tube thoracostomy, management

Tube Thoracostomy Management

By M.A.Moneim

ICU Specialist -- IABFH-ICU

Introduction

• The mechanics of ventilation relate to the negative intrathoracic pressure that draws air into the lungs during spontaneous respiration. This negative pressure is best maintained in the pleural space, which is the potential space between the parietal and visceral layers of the pleura • Collections of air, fluid, or blood in the pleural space not only compress the lung tissue but also cause the pleural pressures to become positive, causing inappropriate ventilation

• Chest drains are inserted to remove pathological collections of air or fluid in the pleural space, to allow the re-creation of the essential negative pressures in the chest, and to permit complete expansion of the lung, thereby restoring normal ventilation

Introduction

• Chest drains are very simple and effective tools in the management of thoracic and pleural pathology. They need

proper safe insertion and correct management

Chest drains are lifesaving in critical care

• Chest drainage systems work by combining the following 3 efforts:

▫ Expiratory positive pressure from the patient helps push air and fluid out of the chest (eg, cough, Valsalva maneuver)

▫ Gravity helps fluid drainage as long as the chest drainage system is placed below the level of the patient’s chest

▫ Suction can improve the speed at which air and fluid are pulled from the chest

Introduction

Indications• Pneumothorax (spontaneous, tension, iatrogenic,

traumatic) • Pleural collection

▫ Pus (empyema) ▫ Blood (hemothorax) ▫ Chyle (chylothorax) ▫ Malignant effusions (pleurodesis)

• Postoperative ▫ Thoracotomy ▫ Video-assisted thoracic surgery (VATS)

Contraindications

When a chest drain is needed for any of the indications listed above, no absolute contraindications exist for chest drain

insertion

Equipment

• Chest drainage bottles• Adequate length (1.5 – 2 m) of sterile, transparent, plastic

tubing (eg, vinyl/silastic) • Appropriate sterile connectors • Adhesive tape • Angled clamps (2) for clamping the tube when needed • Distilled water to fill in the drainage bottle

Drainage system

The typical drainage system consists of 3 bottles :

1. Underwater seal bottle2. Trap bottle3. Suction regulator bottle

The underwater drainage bottle

• The underwater seal bottle is the most important element in pleural drainage.

It is essentially an extension of the chest tube underwater; a low-

resistance, one-way valve for the evacuation of pleural contents

• The underwater seal is a conduit for the expulsion of air and fluid from the chest

against minimal resistance. When intrapleural pressure rises (eg,

expiration, coughing), air is forced out of the lungs through the mouth, and

free contents of the pleural space are forced out through the chest tube and

into the underwater seal drainage bottle

• The underwater seal is also an anti-reflux valve. Re-entry of air into the pleural space when intrapleural pressures become negative (eg, inspiration), is blocked by the underwater seal.

• Water can be drawn up the tube only to the height equal to the negative intrathoracic pressure (usually up to -20 cm of water). Therefore, the apparatus must be kept far enough below the patient to prevent water from being sucked up into the chest (100 cm is sufficient).

• The water in this tube is referred to as the "column" of water; it reflects the changes in intrathoracic pressure with each inspiration and expiration



• The end of the tube in the underwater seal bottle must remain covered with water at all

times.

• The end of the tube must not be kept too far below the surface of water because the

resistance to expulsion of air from the chest is equal to the length of tubing that is

underwater. Keeping the tip of the tube 2-3 cm below the surface of water should be

enough to act as a constant valve.

• The whole system is placed erect, 100 cm below the level of the patient’s chest. This

placement aids gravity drainage of chest contents into the bottle and prevents reentry

of fluid into the chest during the upward swing of the fluid in the tube during inspiration.

Trap bottle• When excessive fluid drains

from the chest, the level of fluid in the underwater seal is raised.

