Chest drain pdf

When using water seal as opposed to digital drainage systems , it is mandatory to keep the canister positioned below the chest.

In the case of massive pleural effusions, the initial drainage should be controlled to prevent re-expansion pulmonary edema. It is necessary to clamp the tube if the patient develops respiratory symptoms i. Drainage may be interrupted for up to one hour or more, or until symptoms resolve, and then resumed. Digital drainage systems e. These devices reduce inter-observer variability in air leak assessment since they provide a continuous digital recording of air leak, fluid drainage and intrapleural pressure 5 , Digital systems give the patient the freedom to ambulate without being attached to wall suction.

Overall, these electronic systems contribute to shortening hospital stay by leading to earlier chest tube removal. Moreover, patients can be discharged with these devices in place, if necessary. Drainage of pleural fluid through an IPC is performed by connecting the external one-way valve to a vacuum bottle. The latter is supplied by the IPC manufacturer 1 L capacity or, alternatively, Redon disposable drainage vacuum bottles , , and mL capacity may be employed Figure 6. Instead of using vacuum bottles for pleural drainage, the Aspira catheter uses a manual pump, which is attached to the catheter and a collection bag in line The patient squeezes the pump to initiate the vacuum effect and the fluid drains into the collection bag.

The first drainage session should generally avoid removal of more than 1. Thereafter, there are no data to guide optimal drainage frequency It usually varies from once daily to 2 to 3 times weekly or may even be tailored to the patient's symptoms.

Most chest tubes are suitable for leaving inside the pleural space for more than 2 weeks. However, the longer the tube remains, the greater the risk of local infectious complications.

On the other hand, aspiration drain systems designed for therapeutic thoracenteses 8F , which may occasionally be used for draining small empyematous collections, are usually made of polyurethane and should be removed no later than three days after their initial insertion 5. Chest tubes are withdrawn when they reach their predefined therapeutic goals or become nonfunctional. In patients with pneumothoraces or following thoracic surgery, a clamping trial and a chest radiograph are unnecessary prior to removal of tube thoracostomy to detect recurrent pneumothorax, provided a digital recording drainage device shows that the patient has no air leaks However, when conventional analogue pleural drainage devices are employed, the chest tube is pulled out if the lung remains fully expanded on a chest radiograph performed off suction, and no air bubbling in the water seal chamber is observed.

A bubbling chest tube should never be clamped, since this may lead to tension pneumothorax. If doubts on the presence of an air leak exist, some clinicians prefer to perform a clamp trial, a risky maneuver that requires close monitoring of the patient and generally leads to unneeded delay of chest tube removal 5. In cases of pleural effusion, the fluid output threshold for chest drain removal is not standardized and depends on the underlying disease.

In preparation for removal, the tube should be taken off suction, placed on water seal and removed quickly at the end of expiration during a Valsalva maneuver while placing a sterile dressing over the insertion site After suturing the opening, an occlusive dressing with povidone-iodine is applied to the wound.

In IPC patients, when the pleural fluid output drops to less than 50 mL on three consecutive drainages, spontaneous pleurodesis is assumed 21 , provided a bedside US rules out the presence of pleural fluid i. In these circumstances the pleural catheter may be removed. For IPC withdrawal, the adhesions surrounding the cuff need to be freed, usually with a metallic groove director.

Fewer complications appear when experienced operators insert SBCT under image guidance. The most frequent immediate complications were pain 4. Chest tube malpositions can be classified as intrafissural, intraparenchymal, and subcutaneous. They should be initially suspected if the chest tube is not draining, and are supported by chest radiographic findings.

But often, a computed tomography is necessary to better assess malpositioned tubes. In cases of intraparenchymal misplacement, a second functioning chest tube should be placed prior to the removal of the original to avoid tension pneumothorax or extensive subcutaneous emphysema Rather than being reintroduced, any dislodged nonfunctional tube should be replaced, due to the risk of infection associated with the reinsertion of the externalized portion of the tube.

Hemothorax may result from intercostal artery laceration or, less commonly, from injury to vascularized pleural tumors. Although this complication is usually evident during or after the procedure, sometimes bleeding remains undetected due to the tamponade effect of the chest tube itself until the drain is removed 33 , Subcutaneous emphysema involving chest wall, neck, and face presents as a subcutaneous crepitation, and is easily detectable on chest radiographs.

