/ CHHS15/100

Canberra Hospital and Health Services

ClinicalProcedure

Transillumination and Chest Drain Management (Neonates)

Contents

Contents

Purpose

Scope

Section 1 – Transillumination of the neonatal chest

Section 2 – Needle aspiration

Section 3 – Chest drain insertion, maintenance and removal

Definition of Terms

References

Implementation

Related Policies, Procedures, Guidelines and Legislation

Search Terms

Purpose

To describe the diagnosis of a pneumothorax by high intensity light and the safe drainage of a pneumothorax by needle aspiration of the chest.

Scope

This document pertains to infants and babies care for by staff in the Neonatal Intensive Care unit.

This document applies to:

  • Medical Officers
  • Nurses and Midwives who are working within their scope of practice (Refer to Scope of Practice for Nurses and Midwives Policy)
  • Student Nurses under direct supervision.

Section 1 – Transillumination of the neonatal chest

In an emergency, a pneumothorax can be diagnosed by using high intensity light.

Equipment

  • High intensity fibre-optic cold light source (Transilluminator)

Procedure

  1. Lower lights in the room to enable hyperlucent areas to be seen if present
  2. Clean the part of the transilluminator touching the patient with alcohol wipes
  3. Place the transilluminator along the posterior axillary line of the baby’s chest wall on the side where air collection is suspected
  4. The transilluminator may be moved up and down along the posterior axillary line to the frontal area to detect any areas of increased light transmission
  5. Compare with the other side of the chest
  6. For a suspected pneumopericardium place the transilluminator in line with the 3rd and 4th intercostal space on the left mid clavicular line and angle the light towards the xiphoid process
  7. If an abnormal air collection is detected notify the Medical Officer immediately
  8. Document findings in the patients clinical record
  9. If a pneumothorax is suspected a Chest X-ray will be ordered if time allows
  10. A Medical Officer may perform a Needle Aspiration to remove the collection of air if there is a pneumothorax present and there are any signs of acute compromise.

ALERT: Severe subcutaneous chest wall oedema or pulmonary interstitial emphysema may give a false positive sign.
In general for an infant with a pneumothorax on respiratory support, a chest drain should be inserted if a needle aspiration has been performed.
If there is a significant deterioration in a non-ventilated patient, the pneumothorax should be drained before a decision is made to intubate the patient.

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Section 2 – Needle aspiration

In case of emergency, if a tension pneumothorax is suspected, the pneumothorax should be drained as soon as possible by needle aspiration.

Equipment

  • Pre warmed isolette or open care centre.
  • Dressing pack
  • Skin antiseptic preparation.
  • 3 way tap.
  • 10ml syringe
  • Sterile gloves

Procedures

  • Monitor oxygen saturation, heart rate, respiratory rate continuously throughout the procedure
  • Attach 3-way tap to 10ml syringe and turn all the 3-way tap ports to the on position
  • Remove all the caps from the 3-way tap ports
  • Add the butterfly needle extension or cannula to one of the 3-way tap ports

  • Place infant into position with the arm of the affected side restrained at a 90-degree angle
  • The involved side should be exposed and slightly elevated to ensure evacuation of air
  • Swab the infants’ skin in the area of the 2nd-3rd rib along the midclavicular line
  • Place a finger on the infant’s 3rd rib and guide the needle along the finger and insert into the 2nd intercostal space at an angle of 90degreesan should AVOID THE NIPPLE.

  • Once in position turn the 3 way tap to aspirate air from the infants chest into the syringe
  • Turn the 3 way tap, closing it off to the chest, to expel the air– operator to measure amount
  • Continue to aspirate until resistance is met and remove needle
  • Arrange for an X-ray to confirm drainage of pneumothorax
  • Record heart rate, oxygen saturation, respiratory rate during the procedure and after.

