Surgical Drainage of plueral Cavity

1. PLUERAL CAVITY
DRAINAGE
SMS

2. WHAT ARE THE ISSUES ?
 When to put a drain
 Site of insertion
 Choosing the drain
 Drainage system
 Clamping the chest drain
 Time & method of removal
 Trouble shooting

3. INDICATIONS
Pneumothorax
 primary spontaneous ptx
Secondary spontaneous ptx
Tension ptx(after initial needle aspiration)
Malignant pleural effusion
Empyema and complicated parapneumonic pleural
effusion
Traumatic haemo pneumothorax
Postoperative,eg: after oesophageal, cardiac,
pulmonary,mediastinal or pleural surgery.
Treatment with sclerosing agents or pleurodesis

4. CONTRAINDICATION
 Lung adherent to the chest wall
 Uncorrected coagulopathy

5. SITE OF INSERTION ?
 Exact site depends on the location of abnormality.
 5th ICS in mid axillary line is the site used most often.
 Earlier it was believed that air can be drained only
through anteriorly placed tube in 2nd ICS in mid-
clavicular line.A tube placed too medially can injure
internal mammary artery causing serious haemorrhage.
 Experience has shown that a tube of proper
size,inserted through 5th ICS in mid axillary line can
drain effectively.

6. TRIANGLE OF SAFETY
Area bordered by the anterior
border of latissmus dorsi,the
lateral border of the
pectoralis major, a line
superior to the horizontal
level of nipple,with its apex
towards axilla
This is the usual site which
corresponds to the 5th or 6th
ICS in mid-axillary line

7. POSITION OF THE
PATIENT
 A chest tube can be inserted in supine,sitting or lateral
position.
 Most preffered is supine position,in which patient lies flat
on the bed,slightly rotated to the opposite side,with
ipsilateral arm behind her/his head.
 Patients who are breathless may be asked to sit upright in
the bed,leaning over a cardiac trolley with a pillow to place
their arms

9.  If chest tube is inserted to drain blood,pus or another fluid, the patient should
be seated when the tube is inserted to ensure that the diaphragm is in the most
dependent position and the fluid is collected in the lower part of the chest
 When chest tube is placed for pneumothorax,the patient should be in
recumbent position if anterior chest tube is placed, and should be in decubitus
position if an axillary tube is placed
 In case of loculated pathology it is good practice to do an USG or CT guided ICD.

10. MATERIALS REQUIRED
 Sterile gloves and gown
 Skin antiseptic solution, e.g. iodine or
chlorhexidine in alcohol
 Sterile drapes
 Gauze swabs
 A selection of syringes and needles (21–
25gauge)
 Local anaesthetic, e.g. lignocaine (lidocaine)
1% or 2%
 Scalpel and blade
 Suture (e.g. “1” silk)
 Instrument for blunt dissection (e.g.
curvedclamp)

11.  Guidewire with dilators (if small tube being used)
 Chest tube
 Connecting tubing
 Closed drainage system (including sterile water if
underwater seal being used)
 Dressing

13. GUIDEWIRE TUBE THORACOSTOMY
Easiest way to insert a chest tube.
Usually done under the guidance of either USG or CT.
This procedure uses the Seldinger technique with guide wires
& dilators.
Skin,periosteum and parietal pleura are anesthetized and
incision is made in skin
18 gauge needle attached to a syringe is introduced into the
pleural space. Fluid or air is aspirated to confirm the diagnosis.
Syringe is removed and J wire is threaded through the needle
in desired direction into the pleural space
Needle is then removed and smallest dilator is been inserted
with a rotating movement, it is advanced into pleural space.

14. The first dilator is removed leaving the wire in place.
Then the next size dilator is advanced over the guidewire
into the pleural space and removed.
Finally chest tube containing the inserter is been threaded
over the guide wire.
Once tube is in place inserter & guide wire are withdrawn.
Tube is then clamped until it is attached to chest drainage
system.
Tube is been anchored in place by means of purse string
suture.
Incision is sutured without tension to avoid necrosis of skin
Sterile dressing applied.

16. TROCAR TUBE THORACOSTOMY
Initially requires a 2-4cm incision parallel to superior border
of the rib through the skin and subcutaneous tissues after LA.
Trocar is inserted between the ribs into the pleural cavity,with
flat edge cephalad to prevent damage to intercostal vessels
The hand not applying force should be placed next to the
chest wall to control depth of penetration
Once trocar is in pleural space,stylet is removed and chest
tube with its distal end clamped is inserted into the pleural
space.
Tocar is then removed.

