chest tube and wsd

7/28/2019 Chest Tube and WSD

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CHEST TUBES ANDWATER SEAL DRAINAGEP. Nandi

University Department of SurgeryQueen Mary Hospital

Chest tubes and bottles are some of the simplest devices used in thepractice of medicine. Yet they are often misunderstood, sometimes misusedand are a mystery to medical students, nurses and some practising doctors.An outline of the indications of their use will be given and consider someof the problems that may arise.

Aim of chest drains is to evacuate air, fluid, pus or blood from thepleural space effectively and as quickly as possible.Dangers of Collection in the Pleural Space

1. Pneumothorax:Free air in the pleura is absorbed into circulation within a few

days unless new air is added. But excessive air within the chest occupiesspace and restricts lung expansion resulting in reduction of lung functionand causing dyspnoea. Any pneumothorax occupying twenty percent ormore of the hemithorax should be drained.

If a tension penumothorax develops, patients life may be indanger from cardio respiratory embarrassment.

2. Pleural effusion:Free fluid within the chest also occupies space and causes

reduction of lung function.3. Empyema:Pyothorax or pus in the chest will evoke inflammatory and

fibrotic response and cause encapsulation of the lung in a thick scar. Thisrestricts Iung expansion leading to decrease in pulmonary function. Tensionpyothorax may develop and the patient may be acutely ill from septicaem iaand respiratory distress.

4. Haemothorax:Blood in pleural cavity can be absorbed provided it is not excessivein amount, clotted or infected. Massive haemothorax will cause shock andrespiratory embarrassment.Water Seal (Fig. 1 & 4)


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42 THE BULLETIN OF THE HONG KONG MEDICAL ASSOCIATION VOL. 29, 1977

In order to evacuate fluid or air effectively from the pleural space,it is necessary to ensure one-way flow through the chest drain, This isdone by connecting the chest drain to a glass straw which is immersed undersaline contained in a bottle. Expiration then forces the air and fluid intothe bottle, but air cannot reenter the submerged tube tip. Saline will belifted a few centimeters up the tube by negative inspiratory intrathoracicpressure, but not up to the bed level from the floor. The flow of air orfluid out of the hemithorax must be unimpeded. The following cansignificantly restrict air and fluid evacuation from the chest tube andlead to dyspnoea, lung collapse, embarrassment of circulation and death.

a. A full bottle with glass straw tip deep under the fluid surface.b. Too narrow or too soft tubing may spontaneously kink orcollapse or the patient may lie on it. Passage through a narrow tube or

straw cannot be as free as through a good size tube and under saline straw.C. An obstructed or small size air vent permits pressure to build up

in the chest bottle.d. Any fluid in a dependent loop of tubing will obstruct flow and

create back pressure, especially to an air leak (Fig. 2 & 3).Water Seal in Infants

Use of large diameter tube and straw can cause persistent air spacein the chest because these have a considerable air capacity and may obstructevacuation of air or fluid during expiration, Infants pleural cavity cannotabsorb enough air from the large tube and straw or blow enough air to-getnegative inspiratory pressure which is needed for full lung expansion.Therefore, narrow tube and pencil size straw should be used in children.

Routine use of chest tubes and water seal drainage in a postoperativeinfant is somewhat controversial. Some centres advocate removal of intra-pleural catheter on mild suction while lungs are being inflated by theanaesthetist at the end of thoracotomy. Others use a smaller water sealapparatus. This is safer as it permits drainage of fluid and air that may collectduring the postoperative period.

Infants chest drain straw generally shows a high fluid level andminimal fluctuation.Drains following Chest Surgery

1. Lung ResectionsAfter operations involving removal of part or parts of lung, two

drains must be inserted in the chest. The apical drain which reaches theapex of the hemithorax is meant for drainage of free air. The basal drainis placed in the lower part of the chest with the last hole above the levelof the dome of diaphragm and it drains out fluid or blood that may


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CHEST TUBES AND WATER SEAL DRAINAGE 43

collect. Both drains should be placed anterior to the midaxillary line. Ifa drain is placed behind this line, the patient will lie on it which causesdiscomfort to him and may block it. Two drains are also necessary aftertransthoracic oesophageal resection.

