Bottle System

8/2/2019 Bottle System

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Chest drain can be used to drain abnormal collections of fluid or air from the pleural cavity.

It is mostly used to treat pneumothorax and pleural effusions. Although chest drains have

been used for over a century, there is surprisingly little research-based evidence. Most

literature is largely anecdotal and often based on expert opinions or retrospective series. In

the following discussion, a review of the current nursing care and management of chest

drains would be made.

Types of chest drainage system

Several drainage systems are available and it is important that the nurse is aware of the

function of each one. The most common employed one is the one-bottle system, but

traditionally there are two- and three-bottle systems, which are now less commonly used.

Instead some manufacturers have produced plastic multi-chamber units. Some knowledge

on the design of such systems will enhance the understanding and management of such

units.

One-bottle system

The simplest way to set up a single bottle with a tube submerged to a depth of 2cm under

water which creates a water seal is illustrated in figure 1a. One tube leads out of the bottle

through the plug at the top, allowing air to open into the atmosphere. However, excessive

accumulation of fluid inside the bottle might impose resistance and hence the optimal

functioning of the unit. The system can also be connected directly to the low regulator

suction if negative pressure is required to improve drainage afterwards. (Figure 1b)


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Two-bottle system

One form of this system involves separate drainage/collection and water seal units, with air

from the pleural space conducted through the tubing that connects the two bottles and

bubbles through the water seal bottle and exits to the atmosphere, as illustrated in figure

2a. By adding a bottle container before the water-seal bottle, rising resistance from

excessive concomitant pleural fluid drainage can be avoided. Another form involves a

water-seal bottle connected to a second suction-regulating bottle to gauze the pressure

created via external suction (Figure 2b). However, the maximum negative pressure

available is usually limited to 10-12 cm H2O due to the limited height of the water column in

the commonly available bottles.


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Three- bottle system

A three bottle system contains a collection chamber, an under water seal & a suction

regulating device to maintain constant negative pressure as illustrated in figure 3. The level

of fluid in the suction control bottle determines the amount of suction provided to promote

drainage from the pleural space. As illustrated, the three bottle system is bulky and

therefore hence is seldomly used. The commercially available plastic multi-chamber

systems incorporate the three bottle system into one unit with three chambers as illustrated

in figure 4


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Nursing management

Once a chest drain is inserted, it is important for the nursing staff to ensure that the patient

and the drain are closely monitored. However, wide variations of practice have been

observed, which are based on local policies and individual preferences rather than

evidence-based protocols (Avery 2000, Charnock and Evans 2001). The suggestions below

have been compiled and highlighted from the literature.

1. Positioning

The patient should be placed in a semi-recumbent position with regular position changes in

order to encourage drainage and prevent stiffening of the shoulder joints. These might

enhance breathing and expectoration, as well as allowing full lung expansion and possibly

preventing complications of prolonged immobilization.

2. Drain patency

Drainage can be impeded by excessive coiling, dependent loops, kinked or blocked tubes,

and which potentially might lead to tension pneumothorax or surgical emphysema. The

tubing should be lifted regularly to drain the fluid into the collection bottle if the coilingscannot be avoided. The effects of clamping, milking and striping of chest tubes are

controversial and are usually not advised. Replacement of tubing is usually advised if

blockage is detected. Lung damage from the sharp pressure changes generated during

stripping of tubing might be resulted. Although clamping of drains are still observed and

practiced in cases where there are no longer any air leakage and when replacement of

tubing or bottle is necessary, this is not recommended in the major international guidelines.


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3. Observation

Patients vital signs, respiratory rate, oxygen saturation as well as the presence of tidaling

and bubbling in chest drainage system should be closely monitored. Any deterioration or

distress of the patient should be reported to the doctors immediately.

4. Pain managementThere are currently no definite guidelines on pain assessment and pain control with regard

to chest

drainage. The pain could be substantial and might affect coughing, ventilation, sleep as well

as re-expansion of the lung. Nurses should be aware of the potential need for prescribed

on-demand pain killers or inform clinicians about the possible requirements.

5. Recording and observing drainage

The drainage system should be kept below the patients chest level to prevent fluid re-

entering the pleural space. Volume, color, tidaling, bubbling of drainage fluid and level of

suction pressure should be regularly evaluated and recorded on patients chest drain chart.The frequency of recording will vary depending on the condition of the patients and their

underlying disease(s).

6. Drain security and wound management

Using of tape to secure connections has been controversial with no apparent clear

recommandation. Some researchers advocated that taping the connections can avoid

potential disconnection but others argued that taped tube may mask disconnections. The

use of transparent, water-proof and secure tapings might be necessary in a busy and

congested ward environment. The insertion site should be checked everyday to ensure that

the wound is dry and clean, with no loosen sutures or visible side hole(s) of chest tube (i.e.slipping out). Presence of or increasing surgical emphysema, pus, or excessive bleeding

around insertion sites should also be noted.

7. Potentially dangerous conditions that require urgent attention

Large amount of bubbling in the water seal chamber, which might signify a large patient

air leak or a leak in a system

Sudden or unexpected cessation of bubbling, which may indicate a blockage in the tubing.

Large amount of bloody discharge might indicate haemothorax or trauma to underlying

organ(s)

Increasing dyspnoea, increased heart rate, lowered blood pressure & low oxygen

saturation: may signify recurrent pneumothorax (after drain removal) or insufficient drainage

or tube blockage

Absence of gentle bubbling in suction control bottle/ chamber may indicate disconnection

of the suction pressure or inadequate suction force to counteract the large air leakage.

Conclusion


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Nursing management of chest drains is important. A comprehensive understanding of the

operations of the chest drain systems and areas requiring special attention would be

important to reduce the complications arising from chest tube drainage.

Bottle System

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