This increases resistance to further outflow of fluid from the

chest

• To decrease this resistance, a trap bottle is introduced

between the chest tube and the underwater seal

• The trap bottle collects the fluid draining out of the chest, while the air passes on to the second

bottle. This keeps the underwater seal at a constant

level

Suction regulator bottle

• Suction hastens the expansion of the lung. Another bottle is needed to introduce suction regulation to this system

• The suction regulator bottle has a 3-hole stopcock▫ Short tubes are passed through 2 of the holes. One short tube

connects to the underwater seal bottle’s vent tube and the other short tube connects to the suction source

▫ An atmospheric vent runs through the 3rd hole, passing below the level of water in this bottle

• When suction is applied, air is drawn down the atmospheric vent in this bottle,

equal to the pressure inside the bottle that is decreased by the vacuum. • Under stronger vacuum, airflow

through the atmospheric vent commences, and air bubbles through the

water in the bottle, but the level of suction in the bottle remains the same

Suction regulator bottle

• This constant level of low pressure suction is now transmitted to the underwater seal bottle and then into the pleural cavity, thus aiding evacuation of contents there, allowing a quicker reexpansion of the underlying lung. The maximum force of suction is determined by the depth of the atmospheric vent underwater in the suction regulation bottle.1 ▫ To obtain a suction of -20 cm of water, set the tip of the tube 20

cm below the surface of the fluid.▫ Now, increase the vacuum gradually until air bubbles gently and

constantly through the atmospheric vent in the water during both phases of respiration.

▫ A constant pressure of -20 cm of water is now transmitted to the underwater seal and on to the chest drain

• The role of suction is now being debated. Some schools of thought say suction delays the sealing of air leaks from the underlying lung.8

Positioning• Emergent and elective chest drains are

usually placed in the triangle of safety, an area delineated by the anterior border

of latissimus dorsi, the lateral border of pectoralis major, and a horizontal line

lateral at the level of the nipple, or about the 5th intercostal space. This

corresponds to an insertion area between the midaxillary and anterior axillary lines

at the level of the nipple The correct taping of the emerging chest

tube from the patient is with a "mesentry" fold of adhesive tape that

holds the tube to the trunk of the patient. This allows some side-to-side movement of the tube, prevents kinking of the tube as it passes through the chest wall, and

is far less painful to the patient than taping the tube directly to the chest wall

Multifunction chest drainage system

• The multiple bottles and numerous connections of the typical 3-bottle

system result in a bulky bedside device, which can be prone to

accidental disconnections and blocks in the system. In addition, sterility is

difficult to maintain in such a system.

• These systems, therefore, have been largely replaced by commercially

produced, disposable plastic multifunction units (eg, Codman, Pleurovac, Atrium) that fit into a

single box and work on the same principles

Chest drain multipurpose unit• Multifunction chest drainage systems

have been designed primarily for management of chest tubes after

cardiothoracic surgery and chest trauma

• Multichamber bottles are provided, incorporating both functional and safety

features. They combine patient protection with effective drainage,

accurate fluid loss measurement, and clear detection of air leaks

• The multifunction systems allow single or multicatheter drainage and are suitable

for both gravity-assisted and suction-assisted drainage. The unit has a latex-

free patient tube and a filtered water seal to prevent contamination

• Units with 3 or 4 chambers are also available, which provide 2 independent

collection chambers, an automatic positive pressure relief vent, and a filtered negative pressure valve.9

Chest drain multipurpose unit

• Each multifunction chest drainage system contains the following:

▫ Collection chamber: Fluids drain directly into this chamber, which is calibrated in mL

▫ Water seal: This is a one-way valve, U-tube design that can monitor air leaks and changes in

intrathoracic pressure ▫ Suction control chamber: This chamber is also a U-

tube; the narrow arm is the atmospheric vent, and the large arm is the fluid reservoir. The system is

regulated, and controlling negative pressure is easy. The suction chamber also helps monitor intrathoracic

pressure• For gravity drainage without suction, the level of water in

the water seal chamber equals the intrathoracic pressure For suction-assisted drainage, the level of water in the

suction control chamber plus the level of water in the water seal

chamber equals the intrathoracic pressure

Multifunction chest drainage system setup

• Follow the manufacturer’s instructions for adding water to the chambers. This is usually 2 cm in the water seal chamber and 20 cm in the suction control chamber• Connect the 6-ft patient tube to the thoracic catheter

• Connect the drain to vacuum• Slowly increase vacuum until gentle bubbling appears in the suction control chamber• Be sure not to allow too much bubbling in the suction control chamber

