Evidence to support the use of occlusive dry sterile dressings for chest tubes.
Chest tubes (CTs), pleural chest drains, or intercostal drainage tubes are placed routinely in patients undergoing thoracic and cardiothoracic surgery (Kwiatt et al., 2014). CTs also may be inserted emergently in patients after thoracic injury, in patients with respiratory compromise, or to drain air or fluid from the pleural space. CTs should be inserted uniformly with adherence to requirements for patients' positioning as well as sterile technique, often using local anesthesia for insertion (Salmon, Lynch, & Muck, 2013; Zisis et al., 2015).
The basic function of the CT is to remove excess fluid or air from the pleural cavity and optimize re-expansion of the unilateral lung. The size and type of CT is usually dependent on the indication for insertion and clinician preference (Salmon et al., 2013; Zisis et al., 2015). Once placed, the CT is attached to a negative pressure system and the clinician customarily applies a secure dressing, often with a suture at the insertion site. Ideally, the CT dressing should secure the tube, provide a comfortable seal, absorb any drainage at the insertion or suture site, and prevent a wound infection (Salmon et al., 2013). While the literature identifies characteristics of optimal CT dressings, variations in practice exist and little evidence supports use of any one dressing.
Despite many advances in surgical techniques and fewer invasive procedures, CT placement remains a common surgical procedure, with many indications for CT use (Kwiatt et al., 2014). Over the last 2 decades, thoracic surgery has evolved and technology improved in offering less invasive methods for diagnosis and resection of lung tumors (Reck, Heigener, Mok, Soria, & Rabe, 2013). Advances in postoperative care related to CTs have occurred, from the simple three bottle negative pressure drainage systems to disposable systems that can identify an air leak using a premeasured water seal chamber (Coughlin, Emmerton-Coughlin, & Malthaner, 2012). Additionally, a more sophisticated electronic negative drainage device measures specific parameters of intrapleural pressure (Zisis et al., 2015). Surgical expertise in CT placement, use of smaller flexible and multi-fenestrated tubes, advances in thoracic surgical closure, use of lung sealants, and attention to patients' skin integrity all play a role in the changing care of the patient with a CT (Kwiatt et al., 2014).
Interprofessional inconsistency and a lack of consensus have existed about expectations of an occlusive dressing and if petroleum gauze at the base of a CT dressing prevents air movement or infection. The application of a petroleum product or dressing applied directly to the CT insertion site has been mentioned commonly in literature describing CT care (Kane, York, & Minton, 2013; Muzzy & Butler, 2015; Salmon et al., 2013). Despite a lack of evidence to support the practice, guidelines for the care of a CT often indicate application of petroleum dressings is required to prevent air leaks. Further, when the CT is removed, a petroleum dressing typically is used to seal the insertion site. Practice guidelines thus typically suggest a petroleum gauze dressing as the standard of care (Kane et al., 2013; Muzzy & Butler, 2015). However, evidence is lacking in support of this practice (Zardo, Busk, & Kutschka, 2015).
The purpose of this retrospective record review was to identify evidence that supports use of an occlusive dry sterile dressing compared to a petroleum occlusive dressing for preventing air leaks and wound infection at the CT site. This study used the Society of Thoracic Surgeons (STS) General Thoracic Database to perform a secondary analysis: to identify the incidence of air leak and wound infection specific to the CT site in a subset of all patients who had undergone thoracic lobectomy and had a dry sterile occlusive dressing applied. The STS database provided necessary guidance for collection of numerous data points around thoracic surgery. Initially, no time parameters were stipulated for data entry regarding a CT leak. However, STS subsequently indicated data were to be collected on any air leak that existed for 5 days. Additionally, the STS database came to include data on surgical sites not specific to CT insertion sites.
A review of the CINAHL, Medline, and PubMed databases for 2012-2105 was conducted using the search terms chest tubes, occlusive dressings, occlusive petroleum dressings, and dry sterile dressings. This search found no research supporting use of occlusive petroleum dressings at the CT site. In fact, only one randomized study testing the tensile properties of sutures exposed to petroleum gauze concluded petroleum-exposed sutures for vaginal surgery failed at a statistically significant lower tension when compared to saline-exposed sutures (Muffly et al., 2012). While not immediately transferable to petroleum dressings at a CT site, these findings suggest the integrity of CT sutures does not benefit from exposure to petroleum gauze.
