Student Nurse Respiratory & Thoracic Placement Guide: Chest Drains, Tracheostomy, and Model Gibbs Reflection

Underwater seal chest drains (such as Atrium or Rocket systems) restore negative intrapleural pressure by allowing air and fluid to exit the pleural space while preventing atmospheric air from entering.

Rule 1: Always keep the drainage bottle upright and below the level of the patient's chest (at least 30–50 cm) at all times to prevent back-siphonage of fluid into the pleural cavity.

Rule 2: Understand "Swinging" vs "Bubbling". Swinging (the water column rising on inspiration and falling on expiration in spontaneously breathing patients) confirms the drain is patent and within the pleural space. Continuous bubbling in the water seal chamber indicates an active air leak (from the lung parenchyma or a loose circuit connection). Intermittent bubbling occurs as air is expelled during coughing.

Rule 3: NEVER clamp a chest drain without a specific medical order, even when mobilising the patient or emptying bottles. Clamping an actively leaking pleural drain can convert a simple pneumothorax into a life-threatening tension pneumothorax within minutes.

At the start of every shift, a student nurse on a thoracic or respiratory ward must inspect bedside emergency equipment as part of handover.

For chest drain patients: ensure two sterile chest drain clamps (with protected jaws), a sterile bottle of water (for emergency underwater immersion if the bottle breaks), and spare sterile dressings are present.

For tracheostomy and laryngectomy patients: verify the National Tracheostomy Safety Project (NTSP) bedside emergency kit is present and complete: (1) spare tracheostomy tube of the same size, (2) spare tube one size smaller, (3) tracheal dilator, (4) functioning suction unit and correct size suction catheters, (5) sterile lubricant, and (6) emergency algorithm chart displayed above the bed.

[Stage 1 - Description]: On an acute thoracic surgical ward, I was caring for Patient T, a 64-year-old gentleman on post-operative Day 1 following a right upper lobe VATS resection for non-small cell lung cancer. During midday observations, I recorded a respiratory rate of 28 breaths/min, oxygen saturation of 91% on room air, a heart rate of 110 bpm, and a pain score of 8/10 on deep inspiration. His chest drain had drained 60 mL of serosanguinous fluid with gentle respiratory swing and no active bubbling.

[Stage 2 - Feelings]: Initially, I felt anxious seeing the patient visibly distressed and splinting his right chest wall. I was concerned about acute respiratory deterioration or a developing hemothorax, but I felt confident in my ability to perform a systematic ABCDE assessment under the direct supervision of my Practice Supervisor.

[Stage 3 - Evaluation]: The positive aspect of this intervention was the rapid recognition that severe post-thoracotomy pain was directly causing shallow hypoventilation (atelectasis) and tachypnoea. The challenge was managing the patient’s fear of coughing and breathing deeply due to incisional wound discomfort.

[Stage 4 - Analysis]: In accordance with NICE Guideline CG50 and the Royal College of Anaesthetists acute pain standards, inadequate post-operative analgesia impairs vital capacity and diaphragmatic excursion, rapidly leading to sputum retention, atelectasis, and hospital-acquired pneumonia. Under my supervisor’s oversight, we administered the prescribed PRN intravenous patient-controlled analgesia (PCA) bolus and titrated oxygen via nasal cannula to 2 L/min to achieve target saturations of 94–98% (BTS Guidelines). Once pain settled to 2/10 within 20 minutes, I supported Patient T with an active cycle of breathing techniques (ACBT) and huffing with an incisional wound support cushion, which cleared retained secretions and normalised his respiratory rate to 18 breaths/min with SpO2 of 96%.

[Stage 5 - Conclusion]: This clinical encounter taught me that respiratory rate is the most sensitive early marker of physiological deterioration. I learned that on a thoracic surgical ward, pain management is not merely a comfort measure but an essential respiratory intervention that prevents pulmonary collapse.

[Stage 6 - Action Plan]: In future practice, when caring for post-thoracic surgery patients, I will proactively assess pain scores prior to planned respiratory physiotherapy and mobilising. I will deepen my knowledge of thoracic epidural and paravertebral block monitoring, mapping this directly to Platform 3 (Assessing Needs) and Platform 4 (Providing and Evaluating Care).

What should I do if a chest drain accidentally disconnects from the drainage bottle?

Immediately submerge the distal end of the chest drain tubing 2 to 4 cm into a sterile bottle of normal saline or sterile water (which must be kept at the bedside). This immediately creates a temporary underwater seal and prevents air from being sucked into the pleural cavity. Call your Practice Supervisor and the medical team immediately.

Why are COPD patients prescribed lower oxygen saturation targets (88–92%)?

Some patients with severe chronic respiratory disease have chronic carbon dioxide (CO2) retention and rely primarily on hypoxic drive to stimulate ventilation. Delivering high-flow oxygen can worsen ventilation-perfusion mismatch and depress respiratory drive, leading to acute hypercapnic respiratory failure and CO2 narcosis. Always check the prescribed target saturation on the EPMA chart.

How do I distinguish between surgical emphysema and wound infection?

Surgical emphysema feels like bubble wrap or crackling ("crepitus") under the skin and is usually non-tender, caused by escaped pleural air tracking into subcutaneous tissue. Wound infection presents with classic inflammatory signs: erythema (redness), heat, purulent discharge, localized tenderness, and systemic pyrexia (fever).