▫ Excessive bubbling is not needed clinically in 98% of patients ▫ Vigorous bubbling is loud and disturbing to most patients

▫ Vigorous bubbling also causes rapid evaporation in the chamber, which lowers the level of suction

Management of Chest Drains

Analgesia

• Chest drains are painful for the patient. Adequate analgesia (orally, rectally, or parenterally) helps the patient cooperate

better for the chest exercises and physiotherapy

• Patients whose chest tubes were inserted postoperatively or who have associated rib fractures need stronger forms of

analgesia, such as patient-controlled anesthesia (PCA) with diluted opioids or even an epidural catheter for direct delivery of

the analgesic medication

Breathing exercises and chest physiotherapy

• Breathing exercises and chest physiotherapy are the mainstays for the quick expansion of the lung.

• Incentive spirometry (eg, TriFlo incentive spirometer) gives the patient the impetus to expand the lung quickly

• Upper limb movements, especially at the shoulder, help restore the movements of the chest wall

• Steam inhalations and nebulized bronchodilators also encourage quick lung expansion


Nursing management

• Keep the patient in a propped-up position (ie, 45-90°)

• Check that all connections are secure▫ All joints must be well-taped with adhesive▫ A single layer of tape across the long axis of each joint holds better than

layers of circular tape over the joint. This prevents disconnection and the subsequent loss of the negative pressure

• Always ensure the correct position of the underwater seal bottle▫ The bottle should be erect and at least 100 cm below the level of the

patient’s chest▫ The tip of the glass tube that connects to the chest drain should be at

least 2 cm below the fluid level in the bottle (and not more than 7 cm below the fluid level)

• In addition to vital signs, the following items need to be monitored every 4 hours: ▫ Swinging or oscillation of the column of water in the glass tube

connected to the chest drain ▫ Blowing or air bubbling in drainage bottle with quiet respiration

and on coughing (Bubbling of air indicates that the lung is still leaking air. The cessation of bubbling during both quiet respiration and coughing indicates that the air leak in the lung has closed)

▫ Type and quantity of drainage (Inform physician if drainage is >100 mL/h or if frank blood)

• Never lift the drainage bottle above the level of the patient’s chest, as fluid from the bottle may siphon off into

the patient’s chest

• Keep 2 clamps (angled) at the bed side

Nursing management

• Do not clamp a bubbling chest drain ▫ All nursing procedures, patient movement, and physiotherapy

are permitted without clamping the drain.▫ Clamp tubes only for procedures related to the tube or bottle

(eg, to change the tube or bottle, to empty the bottle, to reconnect an accidental disconnection of the tube at any of the

joints)

• Avoid kinks in the tubes. Teach the patient to look for kinks and to avoid sitting or lying on the tubes

• "Milk" the tubes frequently to avoid blockage by fibrin plugs or clots

• Change the connecting tube and bottle at least once every 48 hours, and replace them with sterile equivalents. Wash

and disinfect equipment to remove all residue before sterilization

Nursing management

• Suction ▫ When suction is needed, it should be a constant low-pressure suction

to fully remove the pleural contents without causing pain to the patient.

▫ The recommended level of suction is -5 to -20 cm of water. (The measurement of -20 cm of water is based on convention, not

research.) ▫ Higher negative pressure can increase the flow rate out of the chest,

but it can also damage tissue Suction can improve the speed at which air and fluid are pulled from the

chest. However, recent research has shown that suction may actually prolong air

leaks from the lung by pulling air through an opening that would otherwise close on its own

• Radiography▫ Serial chest radiographs are needed to monitor and confirm the

expansion of the lung

• Antibiotics▫ Antibiotics are not needed during the presence of a chest drain for a

simple pneumothorax or hydrothorax ▫ The antibiotic cephalexin can be used to prevent the development of

an empyema when a chest drain has been used in thoracic trauma


Tube removal• Timing of tube removal

▫ The timing of tube removal depends on clinical and radiological evidence of complete expulsion of all contents of the pleural

cavity with complete expansion of the lung. Minimal drainage should have occurred over the previous 24 h (<25

mL/d) When the patient coughs or performs the Valsalva maneuver, no air

leak should ensue The chest radiograph should confirm complete expansion of the lung

