Вы находитесь на странице: 1из 8

41

CHEST TUBES AND WATER SEAL DRAINAGE


P. Nandi
University Queen Mary Department Hospital of Surgery

Chest tubes and bottles are some of the simplest devices used in the practice of medicine. Yet they are often misunderstood, sometimes misused and are a mystery to medical students, nurses and some practising doctors. An outline of the indications of their use will be given and consider some of the problems that may arise. Aim of chest drains is to evacuate air, fluid, pus or blood from the pleural space effectively and as quickly as possible.
Dangers of Collection in the Pleural 1. Pneumothorax: Space

Free air in the pleura is absorbed into circulation within a few days unless new air is added. But excessive air within the chest occupies space and restricts lung expansion resulting in reduction of lung function and causing dyspnoea. Any pneumothorax occupying twenty percent or more of the hemithorax should be drained. If a tension penumothorax develops, patients life may be in danger 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. This restricts Iung expansion leading to decrease in pulmonary function. Tension pyothorax may develop and the patient may be acutely ill from septicaemia and respiratory distress. 4. Haemothorax: Blood in pleural cavity can be absorbed provided it is not excessive in amount, clotted or infected. Massive haemothorax will cause shock and respiratory embarrassment.
Water Seal (Fig. 1 & 4)

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 is done by connecting the chest drain to a glass straw which is immersed under saline contained in a bottle. Expiration then forces the air and fluid into the bottle, but air cannot reenter the submerged tube tip. Saline will be lifted a few centimeters up the tube by negative inspiratory intrathoracic pressure, but not up to the bed level from the floor. The flow of air or fluid out of the hemithorax must be unimpeded. The following can significantly restrict air and fluid evacuation from the chest tube and lead to dyspnoea, lung collapse, embarrassment of circulation and death. A full bottle with glass straw tip deep under the fluid surface. a. Too narrow or too soft tubing may spontaneously kink or b. collapse 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. An obstructed or small size air vent permits pressure to build up C. in the chest bottle. Any fluid in a dependent loop of tubing will obstruct flow and d. 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 space in the chest because these have a considerable air capacity and may obstruct evacuation of air or fluid during expiration, Infants pleural cavity cannot absorb enough air from the large tube and straw or blow enough air to-get negative 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 postoperative infant is somewhat controversial. Some centres advocate removal of intrapleural catheter on mild suction while lungs are being inflated by the anaesthetist at the end of thoracotomy. Others use a smaller water seal apparatus. This is safer as it permits drainage of fluid and air that may collect during the postoperative period. Infants chest drain straw generally shows a high fluid level and minimal fluctuation. Drains following Chest Surgery 1. Lung Resections After operations involving removal of part or parts of lung, two drains must be inserted in the chest. The apical drain which reaches the apex of the hemithorax is meant for drainage of free air. The basal drain is placed in the lower part of the chest with the last hole above the level of the dome of diaphragm and it drains out fluid or blood that may

CHEST TUBES AND WATER SEAL DRAINAGE

43

collect. Both drains should be placed anterior to the midaxillary line. If a drain is placed behind this line, the patient will lie on it which causes discomfort to him and may block it. Two drains are also necessary after transthoracic oesophageal resection. 2. Pneumonectomy Only one basal drain is necessary after pneumonectomy. 3. Operations other than Lung Resection e.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 vertical sternotomy and in most cases, pleura is not opened. Under these circumstances, two drains (an upper and a lower) are left in the anterior mediastinum, the upper one reaching the back of manubriau sterni. If a pleura is accidentally opened an additional drain is inserted in to the chest from the lateral chest wall. Chest Tube Suction Use of suction to chest bottles is somewhat controversial. Many surgeons 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 suction device used cannot maintain negative pressure in the bottle throughout all phases of respiration and coughing. When properly applied, chest tube suction is very useful. If there is any doubt about the efficacy of the suction device, it is safer not to use it. It is important to remember that use of suction on water seal drain is never life saving. There are different ways of applying suction to chest bottles. Thoracic pumps, e.g. Roberts Pump, are connected directly to the air vent of the water seal bottle. Wall suction is usually applied through a three or two bottle system (Fig. 5). Conditions where Chest Tube Suction is Useful A. Pneumothorax (i) When a patient has a large air leak - with small multiple leaks suction may promote healing by drawing the leaking areas against other lung and chest wall surfaces. There is a slight danger that some air leaks could be kept open by excessive early suction on a small or inelastic residual lung. (ii) A persistent small air leak or an unusually large one for the situation being dealt with suggest some leak in the water seal system, e.g. a cracked or loose connector, a leaky rubber tube or a glass straw which is not long enough to enter the water seal