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Section 3 – Chest drain insertion, maintenance and removal

Equipment

  • Chest drain with trochar
  • Underwater seal drain
  • Sterile water
  • Sterile dressing
  • Heimlich valve for transport
  • Howard Kelly clamps

Procedure

RN/Registrar/Medical Officer

  1. Ensure the infant is continually monitored
  2. Consider use of sedation / analgesia /local anaesthesia before commencing procedure
  3. Assemble drainage unit
  4. Position the infant supine on open care centre or in incubator

Alert
The second Intercostal space should be avoided as puncture of the subclavian vein may occur

The Registrar/Medical Officer will insert the chest drain as follows

  1. Medical officer to scrub and don gloves and gown
  2. Appropriate placement of the chest drain will be in the fourth i1ntercostal space just anterior to the mid axillary line
  3. Infiltrate the area with local anaesthetic before making an incision
  4. The infant should be placed with the effected side slightly elevated and the arm raised above the infants’ head
  5. The drain should be inserted following an incision made into the 1ntercostals space – being aware that the i1ntercostal artery, vein and nerve run beneath the ribs surface
  6. A track through to the pleura is then made with blunt dissection using artery forceps. The trocar should not be used to pierce the pleura
  7. The trocar may be bent 30-450 about 1.5-2cm from the tip to facilitate anterior placement of ICC for a pneumothorax. The trocar is NOT to be more than 2cm from the tip to avoid excessive force with perforation of nearby organs. The chest tube should be aimed anteriorly to facilitate drainage of pneumothoraces
  8. The drain is then inserted 2-3cms into the chest in preterm infants and 3-4cms in term infants ensuring that the side holes are within the pleural space
  9. The trocar is withdrawn and the tube is clamped until connected to underwater seal drainage system or to Heimlich valve

  1. In preterm infants tape the chest tube in place with steri strips in term infants it is preferable to tape with steri-strips, alternatively suture the chest tube in place with 4.0 vicryl, do NOT use silk

The RN/Registrar/Medical Officer

  1. Check whether the fluid in the underwater drainage bottle is swinging or bubbling
  2. Cover ICC insertion site with transparent dressing to allow for site observation
  3. Apply low wall suction if requested at 5-10kPa
  4. Tape all connection sites on tubing to help prevent disconnection
  5. Arrange chest x-ray to confirm placement of the ICC and evaluate the effectiveness of the procedure and reduction in size of pneumothorax, chylothorax or pleural effusion

Management

To check the chest drain is correctly positioned and working effectively

  1. Ensure continuous monitoring of the infant with frequent assessment of vital signs and hourly documentation of same
  2. Assess blood gases as requested
  3. Assess and document breath sounds and chest symmetry with cares
  4. Complete a pain score hourly and administer analgesia/sedation as ordered and when required
  5. Evaluate serial chest x-rays to monitor the chest tube placement and visualise the effectiveness of the evacuation
  6. Check dressing is intact and airtight at the insertion site; observe for any drainage or leaking from same. Do not change if dry and intact
  7. Observe for signs of infection-erythema and purulent discharge around drain site and/or purulent discharge in drainage
  8. Check the system is connected to low wall suction at between 5-10kpa if requested
  9. Ensure there is no pulling on the tube by securing the tubing to the bed – encircle the tube with adhesive tape and pin the tape to the bed
  10. When moving the infant stabilise the tube by holding it close to the baby’s chest
  11. The underwater seal drainage system must be positioned below the level of the infant’s chest to prevent water from being drawn into the pleural space
  12. The length of the drain below the level of the fluid should not be greater than 2-3cm as this will increase resistance to the drainage of air
  13. Check clamps are available at the bedside to clamp tube if disconnected and during changing of the drainage system when necessary
  14. If disconnection occurs immediately reconnect and inform the Medical Officer
  15. Frequently reposition the infant to provide maximum drainage and lung expansion
  16. Mark the water level in the chamber each shift to assess amount of fluid loss
  17. Monitor and record the amount, colour and consistency of the drainage hourly
  18. Check and document hourly for bubble and swing in the chamber, the water level rising with inhalation and falling with exhalation reflecting respirations and tube patency (ventilated infants may have dampened oscillations)
  19. Ensure the ICC remains patent at all times

Removal

Chest drains are removed on medical orders when air and fluid accumulation has resolved

Equipment

  • Basic dressing pack
  • Gauze squares
  • Sterile gloves
  • Op-site 3000
  • Stitch cutter if required
  • Steri- strips
  • Aqueous Antiseptic solution 0.1%
  • Sucrose