2. PneumonectomyOnly one basal drain is necessary after pneumonectomy.

3. Operations other than Lung Resectione.g. Closed mitral valvotomy, suture and division of patent ductus

arteriosus. Only a basal drain is necessary.4. Following Open Heart Surgery

Open heart operations are usually done through a verticalsternotomy and in most cases , pleura is not opened. Under these circums-tances, two drains (an upper and a lower) are left in the anteriormediastinum, the upper one reaching the back of manubriau sterni. If apleura is accidentally opened an additional drain is inserted in to the chestfrom the lateral chest wall.Chest Tube Suction

Use of suction to chest bottles is somewhat controversial. Manysurgeons always use chest bottle suction and maintain that it is essential.Others do not use suction and feel that it is hazardous, especially if a suctiondevice used cannot maintain negative pressure in the bottle throughout allphases of respiration and coughing. When properly applied, chest tubesuction is very useful. If there is any doubt about the efficacy of the suctiondevice, it is safer not to use it. It is important to remember that use ofsuction on water seal drain is never life saving.

There are different ways of applying suction to chest bottles. Thoracicpumps, e.g. Roberts Pump, are connected directly to the air vent of thewater seal bottle. Wall suction is usually applied through a three or twobottle system (Fig. 5).Conditions where Chest Tube Suction is Useful

A. Pneumothorax(i) When a patient has a large air leak - with small multipleleaks suction may promote healing by drawing the leaking areas

against other lung and chest wall surfaces. There is a slight dangerthat some air leaks could be kept open by excessive early suctionon a small or inelastic residual lung.

(ii) A persistent small air leak or an unusually large one forthe situation being dealt with suggest some leak in the water sealsystem, e.g. a cracked or loose connector, a leaky rubber tubeor a glass straw which is not long enough to enter the water seal


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THE BULLETIN OF THE HONG KONG MEDICAL ASSOClATlON VOL. 29 , 1977

system during negative inspiratory pressure resulting in persistentpartial lung collapse. If such air leak cannot be easily occludedchest bottle suction should be applied.

B Pleural Effusion or HaemothoraxSuction is routinely applied to drain out fluid or blood from the

chest as quickly as possible.C. After Open Heart Operations

Suction is applied immediately to evacuate the blood as quicklyas possible so that it does not get a chance to clot inside. Blood clotsinside will block the drain and also cause increased fibrinolysis which inturn will provoke more bleeding. The clotted blood may also cause post-operative cardiac tamponade. To ensure patency, the chest drains shouldbe milked as frequently as necessary.

Suction is never applied to a chest drain in a patient who has apneumonectomy. Suction on chest drain in pneumonectomy patient willcause mediastinal shift resulting in cardiorespiratory embarrassment whichmay be fatal if not corrected immediately.Care and Removal of Chest Drains

1; Never Clamp Chest Tubes except in Two Conditions(a) In a pneumonectomy patient, the chest drain is usually

kept c lamped because removal of a lung leaves an empty spacefilled with air or air and fluid. This empty hemithorax is subjectto considerable pressure variation with respiration and especiallywith cough. Such sudden pressure changes can cause significantmediastinal oscillation and cardiac arrhythmia. The pressurechange can also result from a siphon effect if the tube is openedwhile submerged in pleural fluid. The siphoning can be avoidedby raising the chest bottle to bed level before unclamping thetube, with simultaneous venting of air into the tubing by ahollow needle to drain all fluid from the tube into the bottle,thus breaking the siphon. The chest tube is usually unclampedfor a few minutes every hour; Eventually by fibrosis and con-traction the mediastinum, diaphragm and ribs surrounding theresidual pneumonectomy space becomes relatively immobile.