Fortunately, it is usually a minor and self-limiting complication. Tube blockade or migration of the sentinel hole out of the pleural space should be checked. This complication may need tube thoracostomy replacement and even subcutaneous incisions or drains. Many are common for any chest tube drain, as referred to above, though others are more specific to this procedure. IPC blockage and symptomatic loculations i. However, the infections are generally mild and can often be managed conservatively e.

Tube thoracostomy is a procedure which can be performed by trained pulmonologists. Detection of air leaks in patients with pneumothoraces or following thoracic surgery has been greatly improved with the use of electronic CDS. Finally, IPC are becoming a first-line therapy of symptomatic malignant and persistent benign pleural effusions. They are commonly placed as a day case and allow long-term intermittent fluid drainage in the outpatient setting.

Pulmonologists should be familiar with the common complications that may occur during or after chest tube insertion, some of which are potentially dangerous e. Conflicts of Interest: No potential conflict of interest relevant to this article was reported. National Center for Biotechnology Information , U. Tuberc Respir Dis Seoul. Published online Jan Porcel , M. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Porcel, M. Phone: , se.

This article has been cited by other articles in PMC. Abstract Chest tube insertion is a common procedure usually done for the purpose of draining accumulated air or fluid in the pleural cavity. Introduction Chest tube placement also called tube thoracostomy is a common procedure in daily clinical practice which is performed to drain fluid, blood, or air from the pleural cavity.

Indications and Contraindications of Chest Tube Placement Indications for the insertion of an intercostal chest drain are listed in Table 1. Table 1 Indications for the insertion of a chest tube. Open in a separate window. Chest Tube Types and Sizes There are many kinds of chest tubes or catheters, but they are basically classified according to size and method of insertion 5.

Figure 1. Figure 2. Indwelling pleural catheter. Note the midway polyester cuff C and the external portion with a one-way safety valve V. Preparation, patient positioning, and local anesthesia After an explanation of the advantages and possible complications of the procedure, patients should give written informed consent, except in emergency situations.

Small-bore chest tubes Seldinger technique SBCT are commonly placed using the catheter-over-guide wire Seldinger technique, in which a guide wire is inserted into the pleural space through an introducer needle; the wire should pass without resistance. Large-bore chest tubes blunt dissection technique Blunt dissection is the standard technique for inserting LBCT. Indwelling pleural catheters IPC insertion entails the subcutaneous tunneling of the catheter between two incisions about 5 cm apart.

Heimlich valve The one-way Heimlich valve is a simple device which contains a rubber flutter valve that is occluded during inspiration negative intrapleural and intratube pressure , thus preventing air from entering the pleural space; while being held open during expiration positive pleural pressure allowing the egress of air or fluid from the pleural space Figure 3.

Figure 3. Three-compartment chest drainage systems Three-chamber plastic units e. Figure 4. Three-chamber system using a wet A or dry B suction mechanism. Note the drainage d , water seal b , and suction a chambers. An air leak meter indicates the degree of air leak, measured in columns from 1 to 5 wet system or 1 to 7 dry system.

Digital drainage systems Digital drainage systems e. Figure 5. Vacuum bottles Drainage of pleural fluid through an IPC is performed by connecting the external one-way valve to a vacuum bottle. Figure 6. Vacuum bottles for draining fluid in patients with indwelling pleural catheters. Chest Tube Removal Most chest tubes are suitable for leaving inside the pleural space for more than 2 weeks. Table 2 Complications of chest drain insertion. Conclusion Tube thoracostomy is a procedure which can be performed by trained pulmonologists.

Footnotes Conflicts of Interest: No potential conflict of interest relevant to this article was reported. References 1. Interventional pulmonology fellowship accreditation standards: executive summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. Colt H. Drainage techniques. Textbook of pleural diseases. Manual of pleural procedures. Management of anticoagulant and antiplatelet therapy in patients undergoing interventional pulmonary procedures.

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Cleve Clin J Med. Pleural procedures: intercostal chest drains and indwelling pleural catheters. Br J Hosp Med Lond ; 72 — Heimlich valve and pneumothorax. Ann Transl Med. Copyright and License information Disclaimer. Copyright notice. This article has been corrected. See Thorax. This article has been cited by other articles in PMC. Selected References These references are in PubMed. Chest tubes.

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