Chest drains and thoracotomy

Chest drains and thoracotomy

Chest drain is a conduit to remove air or fluid from the pleural cavity

The fluid can be blood, pus or a pleural effusion

Allows re-expansion of the underlying lung

Must prevent entry of air or drained fluid back into the chest

A chest drain must therefore have three components

An unobstructed chest drain

A collecting container below chest level

A one-way mechanism such as water seal or Heimlich valve

Indications for chest drain insertion

Pneumothorax

In any ventilated patient

Tension pneumothorax after initial needle insertion

Persistent pneumothorax after simple aspiration

Large spontaneous pneumothorax in patients over 50 years

Malignant pleural effusion

Empyema and complicated parapneumonic pleural effusion

Traumatic haemopneumothorax

Post thoracotomy, oesophagectomy and cardiac surgery

Mechanism of action

Drainage occurs during expiration when pleural pressure is positive

Fluid within pleural cavity drains into water seal

Air bubbles through water seal to outside world

The length of drain below fluid level is important

If greater than 2-3 cms increases resistance to air drainage

Insertion

Unless emergency situation then pre-procedure chest x-ray should be performed

Drain usually inserted under local anaesthesia using aseptic technique

Inserted in 5th intercostal space in mid-axillary line

Inserted over upper border of rib to avoid intercostal vessels and nerves

Blunt dissection and insertion of finger should ensure that pleural cavity is entered

Used to be taught that:

To drain fluid it should be inserted to base of pleural cavity

To drain air it should be inserted towards apex of lung

Probably does not matter provided there is no loculation of fluid within pleural cavity

A large drain (28 Fr or above) should be used to drain blood or pus

Drain should be anchored and purse-string or Z-stitch inserted in anticipation of removal

Does and don'ts of chest drains

Avoid clamping of drain as it can result in a tension pneumothorax

Drain should only be clamped when changing the bottle

Always keep drain below the level of the patient

If lifted above chest level contents of drain can siphon back into chest

If disconnection occurs reconnect and ask patient to cough

If persistent air leak consider low pressure suction

Observe for post-expansion pulmonary oedema

Removal

Remove drain as soon as it has served it purpose

For a simple pneumothorax it can often be removed within 24 hours

To remove drain ask patient to perform a Valsalva manoeuvre

Remove drain at the height of expiration

Tie to pre-inserted purse-string or Z-stitch

Perform a post-procedure chest x-ray to exclude a pneumothorax

Complications

"There is no organ in the thoracic or abdominal cavity that has not been pierced by a chest drain."

Early complications

Haemothorax

Lung laceration

Diaphragm and abdominal cavity penetration

Bowel injury in the presence of unrecognised diaphragmatic hernia

Tube placed subcutaneously

Tube inserted too far

Tube displaced

Late complications

Blocked drain

Retained haemothorax

Empyema

Pneumothorax after removal

Thoracotomy

A surgical incision into the chest

Used to gain access to thoracic organs

Approach depends on procedure planned

Anterior incision

Principle option is anterior thoracotomy

Used for:

Access to right middle lobe

Partial pericardectomy

Provides poor access for pulmonary and oesophageal resections

Lateral incisions

Options include:

Axillary thoracotomy

Lateral (muscle-sparing) thoracotomy

The 'French' incision

Used for access to mediastinum

Posterior thoracotomy

Option include:

Posterolateral thoracotomy

Posterior thoracotomy

Used for:

Pneumonectomy

Oesophageal surgery

Tracheal surgery

BibliographyLaws D, Neville E, Duffy J et al. BTS guidelines for the insertion of a chest drain. Thorax 2003; 58(Suppl 2): 53-59.

Parry G W, Morgan W E, Salama F D. Management of haemothorax. Ann R Coll Surg Eng 1996; 78: 325-326.

Tomlinson M A, Treasure T. Insertion of a chest drain. How to do it. Br J Hosp Med 1997; 58: 248-252.