(b) When the drainage bottle or bottles have to be raisedto level of the patient, e.g. while moving a patient from bed to -trolley or vice versa, the chest tubes must be unclamped as soonas the process of lifting the patient has been completed especiallyif there is an air leak. If the tubes are kept clamped or forgottento be released while being transported the patient may developtension penumothorax and be in serious trouble. This situation


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CHEST TUBES AND WATER SEAL DRAINAGE

often arises when a patient suffering from persistent spontaneouspneumothorax is being taken to operating theatre for surgery.It is extremely dangerous to clamp the chest tubes or worsestill to remove them before sending such a patient to the operatingtheatre. The chest tube and the water seal drain must be left insitu under these circumstances. This cannot be emphasised toostrongly.

2. Amount of DrainageDaily or hourly increments in fluid level by drainage are noted

from the scale on the side of the bottle and recorded on a chart as chestfluid drainage. When the fluid level in the bottle rises several centimetersabove the tip of the straw the bottle should be changed especially if thereis air leak, as back pressure may develop under these conditions.

3. Milking of TubesMilking will expel tissue or clot from the chest tube and this will

permit better drainage. Small clots that may be pushed back into the chestcan be absorbed. Special devices are available for effective milking. If theseare not available, tubes can be milked by using two clamps applied downthe tube in succession. Hard plastic tubes are difficult or impossible to milk.

4. Foaming ProblemFoaming in the chest bottle can be a nuisance in situations of high

volume air leak. This can be controlled by a silicone antifoam spray or byadding ethanol in the bottle from time to time.5. Removal of Chest Drains

Chest tubes can be taken out when the following conditions aresatisfied.

(a) Air leak (bubbling) has stopped for over twenty-fourhours.

(b) Fully expanded lung as shown in chest x-ray.(c) Serous drainage from the tube is down to 50 to 80 ml.

in a day.These criteria can be applied to any condition for which chest

drains have been inserted, e.g. spontaneous pneumothorax, pleural effusionor after chest surgery. It may be two to six days before these conditionsare met. But it is desirable to have most chest surgical patients walk Onsecond postoperative day. The bottles on wheels will facilitate ambulationof the patients.

A chest tube in a pneumonectomy patient is usually removed intwenty-four to forty-eight hours. It is important to avoid formation Of afistulous fluid track to skin. Therefore, the drain site after removal of thetube should be stitched. The drain site should also be stitched in a childbelow twelve years of age.


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THE BULLETIN OF THE HONG KONG MEDICAL ASSOCIATION VOL. 29, 1977

LEGENDSFigure 1 : Wate r Seal Drainage System.

Straw tip not to be more than 1 - 2 cm. under saline surface.Rubber stopper - should be well-seated or taped down tostabilise the straw, It should be air tight if suction is to beapplied. Bottle size - 1 L or 2L (for postoperative cases),smaller in children.

DRNIAGEI- DO NOT I

FIGURE


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CHEST TUBES AND WATER SEAL DRAINAGE

Figure 2 : There must be no dependent loop with fluid in it.

Figure 3 : Loops between the fixing pin and the patient allows adequatepatient mobility in bed. Inset shows the tube direct from bedto the bottle without any loop.

FIGURE 3

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48 THE BULLETIN OF THE HONG KONG MEDICAL ASSOCIATION VOL. 29,1977

Figure 4 : Chest drain wrongly connected to the air vent instead of tothe under saline straw. Result - vigorous bubbling and thebottle is emptied on the floor.

Figure 5 : Three Bottle Suction System.Bottle no. 3 can be omitted and suction applied to Bottle no. 2.instead.

VACUUM BREAKER STRAW -

VACUUMBREAKER

BOTTLE (NO. 2)

BOTTLE (NO. 3)

WALLSUCTION

WATER SEALBOTTLE (NO. 1)

chest tube and wsd

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