17. Alternate trocar method uses a chest tube
with a trocar positioned inside the tube
DISADVANTAGES
More chances for puncturing lung & other
vital organs.

19. OPERATING TUBE
THORACOSTOMY Most commonly practiced
 Patient should be given anxiolytic 10-15mins before the
procedure and liberal doses of LA be used.
 3-4cm incision is made in the skin parallel to the chosen
intercostal space. The incision should be made down to the
fascia overlying the intercostal muscle.
 Once fascia has been incised the muscle fibers are spread
with a blunt tipped hemostat
 Incision is then made in the intercostal fascia just above the
superior border of the inferior rib over which tube will pass
 Parietal pleura is then penetrated using blunt tipped hemostat

20.  Hole in the parietal pleura is then enlarged with
operators index finger
 Operator should then palpate adjacent pleural space to
detect any adhesions.
 Chest tube with its distal end clamped is then introduced
with help of a hemostat into the pleural space
 Tube is sutured in place(mattress sutures) as per BTS
guidelines
 Site is cleaned and sterile dressing applied

24.  ADVANTAGES
 Safer then other methods
 Adhesions between lung & chest wall can
be removed.
 DISADVANTAGES
 Insertion of tube ectopically

25. SINGLE PORT THORACOSCOPY
 Hopkins rod –lens telescope is loaded into the most proximal port of chest tube.
Under direct visualization the chest tube is placed into the costodiaphragmatic
gutter and scope is been removed & tube fixed.

26. HOPKINS ROD - LENS TELESCOPE

27. CHOOSING THE CHEST DRAIN.
SIZE MATTERS ??
MALIGNANT EFFUSION FOR
PLEURODESIS
SMALL BORE TUBES 10-14F
HEMOTHORAX 28-32F
PNEUMOTHORAX 8-14F(SUCCESS RATE OF 84-97%)
EMPYEMAS 24-28F

28. PLEURAL DRAINAGE SYSTEMS
– ONE WAY(HEIMLICH)VALVE
 this drainage system is by far the simplest
 Chest tube is attached to a one way flutter valve
assembly, which is constructed so that the flexible
tubing is occluded whenever the pressure inside the
tubing is less than atmospheric pressure & is patent
whenever the pressure inside the tubing is above the
atm pressure
 When pleural pressure and pressure in the tube are
negative flutter valve is closed and no air enters
pleural space.
 When pleural pressure becomes positive the tube is
patent and air or fluid can egress from pleural space.

30. ADVANTAGE
 It is a simple & renders freedom of the patient from a
bulky drainage apparatus
 Patients can be sent home with the flutter valve in place

31. ONE BOTTLE COLLECTION
SYSTEMConsists of one bottle that serves as both a
collection container and a water seal.
Chest tube is connected to a rigid straw
inserted through a stopper into a sterile
bottle
Enough sterile solution is instilled into the
bottle so that tip of the rigid straw is
approximately 2cms below the surface of
saline solution.
Bottles stopper must have a vent to prevent
pressure from building up when air or fluid
coming from pleural space enters the bottle.

32. When pleural pressure is positive,the pressure in the rigid straw
becomes positive,and if the pressure inside the rigid straw is
greater than the depth to which straw is inserted into the saline
solution,air(or liquid)will enter the bottle and will be vented to the
atmosphere(or collect in the bottle).
If the pleural pressure is negative,fluid will be drawn from the
bottle into the rigid straw and no extra air will enter the system.
Thus water in the bottle seals the pleural space from air or fluid
from outside the body

33. – ADVANTAGES:
– Easy to carry & works well for uncomplicated
pneumothorax
– DISADVANTAGES:
– If large amounts of fluid is draining from patients pleural
space level of fluid will rise in one bottle system and
therefore pressure will have to be higher & higher in the
rigid straw to allow additional air or fluid to exit from
pleural space
– If the bottle is inadverently placed above level of the
patients chest,fluid can flow back into the pleural cavity.

34. TWO BOTTLE COLLECTION
SYSTEMPreferred when substantial amounts of fluid is draining
from pleural space
With this system, bottle adjacent to the patient acts as a
collection bottle for drainage, and second bottle provides
the water seal and the air vent.
Degree of water seal does not increase as the drainage
accumulates.