Procedure

  1. Ensure patient has adequate analgesia
  2. Position patient in lateral position to ensure easy access with affected side uppermost
  3. Remove dressing over chest tube and clean the drain site(s) and area with antiseptic solution
  4. Wash hands and don non-sterile gloves
  5. Remove sutures if present
  6. To reduce the chance of introducing air into the pleural space, cover the chest wound with a small occlusive dressing (gauze) while removing the ICC
  7. During expiration in spontaneously breathing infants and during inspiration in mechanically ventilated infants, rapidly remove the tube while applying pressure with the gauze over the site to produce an airtight seal
  8. Close the wound with steri-strips
  9. Cover site with transparent Op-site dressing to allow for site observation
  10. Monitor the infant’s vital signs hourly and continue observation of patient for signs of respiratory distress
  11. Document procedure

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Definition of Terms

Pneumomediastinum – an air or gas travelled from alveoli and penetrated into the mediastinal tissue.

Transillumination–The passing of a light through the walls of an organ to facilitate medical inspection.

Pneumopericardium–a medical condition where air enters the pericardial cavity.

Pulmonary interstitial emphysema– is a collection of gases outside of the normal air passages and inside the connective tissue of the lung.

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References

Cifuentes, J., Segars, A.H., & Carlo, W.A. (2007). Respiratory System Management andComplications. In C. Kenner & J. Lott (Eds.), Comprehensive Neonatal Nursing, a Physiological Approach. Philadelphia, W.A.: Saunders.

Cloherty, J., Eichenwald, E., & Stark, A. (2008). Manual of Neonatal Care. Philadelphia: Lippincott.

Cunningham, M., & Gomella, T. (2004). Neonatology: Management, Procedures, On-call Problems,Diseases, and Drugs. St Louis: McGraw-Hill

Gomella, P. (2009). Neonatology Management, Procedures, On Call Problems, Diseases and Drugs.New York: McGraw Hill.

Harris,P., Nagy, S., & Vardaxi, N. (2010). Mosby’s Dictionary of Medicine, Nursing & Health Professions (2nd Australian & New Zealand ed.). New South Wales: Elsevier Australia.

Henry, M., Arnold, T., & Harvey, J. (2003). British Thoracic Society Guidelines for the Management of Spontaneous Pneumothorax. Thorax, 58, (Suppl ll), ii39-ii52.

Kattwinkel, J. E. (2005). Textbook of Neonatal Resuscitation (5th ed.). USA: American Academy of Pediatrics and Heart Association.

5 Moments of Hand Washing- Hand Hygiene Australia.

Taeusch H.W. et al. (2005). Avery’s Diseases of the Newborn (8th ed.).Philadelphia: Elsevier Saunders.

Truog, W., & Golomeb, S. (2005). Principles of Management of Respiratory Problems In M. MacDonald, M. Mullett, & M. Seshia (Eds.), Avery’s Neonatology Pathophysiology & Management of the Newborn (6th ed.). Philadelphia: Lippincott.

Verklan, M.T. (2004). Adaptation to Extrauterine Life. In M.T. Verklan & M. Walden, Core Curriculum for Neonatal Intensive Care Nursing. St Louis: Elsevier.

‘World Health Organisation (WHO) Guidelines on Hand Hygiene in Healthcare.

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Implementation

This clinical procedure will be communicated at orientation.

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Related Policies, Procedures, Guidelines and Legislation

Policies

Healthcare Associated Infection (CHHS15/072) Section 2.2

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Search Terms

Doc Number / Version / Issued / Review Date / Area Responsible / Page
CHHS15/100 / 1 / 01/05/2015 / 01/04/2020 / WY&C – Neonatology / 1 of 10
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
/ CHHS15/100

Neonatal

Chest drain

Transillumination

Aspiration

Pneumothorax

Under water seal drain

Doc Number / Version / Issued / Review Date / Area Responsible / Page
CHHS15/100 / 1 / 01/05/2015 / 01/04/2020 / WY&C – Neonatology / 1 of 10
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
/ CHHS15/100

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Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended / Section Amended / Approved By
Eg: 17 August 2014 / Section 1 / ED/CHHSPC Chair
Doc Number / Version / Issued / Review Date / Area Responsible / Page
CHHS15/100 / 1 / 01/05/2015 / 01/04/2020 / WY&C – Neonatology / 1 of 10
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register