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Nurse specialists help sound the alarm over chest drain risks

Respiratory nurse specialists are urging hospitals to ensure they are following best practices in relation to pleural effusion chest drains, following two patient deaths.


The Association of Respiratory Nurse Specialists (ARNS) is working with NHS leaders and other experts to highlight the risks to patients if chest fluid is drained too quickly and without monitoring.

“I was approached to provide expert opinion and a strong nursing voice to the multidisciplinary working group” Maria Parsonage

A joint National Patient Safety Alert has been published by ARNS, NHS England and NHS Improvement and the British Thoracic Society (BTS).

The intervention comes after a review of hospital reporting data between May 2017 and October 2020 uncovered 16 incidents in which patients experienced acute and significant deterioration, after uncontrolled or unmonitored drainage of a pleural effusion.

Of these incidents, two patients died and a cardiac arrest call was made for one patient although the outcome was not reported.

Pleural effusions are the accumulation of fluid between the lung and chest wall. Large effusions, such as those caused by pleural malignancy, may require insertion of a chest drain and controlled drainage of fluid to allow the lung to inflate.


The National Patient Safety Alert stated: “If large volumes of pleural fluid are drained too quickly, patients can rapidly deteriorate.

“Their blood pressure drops, and they can become increasingly breathless from the potentially life-threatening complication of re-expansion pulmonary oedema.

“This is due to a sudden re-expansion of the compressed lung with an accumulation of oedema within the lung(s),” it said.

“The rate at which fluid is drained must be controlled in order to prevent cardiovascular instability and collapse,” it added.

However, a review of the reported incidents suggested that observations and monitoring of patients after chest insertion were either not being done at all or were being carried out too late.


“If large volumes of pleural fluid are drained too quickly, patients can rapidly deteriorate” National Patient Safety Alert

In other incidents, it may have been the case that plans to manage the rate of fluid drainage were not documented or followed, said the alert.

There was also the possibility that staff were not expecting large quantities of pleural fluid to drain during the procedures, it added.


To help reduce variation in practice, ARNS has developed new good practice standards, which have been endorsed by the Royal College of Nursing.

For ARNS, the work has been led by its pleural lead, Maria Parsonage, consultant respiratory nurse and pleural disease specialist at Wirral University NHS Trust.


Maria Parsonage

Ms Parsonage told Nursing Times: “As the ARNS pleural lead, I was approached to provide expert opinion and a strong nursing voice to the multidisciplinary working group.

“Exemplar chest drain resources were then developed to fulfil the essential safety criteria set out in the alert and these have been endorsed by the RCN.”

She added: “The ARNS good practice standards and chest drain resources provide clear instruction on frequency of observation, red flag triggers and local escalation procedures for patient deterioration are available to staff at the patient’s bedside.

“These standards will support staff to provide safe and effective care when managing patients with a pleural effusion requiring a chest drain.”


As part of the National Patient Safety Alert, all hospitals that carry out pleural chest drains are being told they must review their procedures and implement the ARNS standards by June 2021.

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