The swing in the fluid level in the tube in the underwater seal bottle should be minimal, relating to the normal negative pressures in the

chest during the phases of respiration

▫ Generally, for pneumothorax, a trial period of tube clamping for 6 hours is done

A repeat chest radiograph is then taken. If this shows complete expansion of the lung, it confirms that the lung leak has sealed and

that a proper adhesion between the layers of the pleura has occurred The tube may be safely removed at that time

Tube removal

• Method of tube removal ▫ Tube thoracostomy removal is a sterile procedure that requires a

physician and an assistant▫ Before removal, give the patient a bolus dose of analgesia.

Infiltrating 5 mL of 1% lidocaine hydrochloride with a 24-gauge needle around the emerging chest drain can increase patient

comfort▫ Cut loose the securing stitch while the tube is being supported

▫ Free the mattress (sealing) stitch that was inserted and kept long at the time of tube insertion. If this stitch is not in position, place a vertical mattress stitch with strong suture material (NW 3397 of

Ethicon) across the center of the incision▫ Hold the ends of the mattress suture ready to tie a knot

▫ Instruct the patient to cease respiration in full expiration. Gently ease out the tube while simultaneously tying the knot to close the

track▫ Apply a soft dressing

▫ If the stitch breaks or cuts through, simply compress the oblique track and apply an occlusive dressing.9

• Follow-up radiography ▫ A chest radiograph is repeated 4 hours after the removal of the tube

thoracostomy▫ The results of this radiograph should confirm that no air has entered

the chest and that the lung continues to remain fully expanded

Tube removal

Pearls

• The underwater seal acts as a one-way valve through which air is expelled from the pleural space and prevented from

reentering during the next inspiration

• Retrograde flow of fluid may occur if the collection chamber is raised above the level of the patient’s chest. The collection

chamber should be kept below the level of the patient’s chest at all times to prevent fluid being siphoned into the pleural space

• Absence of fluid oscillations may indicate obstruction of the drainage system by clots or kinks, loss of subatmospheric

pressure, or complete reexpansion of the lung

• Persistent bubbling indicates a continuing bronchopleural air leak

• Clamping a pleural drain in the presence of a continuing air leak results in a tension pneumothorax

• The water seal is a window into the pleural space. It reflects the pressure in the pleural space and exhibits bubbling if air is

leaving the chest. In the multifunction chest drainage systems, a graduated air leak meter (graduated 1-5) provides a way to

measure the leak and monitor over time

Pearls

Troubleshooting chest drain management

• Column is not oscillating: If the column of fluid in the tube that connects the chest drain to below the water level in the drainage bottle is not oscillating, the tube has been

blocked. All efforts must be made to restore patency of the tube by squeezing, milking, and even flushing the drainage

tubing. Restoration of patency is confirmed by a respiration-related swing in the draining tube

• Tubes got disconnected: This is no great disaster. Reconnect the tubes and ask the patient to cough; any air

that has entered the chest is forced out

• Tube has been pulled out: If the tube has been pulled out, it needs to be repositioned. Using all sterile precautions,

position a new tube into the chest and secure it properly. The new tube should not be inserted through the same hole. A new thoracostomy is used, and the initial site is

sealed with a vertical mattress suture

• Leak around the tube: A leak around the tube indicates a partial block in the draining system. If all blocks have been

removed and the leak around the tube persists, a single suture may need to be placed along the side of the tube to

narrow the wound and seal the leak. Use of tapes and heavy dressings to occlude such leaks is not useful

• Underwater seal bottle broken: A broken bottle has to be replaced immediately with a fresh bottle with a 2-hole

stopcock, and the underwater seal must be recreated. Then ask the patient to cough. Any air that has entered the chest

is forced out

Troubleshooting chest drain management

Chest drain complications• Blocked tube due to poor positioning: Sometimes the tube

gets trapped in the major fissure of the lung. If this occurs, the tube needs to be withdrawn and reinserted

• Cardiac dysrhythmia: The tube may abut the mediastinum and occasionally cause cardiac irregularities. First, try withdrawing the tube 2-3 cm. If this does not resolve the problem, the tube may need to be reinserted at a separate location. Medical management of the arrhythmia is also needed

• Persistent pneumothorax: If a pneumothorax persists, check for obstructions or leaks. Clear any obstructions and seal any leaks in the drainage system. If no leak or obstruction is found, apply suction of up to -20 cm of water to the drainage system

• Failure of the lung to fully reexpand: This is rarely due to blockage of the tubes, and change of tubes seldom helps.