In the large urban medical center that served as the site for this study, evidence of altered skin integrity at the CT site was based on individual case reports by the thoracic team and clinical nurses consulting with the clinical nurse specialist. After CT removal, the care team noted excess moisture from drainage, skin maceration, blisters, and/or skin tears from removal of adhesive dressings and tape framing the tube. Excess petroleum at the tube insertion site occasionally seemed to delay closure. This led to a trial of dry gauze dressing covered with a mild adhesive-backed foam patch or transparent dressing. Skin integrity around CTs improved markedly when harsh adhesive and petroleum dressings were replaced with the dry sterile dressing alternative. Due to collective case reports and lack of evidence to support use of petroleum dressings, the surgical team and nurses in the thoracic specialty agreed to discontinue petroleum dressing for dry occlusive dressings in 2001.
Before the start of the study, Institutional Review Board approval was obtained at the study site, a large academic medical institution in the northeastern United States. This retrospective record review used a descriptive design and included STS data pertinent to similar institutions where use of dry sterile occlusive dressings was implemented. Collected data included the type of dressings applied and reapplied by registered nurses (RNs), presence of air leak, and occurrence of wound infection. Within a subset of this population, data were analyzed further to examine wound infection specifically related to the CT site.
As the convenience sample to address the first purpose, cases of thoracic surgery requiring CT placement without the use of any petroleum product in the dressing were isolated over a 5-year period (January 2005-December 2010). Of 4,361 cases, all used the same disposable negative-pressure drainage system and were assessed for air leaks in the same way. The primary CT dressing consisted of two or three dry sterile gauze pads under and/or above the insertion site, covered with a foam-based occlusive patch or transparent film dressing. If the integrity of the CT dressing was compromised by leaking drainage or lifting, an RN removed and reapplied it in a sterile procedure. To address the second purpose of the study, researchers identified 373 cases in which CTs were placed following lobectomy using open thoracotomy and video-assisted thorascopic surgery (VATS) for lung cancer over a 2-year period (January 2009-December 2010).
Within the sample of 4,361 thoracic cases requiring CT placement, 134 air leaks (3.1%) and 21 wound infections (0.5%) occurred. These data reflect all surgical thoracic procedures regardless of disease process, and wound infections were not specific to the CT site. Further, the number of CTs placed was not documented. Thus, more specific criteria regarding the CT wound site and homogenous thoracic surgical population were needed to determine outcomes related to an occlusive dry sterile dressing. A 2-year (2009-2010) subset of homogenous patients who underwent thoracotomy for lung cancer then was chosen with two controls: all had a lobectomy, and all were managed postoperatively with the same disposable drainage collection system.
This sample included 373 surgeries for lung cancer (232 open thoracotomy, 141 VATS). Thirty complications of air leak (8%) and two of wound infection (0.5%) were documented. The same disposable chest drainage system was used for each CT, but the actual number of placed tubes was not recorded consistently. These patients ambulated with portable suction within the first 24 hours of surgery and mobilized routinely two to four times daily.
The sample of 232 open thoracotomy procedures had 22 air leaks (9%) and two CT site wound infections (0.8%), while the 141 VATS cases had eight air leaks (17%) and no wound infections. Combined data showed an 8% air leak rate and 0.5% infection rate in this sample of patients with lung cancer, with none attributable to the CT dressing or CT site itself.
Findings suggest a lack of evidence to support current practice around dressings at the CT site. The low incidence of air leaks and CT wound infections in this institution provides the first evidence to date to support occlusive dry sterile dressings as an alternate to petroleum dressings. Findings from this report suggest a dry sterile dressing rather than a petroleum dressing at the CT site resulted in low infection and air leak rates. These findings provide the first support for changing practice from petroleum occlusive dressings to dry sterile dressings. Practice has changed from petroleum to dry sterile dressings in this institution.
This study was a retrospective review. In addition, the 5-year data were from only one institution using only one type of chest drainage system in the postoperative thoracic patients. All thoracic procedures required CT placement, but the size and number of tubes placed after each thoracic surgical intervention were not considered. Only the total number of cases with CTs was recorded in the STS database. With the common practice of placing two CTs postoperatively, the findings could have indicated an even lower leak rate.
