Chest drains are used to drain fluid, air or blood from the pleural space between the lungs and chest wall. Indications include pneumothorax, pleural effusions, and trauma. Proper placement requires sterile technique and imaging guidance. Chest drainage systems use water seals and suction to remove fluid while preventing re-entry of air into the chest. Patient care involves monitoring drainage, lung re-expansion and preventing complications like infection. Tubes are typically removed once drainage decreases and lungs are fully re-expanded.

1. CHEST DRAINS Presenter: Dr.Nishad.P.K Moderator :Prof: Lokesh AIIMS , NewDelhi

2. Anatomy Pleural fluid separates parietal and visceral pleural surfaces Amount of pleural fluid in 24 hrs:0.3ml/kg or 25 ml Natural tendency of lung to recoil v/s adherence of pleura Negative intrapleural pressure keeps the lung expanded during inspiration :-8cmH2O expiration:-4cmH2O Air, fluid or blood in pleural cavity disruption of –ve IPP leads to lung collapse Lung Visceral pleura Parietal pleura

3. Physiology Inspiration Expiration

4. Indications Emergency Pneumothorax Tension ptx after needle decompression Pt on MV Large Clinically unstable Recurrent/persistent Secondary to chest trauma Iatrogenic Traumatic hemopneumothorax Esophageal rupture Nonemergency Malignant pleural effusion Tx with sclerosing agents or pleurodesis Recurrent PE Parapneumonic effusion or empyema Chylothorax Postop care (eg: after esophageal, cardiac,pulmonary,mediastinal or pleural) Post pneumonectomy bronchopleural fistula

5. Pleural effusion

6. Pre-drainage risk assessment Careful clinical evaluation Differentiate between Pneumothorax and bullous disease Collapse and pleural effusion Risk of hem/g: correct any coagulopathy /platelet defect Contraindications Absolute Lung completely adherent to chest wall Relative Bleeding diathesis Pt on anticoagulants

7. Pneumothorax Lung bulla

8. Chest drainage systems Goals Remove the fluid and/or air as quickly as possible Prevent drained air and/or fluid from re entering the chest cavity Re expand the lungs and restore normal negative intra pleural pressure Components Chest tube Flexible patient tubing Drainage system made up of three compartments collection chamber water seal chamber suction control chamber

9. Chest tubes 20 inches long,4-6 eyelets, radio opaque line Three types 1.Thoracotomy chest tube- Straight, right angled Silicon / PVC 2.Trocar chest tube (2-3 eyelets) 3.Malecot catheter

10. Chest tubes

11. Chest tube size Size : Infants and young children :8-12 F Children and young adults:16-20 F Most adults :24-32 F Large adults : 36-40 F Diameter depends on Size of pt Type of drainage (air/fluid) Duration of drainage

12. Patient tubing 6 foot tube connects chest tube to collection chamber Clear ,flexible and sufficiently strong Adv: 1. pt can turn and move in bed 2.minimize the chance that a deep breath could draw drainage back up into chest b c a a b c

13. Physics and physiological aspects Flow depends on 1.Length of tube 2.Inner diameter of tube 3.Amount of negative pressure applied Air : laminar flow :Hagen–Poiseuille equation V = π R 4 Δ P/8 η L Hydropneumothorax : Turbulent flow : Fanning equation V = π 2 r 5 P/fl

14. One bottle chest drainage system Water seal –low resistance one way valve Positive pressure > +2cm H2O Tidalling –pressure changes in the pleural space with breathing seen as fluctuations Combination of water seal and fluid collecton bottle Tube from patient Tube open to atmosphere vents air

15. Physics and physiological aspects Distal end of drainage tube 2 cm below water ( the depth determines the hydrostatic pressure needed to overcome during expiration ) Collection chamber always 100 cm below the chest ( to prevent the chamber fluid getting sucked up the tube during obstructed inspiration) Large diameter collection chamber (20 cm diameter) ( to prevent loss of under water seal as water moves up the drainage tube during deep inspiration)

16. Two bottle chest drainage system Collection bottle and water seal Amount and rate of fluid drainage can be measured Water seal remain fixed Rely on gravity to create pressure gradient Tube from patient Tube open to atmosphere vents air 2cm fluid Fluid drainage

17. Three bottle chest drainage system Straw under 20cm H2O Tube to vacuum source Tube open to atmosphere vents air Tube from patient Fluid drainage

18. Contd.. The depth of the water in the suction bottle determines the amount of negative pressure that can be transmitted to the chest, NOT the reading on the vacuum regulator Expiratory positive pressure from the patient helps push air and fluid out of the chest (cough, Valsalva) Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest Suction can improve the speed at which air and fluid are pulled from the chest

19. Draw backs of three bottle system Bulky with 16 pieces and 17 connections Lot of time to set up Potential for error or contamination high Expense for hospital to clean ,sterilize and track the processing

20. Disposable chest drainage systems In 1967, a one-piece, disposable plastic box was introduced The box did everything the bottles did – and more Compact, sterile and disposable Chambers corresponds to bottle in three bottle system

