INTERCOSTAL DRAINAGE

1. Shilpasree Saha
Assistant Professor, NIHS

2.  Chest drains, also referred to as chest tubes, under
water sealed drainage (UWSD), thoracic catheter, tube
thoracostomy, or intercostal drain.
 Chest drains provide a method of removing air & fluid
substances from the pleural space.
 In consists of 3 component: gravity assisted drainage,
underwater seal and creation of pressure gradient.

3.  The idea is to create a one-way mechanism that will let
air/fluid out of the pleural space and prevent outside
air/fluid from entering into the pleural space.
 This is accomplished by the use of an underwater seal.
 The distal end of the drainage tube is submerged in
2cm of H2O.
 It uses flexible plastic tube which is inserted through
the chest wall and into the pleural space between the
5th and 6th intercostal space in the mid-axillary line,
venting the space which allows air back out.

4. Principles of underwater seal
drainage
 The underwater seal prevents air to re-enter the pleural space. Usually,
the distal end of the drain tube is submerged 2cm under the surface
level of the water in the drainage (or collection) chamber.
 This creates a hydrostatic resistance of +2cmH20 in the drainage
chamber.
 Normal intrapleural pressure is negative.
 However, if air or fluid enters the pleural space, intrapleural pressure
becomes positive.
 Air is eliminated from the pleural space into the drainage chamber
when intrapleural pressure is greater than +2cmH20.
 Thus, air moves from a higher to lower pressure along a pressure
gradient. The drainage chamber has a vent to allow air to escape the
chamber, and not build up within the chamber.
 Fluids will drain by gravity into the drainage chamber, and will not spill
back into the pleural space if the bottle is always kept below the level of
the patient's chest.

5. Types
 One bottle UWSD system
 Two bottle UWSD system
 Three bottle UWSD system
 All in one disposable
system are also used in
which one chamber collect
fluid, one chamber will
have under water seal to
allow air to escape from
chest, third chamber is
used to control suction .

7. Implications for physiotherapy
 Important expects of examination:
I. Swinging
II. Bubbling
III. Drainage
IV. Suction

8. Swinging
 Fluid in tube or water sealed chamber should move up
and down with respiration.
 5 cm of swinging is usual in UWSD and reflects
change in pleural pressure
 Quite breathing causes small swing
 Coughing or increased respiratory effort causes large
swing
 No swing represents occluded , obstructed,
compressed, kinked or detached tubing from pleural
space

9. Bubbling
 Presence of bubbling in underwater seal chamber
indicates air leak from pleural space
 Bubbling on coughing- mild air leakage
 Bubbling on expiration- moderate air leakage
 Bubbling through out inspiration and expiration-
severe air leakage
 Bubbling in suction chamber indicates suction is
applied correctly

10. Drainage
 When drainage is reduced to 100 ml over 24 hours, the
tube is usually removed.
 Large amount of blood drain over short period
indicates hemorrhage
 Large amount of haemoserous drainage indicates
hypovolaemia, hypotension, low Hb
 Drainage more than 100 ml per hour needs emergency
medical attention

11. Suction
 When wall suction is applied, it should result in gentle
bubbling only in suction chamber only.
 No bubbling indicates insufficient suction pressure.
 Vigorous bubbling does not mean increase suction ,
rather it will evaporate.

12. Persistent air leaks
 Air leaks fail to resolve before an expected length of
time
 Common complication of patients with emphysema
undergoing thoracic surgery and causes longer
hospital stay.


13.  If tubing become disconnected , it should be clamped
by hand close to patient