Other limitations reflect more recent improvements in surgical technique and in the size of the CT drain placed. The chest drains used during the time frame of this review were considered large-bore tubes measuring 24-28 French. Smallerbore chest drainage catheters have gained popularity since the review. CTs now have varying diameters and are available in more flexible silicone materials with multi-fenestrated drainage channels that maximize drainage and limit pain (Fysh, Smith, & Lee, 2010).
These findings are based on a homogenous sample of surgical patients so it is not clear if this practice translates to other practice areas that use CTs (e.g., medical for infection or pneumothorax, or trauma such as a motor vehicle collision). Data related to patient skin integrity, comfort, and length of stay (LOS) were not examined but would have provided further insight into patient satisfaction and potential cost savings. Exploring these findings across settings and considering varying reasons for CT placement and system use could provide further evidence to support a practice change.
Despite uniform recommendations to use occlusive petroleum dressings at the CT site, no past research supported its use. In the setting where this study occurred, nurses and physicians questioned the tradition of this practice because they noticed skin maceration at the CT insertion site with petroleum-based occlusive dressings. Findings suggest a dry occlusive dressing at the CT insertion site is sufficient in preventing air leaks and CT site infection post thoracic surgery, but it may have implications for patient comfort. These findings also support the use of retrospective medical record reviews when there is a lack of data-based evidence to support practice.
Since this study was completed, preventing maceration to the periwound skin around the CT insertion site was addressed. The term maceration often is used to describe moisture-associated skin damage (Bryant, 2016; Gray & Weir, 2007; National Pressure Ulcer Advisory Panel, 2016). Maceration results from prolonged presence of moisture (more than 2 hours) on the skin that compromises the skin's protective mechanisms and reduces the ability of the skin to resist the additional stressors of shear, friction, and pressure (Bryant & Nix, 2016). Drainage leaking from around the CT insertion site that remains on the skin for long periods of time can lead to epidermal breakdown. Changing the CT dressing more frequently is one option to avoid potential periwound maceration. A second option is to add a liquid skin barrier around the CT insertion site under the gauze dressing to protect the skin (Bryant, 2016; Guest, Greener, Vowden, & Vowken, 2011).
Recommendations for Future Research
More research is needed to compare underlying diagnosis, procedure, type of CT and drainage system, and other patient characteristics to support these findings. Future studies also should consider the use of occlusive dry sterile dressings and its impact on patient comfort, LOS, and cost.
This study's retrospective record review of 4,361 thoracic cases was conducted to identify evidence supporting use of a dry sterile dressing for preventing air leaks and wound infection at CT sites. Findings sup ported occlusive dry sterile dressings as an alternate to petroleum dressings because of the low incidence of air leaks and wound infections. When evidence is absent, nurses have a role in conducting research to support safe patient practice, improve patient comfort, and reduce costs.
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Bryant, R.A. (2016). Types of skin damage and differential diagnosis. In R.A. Bryant & D.P Nix (Eds.), Principles of wound healing and topical management (5th ed.) (pp. 82-108). St. Louis, MO: Mosby.
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Fysh, E.T, Smith, N.A., & Lee, Y.C. (2010). Optimal chest drain size: The rise of the small-bore pleural catheter. Seminars in Respiratory Critical Care Medicine, 12(6), 760-768.
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Salmon, N., Lynch, S., & Muck, K. (2013). Chest tube management. Retrieved from https://lms.rn.com/getpdf.php/1933.pdf
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Marian Jeffries, MSN, CNS, FNP, CWS, is Clinical Nurse Specialist, Thoracic and Laryngeal Surgery, Massachusetts General Hospital, Boston, MA.
Jane Flanagan, PhD, ANP-BC, AHN-BC, is Associate Professor, Boston College William F. Connell School of Nursing, Boston, MA.
Diane Davies, BSN, RN, is Research Nurse, Massachusetts General Hospital, Boston, MA.
Sheila Knoll, BSN, RN, is Data Manager, Thoracic Surgery, Massachusetts General Hospital, Boston, MA.
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|Title Annotation:||Research for Practice|
|Author:||Jeffries, Marian; Flanagan, Jane; Davies, Diane; Knoll, Sheila|
|Date:||May 1, 2017|
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