The common causes of nonexpansion of the lung are as follows:

▫ Bronchial blockage leading to collapse, usually by retained sputum (Fiberoptic bronchoscopy helps clear secretions and rule

out other causes of bronchial obstruction [eg, tumor].) ▫ The presence of a fibrinous "peel" (cortex) over the lung (This is

the thickened visceral pleura over the collapsed lung tissue and is usual in cases of delayed treatment of an empyema. A

decortication is the best way to deal with this problem)

• Infections: Infections occur rarely with chest drains but can range from wound infection to empyemas. They reflect

breaks in sterility and incorrect management of the chest drai

• Re-expansion pulmonary edema: This is also a rare chest

drain complication and is seen when large effusions are drained in a short period of time. It is best prevented by

gradual decompression

Chest drain complications

Frequently Asked Questions• What size chest drains should be used?

▫ Use as large a tube as will pass comfortably through the intercostal space. By rule of thumb, in an adult patient, 24-28F is adequate to drain air, but 32-36F may be necessary to drain fluid

• Can chest drains be clamped?

• Never clamp a bubbling drain, as the resultant pneumothorax can cause more problems to the patient. Check that all connections are secure, and then the patient can be subject to all nursing procedures, movement, and physiotherapy with no clamps on the drain.12

• When are chest drains clamped? Drains are clamped only in the following situations:

▫ When the draining tubes and underwater seal bottle are to be changed

▫ Just prior to tube removal, as a trial of clamping for 4-6 hours, to confirm that the air leak has stopped

▫ When reconnecting an accidentally disconnected tube that resulted in loss of the underwater seal

▫ If the drain is clamped, it should be unclamped as soon as possible by the same individual who put the clamp on. Clamps are sometimes overlooked when patients are handed over during shift changes of medical personnel. Clamps that are not removed lead to deterioration of the patient

• Can a patient with a chest drain inserted be moved? • Yes, patients with chest drains can be moved around as usual. All

connections have to be checked for security, and the underwater seal bottle has to be kept erect at a level of about 100 cm below the patient’s chest

Frequently Asked Questions


• What suction pressure should be applied?

▫ As a general rule, suction pressures need to be between -10 and -20 cm of water (-2 to - 3 kPa). While up to 25 cm of water suction pressure is needed for massive air leaks, 5 cm of suction pressure is sufficient to help drain fluid contents out of the chest

• How long should chest drains be left in?▫ Apposition of the 2 layers of the pleura is essential to seal air leaks

and reduce the drainage. All air leaks eventually stop if the lung can be kept fully expanded constantly. This usually occurs within a week, but it may take as long as 4-6 weeks

▫ If the air leak persists, the case needs to be reviewed by a thoracic surgeon. If significant discharge is evident, but the lung seems to be adherent, conversion to open tube drainage may be needed

• Do alternatives to underwater bottle drainage exist?

▫ Yes; artificially made one-way valve systems may be alternatives to underwater bottle drainage

• The flutter valve (Heimlich):

▫ This is a one-way system created with a plastic diaphragm, which allows air to escape from the chest and yet maintains expansion of the lung. It is attached to the chest drain and strapped to the patient’s side, allowing greater mobility of the patient. The flutter valve can be used for pneumothorax only


• The intercostal drainage bag:

This is a plastic bag built around a tube that reaches to

the bottom of the bag. The bag is then filled with fluid to the

prescribed level, and this acts as the underwater seal. The

tube, which is about 1 meter long, is connected to the

intercostal tube. This bag can now collect up to 200 mL of

drainage before the contents have to be drained and fresh

fluid poured in to recreate the underwater seal. The bag can

be strapped to the thigh of the patient and must always be

kept erect. If fluid is draining but air is not leaking, a simple Urosac can be attached to the

end of the intercostal tube