THE BULLETIN

OF THE HONG KONG MEDICAL

ASSOClATlON

VOL. 29, 1977

system during negative inspiratory pressure resulting in persistent partial lung collapse. If such air leak cannot be easily occluded chest bottle suction should be applied. Pleural Effusion or Haemothorax B Suction is routinely applied to drain out fluid or blood from the chest as quickly as possible. After Open Heart Operations C. Suction is applied immediately to evacuate the blood as quickly as possible so that it does not get a chance to clot inside. Blood clots inside will block the drain and also cause increased fibrinolysis which in turn will provoke more bleeding. The clotted blood may also cause postoperative cardiac tamponade. To ensure patency, the chest drains should be milked as frequently as necessary. Suction is never applied to a chest drain in a patient who has a pneumonectomy. Suction on chest drain in pneumonectomy patient will cause mediastinal shift resulting in cardiorespiratory embarrassment which may be fatal if not corrected immediately. Care and Removal of Chest Drains Never Clamp Chest Tubes except in Two Conditions 1; (a) In a pneumonectomy patient, the chest drain is usually kept clamped because removal of a lung leaves an empty space filled with air or air and fluid. This empty hemithorax is subject to considerable pressure variation with respiration and especially with cough. Such sudden pressure changes can cause significant mediastinal oscillation and cardiac arrhythmia. The pressure change can also result from a siphon effect if the tube is opened while submerged in pleural fluid. The siphoning can be avoided by raising the chest bottle to bed level before unclamping the tube, with simultaneous venting of air into the tubing by a hollow needle to drain all fluid from the tube into the bottle, thus breaking the siphon. The chest tube is usually unclamped for a few minutes every hour; Eventually by fibrosis and contraction the mediastinum, diaphragm and ribs surrounding the residual pneumonectomy space becomes relatively immobile. (b) When the drainage bottle or bottles have to be raised to level of the patient, e.g. while moving a patient from bed to trolley or vice versa, the chest tubes must be unclamped as soon as the process of lifting the patient has been completed especially if there is an air leak. If the tubes are kept clamped or forgotten to be released while being transported the patient may develop tension penumothorax and be in serious trouble. This situation

CHEST TUBES AND WATER SEAL DRAINAGE

2.

often arises when a patient suffering from persistent spontaneous pneumothorax is being taken to operating theatre for surgery. It is extremely dangerous to clamp the chest tubes or worse still to remove them before sending such a patient to the operating theatre. The chest tube and the water seal drain must be left in situ under these circumstances. This cannot be emphasised too strongly. Amount of Drainage

Daily 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 chest fluid drainage. When the fluid level in the bottle rises several centimeters above the tip of the straw the bottle should be changed especially if there is air leak, as back pressure may develop under these conditions. Milking of Tubes 3. Milking will expel tissue or clot from the chest tube and this will permit better drainage. Small clots that may be pushed back into the chest can be absorbed. Special devices are available for effective milking. If these are not available, tubes can be milked by using two clamps applied down the tube in succession. Hard plastic tubes are difficult or impossible to milk. Foaming Problem 4. Foaming 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 by adding ethanol in the bottle from time to time. Removal of Chest Drains 5. Chest tubes can be taken out when the following conditions are satisfied. (a) Air leak (bubbling) has stopped for over twenty-four hours. (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 effusion or after chest surgery. It may be two to six days before these conditions are met. But it is desirable to have most chest surgical patients walk On second postoperative day. The bottles on wheels will facilitate ambulation of the patients. A chest tube in a pneumonectomy patient is usually removed in twenty-four to forty-eight hours. It is important to avoid formation Of a fistulous fluid track to skin. Therefore, the drain site after removal of the tube should be stitched. The drain site should also be stitched in a child below twelve years of age.

THE BULLETIN

OF THE HONG KONG MEDICAL

ASSOCIATION

VOL. 29, 1977

LEGENDS
Figure 1 : Water 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 to stabilise the straw, It should be air tight if suction is to be applied. Bottle size - 1 L or 2L (for postoperative cases), smaller in children.

I-

DRNIAGE DO NOT I

FIGURE

CHEST TUBES AND WATER SEAL DRAINAGE

47

Figure

2 : There must be no dependent

loop with

fluid

in it.

Figure

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

FIGURE

48

THE BULLETIN

OF THE HONG KONG MEDICAL

ASSOCIATION

VOL. 29,1977

Figure 4 : Chest drain wrongly connected to the air vent instead of to the under saline straw. Result - vigorous bubbling and the bottle 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.
WALL SUCTION VACUUM BREAKER STRAW -

BOTTLE VACUUM BREAKER BOTTLE (NO. 2) WATER SEAL BOTTLE (NO. 1)

(NO. 3)