21. From bottles to a box To suction From patient Suction control chamber Water seal chamber Collection chamber from patient Collection bottle Water seal bottle Suction control bottle

22. Contd… Collection chamber :Amount and rate of fluid drainage Water seal chamber :Asymmetric u tube,one way valve,used to measure IPP Dry seal chest drain: mechanical one way valve Suction control chamber: protect the pt from excess suction pressure wet: regulate by height of column of water dry: mechanical screw type valve: varies the size opening to vaccum source calibrated spring loaded self regulating mechanism Positive pressure relief valve-that vent accumulated pressure >2cmH2O

23. Heimlich valve Mechanical one way valve Allow air to escape from chest and prevent air from entering chest Adv : Does not require water to operate Not position sensitive Early ambulation of the patient Disadv : Less patient assessment information Cannot see changes in IPP

24. From box to bedside

25. Our drainage systems a b c d

26. Setting up a chest drain system Thoracostomy Setting up a drainage unit Making proper connecting and applying suction

27. Equipments Sterile gloves and gown Skin antiseptic solution Sterile drapes Gauze swabs Syringes and needles Local anesthetic Scalpel and blade Suture (“1” silk) Dressing Curved Kelly clamps

28. Equipments Chest tube Connecting tubing Closed drainage system

29. Patient preparation Explain the procedure Informed written consent Verify the site of abnormality Mark the site on patient’s chest Premedication Monitor O2 saturation and supplemental O2

30. Patient position Supine ,slightly rotated with arm on side of lesion behind patient’s head to expose the axillary area Or sit upright leaning over an adjacent table with a pillow Or lateral decubitus position

31. Insertion site Triangle of safety(in mid axillary line) - 4 th or 5 th ICS Ant.border of latissimus dorsi Lateral border of pectoralis major Line superior to horzontal level of nipple Apex below axilla Midclavicular -2 nd ICS Thick pectoralis major –difficult to penetrate Scar-cosmetic

32. Direction of tube Air :anterior and superior (towards apex) Fluid :posterior and inferior (towards base) Surgical Any tube position can be effective at draining air or fluid and an effectively functioning chest tube should not be repositioned solely because of position in CXR

33. Procedure Strict aseptic technique Skin preparation

34. Procedure contd..

37. Suturing and sterile dressing

38. Improper chest tube fixation

39. Get a CXR done

40. Complications Wound infection Empyema Infective Drain failure(dislodgement,kinked,blocked) Re expansion pulmonary edema Bronchopleural fistula pneumothorax Positional Pain Placement outwith pleural cavity-( s/c,intra abdominal,solid organ) Puncture of solid organ (liver,spleen,heart,lung,oesophagus) Puncture of inter costal artery- hemothorax Insertion on incorrect side Inter costal neuralgia S/C emphysema Insertional

42. Patient care Respiration Rate, regularity, depth and ease Breath sounds Deep breaths and cough Splintage of thoracic incision with pillow Knowledge level Pain control Vital signs Patient position/movement Encourage movement Gravity drainage v/s suction If discontinued from suction tube should be open to air

43. Patient care (contd …) Keep drain below level of chest High or semi fowler’s position Avoid dependent loops in pt tubing Chest tube should not be clamped during patient movement ambulation or trips Clamp only to : Locate air leaks Simulate tube removal Replace a drain Connect and disconnect an inline auto transfusion bag Milking with caution

44. Patient care Chest tube site/dressing Dressing dry and intact Palpate for s/c emphysema If present ,take down the dressing and inspect site, look for the eyelets. Tubing Regular inspection for leaks, kink, dependent loops compression/occlusion Drain fluid Samples Monitor volume, rate, colour and characteristics

45. Patient care (contd…) Water seal Water seal is filled to appropriate level Water level moves on patient breaths ( tidalling ) If no : Kinked, clamped, lying on tubing Dependent fluid filled loop Lung tissue or adhesions are blocking the eyelets No more air leaking to pleural space and lung has re-expanded To locate air leaks Suction :check connections and tubing typical suction level: -15 to – 20 cmH2O

46. Timing of chest tube removal Depends on indication Pneumothorax Bubbling movement has ceased Lung fully expanded in CXR Controversial: Duration of observation Clamping the tube Get CXR 12-24 hrs after last air leak Pleural fluid drainage Volume < 100 ml in 24 hrs Serous fluid Lung re expanded and clinical status improved No fresh or altered blood coming out of chest tube

47. Removing the chest tube Explain the procedure to the patient Prevent risk of pneumothorax End expiration v/s end inspiration If on MV :End expiration Two people – Instruct the patient and pull the tube _ Occlude the insertion site Tighten the suture and occlusive dressing CXR 12 -24 hrs after removal

48. Removing the chest tube

49. Looking towards future-mobile chest drains Facilitate early ambulation Reduce hospital stay Air alone-oneway valve:Heimlich valve For both fluid and air :mini chest drain