_Web.pdf

VIII. REVIEWED BY

Clinical Nurse Specialist, Thoracic Surgery
Clinical Nurse Specialist, Cardiac Surgery, VAD, Heart and Lung Transplant
Clinical Nurse Specialist, Critical Care
Clinical Nurse Specialist, Emergency Services
Clinical Nurse Specialist, Pediatric Intensive Care
Nursing Patient Care Policy and Procedure Committee, May 2015

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer