Chest Drain Management

Introduction to Chest Drain Management

Chest drains for pleural effusion should be removed when there is no ongoing air leak and fluid drainage is less than 300 mL/24 hours, with monitoring of respiratory swing as an indicator of drain patency, as recommended by the British Thoracic Society 1
The decision to remove a chest drain should be based on resolution of air leak, minimal fluid drainage, radiographic improvement, and clinical improvement, with the British Thoracic Society recommending removal when fluid drainage is less than 300 mL/24 hours 1

Initial fluid removal should be limited to 10 mL/kg body weight, after which the drain should be clamped for 1 hour to prevent re-expansion pulmonary edema (RPO), according to the British Thoracic Society guidelines 2
In adults and larger children/adolescents, no more than 1.5 liters should be drained at one time, or drainage should be slowed to about 500 mL/hour, as suggested by the British Thoracic Society 2
Care must be taken when clamping to ensure no air leak has developed during insertion, as this risks tension pneumothorax, as warned by the British Thoracic Society 2

Daily assessment of drainage volume, color, consistency, and presence of respiratory swing should be documented, as recommended by the British Thoracic Society 2
The underwater seal bottle must remain below the patient's chest level at all times to prevent backflow, according to the British Thoracic Society guidelines 2
If suction is used, it should be maintained at 5-10 cm H₂O pressure via the underwater seal, as suggested by the British Thoracic Society 2
The drain should be monitored for bubbling, where continuous bubbling suggests ongoing air leak from the lung, and absence of bubbling in pneumothorax may indicate resolution 2
The drainage characteristics, including volume, color, and consistency, should be assessed regularly, and the insertion site should be inspected for signs of infection, air leakage, and proper dressing integrity 2

A chest radiograph should be performed if the drain was placed for pneumothorax or pleural effusion, as recommended by the British Thoracic Society 2
A chest radiograph must be performed after insertion to confirm proper drain position, rule out iatrogenic pneumothorax, and establish baseline for subsequent assessments 2
Consider imaging (ultrasound or CT) to check drain position and assess remaining fluid if the drain remains blocked despite flushing, with contrast-enhanced CT being most useful for evaluating anatomical details such as locules 2, 3

A bubbling chest drain should never be clamped due to risk of tension pneumothorax, as warned by the British Thoracic Society 2
If a drain is clamped, it should be immediately unclamped if the patient complains of breathlessness or chest pain, according to the British Thoracic Society guidelines 2
If replacement is needed, a new sterile drain must be placed by properly trained personnel, and patients with chest drains should be managed on specialized wards by staff trained in chest drain management, according to the British Thoracic Society guidelines 2
The decision to replace an accidentally removed drain should prioritize patient safety and clinical necessity, rather than routine replacement, with consideration of factors such as clinical resolution, significant fluid remaining, and underlying condition requiring continued drainage 2

Patients with chest drains should be managed on specialized wards by staff trained in chest drain management, as recommended by the British Thoracic Society 2
Patients should be educated about drain care and movement restrictions, to prevent accidental removal and ensure proper management of the drain 2
Patients should be monitored for signs of fluid reaccumulation or infection, and ensure proper wound care at the former drain site, with consideration of follow-up imaging if clinically indicated 2
Brief disconnection from suction for activities like radiographs or mobilization is acceptable, provided the underwater seal bottle remains below chest level, according to the British Thoracic Society guidelines 2
When a chest drain is accidentally removed, the patient's clinical status should be assessed for signs of respiratory distress, chest pain, or hemodynamic instability, and monitored closely for tension pneumothorax if a bubbling chest drain was removed, indicating an air leak, according to the British Thoracic Society guidelines 2