35. SUCTION & THREE BOTTLE
COLLECTION SYSTEMS
 Applying negative pressure to the pleural space helps in facilitating reexpansion
of the underlying lung or to expedite removal of air or fluid from pleural space
 Suction at a fixed level, usually -15 to -20cm H2o,can be applied to the vent on a
one or two bottle collection system with an Emerson pump
 In this system, suction is poorly controlled.

36.  Controlled amount of suction can be
applied to a three bottle collection
system.
 A vent on suction control bottle is
connected to a vent on the water seal
bottle.
 Suction control bottle has a rigid straw.
Suction is connected to a second vent
on the suction control bottle.

37.  When suction is applied to suction control
bottle, air enters this bottle through it rigid
straw if the pressure in the bottle is more
negative than the depth to which straw is
submerged.
 Amount of negative pressure in the system is
equal to the depth to which rigid straw in the
suction control bottle is submerged below the
surface as long as bubbles are entering suction
control bottle through its rigid straw.

38. Air enters the suction control bottle from
the atmosphere while its rigid straw is
submerged at 20cm H2o.Thwe pressure in
the suction control bottle is -20cm H20.
Same pressure exists in water seal
bottle,since these two bottles are in direct
communication.The pressure in drainage
bottle is less negative than in other bottles
In this case depth of water seal is 2cm,so
pressure in the drainage collection bottle
and pleural space is --18cm H20.
Amount of negative pressure in the
system can be adjusted by changing the
position of rigid straw or depth of water in
suction bottle.

39. INTRINSIC NEGATIVE PRESSURE IN CHEST
TUBES
If the distance from patients chest to the top
of collection apparatus is 50cms and tube is
filled with liquid, there will be a negative
pressure of 50cm H2o in the pleural space if
no suction applied
Actual negative pressure applied to the
pleural space from the entire system is the
net vertical distance that the liquid occupies
the tube(A-B)minus the level of fluid in the
water seal(C) plus negative pressure applied
through suction(D).negative pressure in chest
is A-B-C+D
If there is no liquid in the tube, actual applied
pressure will be suction pressure minus the
depth of the water seal.

40. PLEUR EVAC UNIT
 The drainage system is
disposable,molded plastic unit
with three chambers
duplicating the classic three
bottle system

43. CHOICE OF DRAINAGE
SYSTEMCost
Indication of the chest drain
Type of patient
Water seal should be easily visualized
Tube should be functional when no suction is applied
Volume of collection chamber should be adequate and
markings should be such that drainage is easily
quantitated.
Pop up valve to provide safety if pressure builds up in
the system.

44. INJECTION OF MATERIALS THROUGH
CHEST TUBES
 Injection of a fibrinolytic or DNAase in a patient with a
loculated complicated parapneumonic effusion
 Tetracycline derivative or a different sclerosing agent
through the chest tube in patients with malignant pleural
effusion
 This is usually done by taking chest tube apart and
injecting material through a Toomey syringe.
 This procedure compromises the sterility of the system
and increases chances of pneumothorax.

45. THAL QUICK CHEST TUBE
ADAPTER This unit consists of two adapters
separated by flexible tubing with a
clamp.
 On the proximal end there is a
sideport with a short segment of
connecting tubing to which
attached a three way stopcock.
 When one wishes to inject
anything through the chest
tube,the tube is clamped and
material is injected through the
three way stop cock
 Indicated when a sclerosing or
fibrinolytic agent is been injected.

46. SECURING THE DRAIN
 Mattress suture
 1 zero mersilk
 Complicated “purse string” sutures must not be used as
they convert a linear wound into a circular one that is
painful for the patient and may leave an unsightly scar.A
suture is not usually required for small gauge chest tubes.

48. CHEST DRAIN DRESSING
 Large amounts of tape and padding to dress the site are unnecessary and
concerns have been expressed that they may restrict chest wall
movement or increase moisture collection.
 A transparent dressing allows the wound site to be inspected by nursing
staff for leakage or infection.
 An omental tag of tape has been described which allows the tube to lie a
little away from the chest wall to prevent tube kinking and tension at the
insertion site.

49. – Omental tag to support the tube
while allowing it to lie a little away
from the chest wall.

51. CLAMPING
 A bubbling chest tube should never be clamped.
 Drainage of a large pleural effusion should be controlled to prevent
the potential complication of re-expansion pulmonary oedema.
 In cases of pneumothorax, clamping of the chest tube should usually
be avoided.

52. BUBBLING CHEST TUBE-
DIFFRETIALS
– If tube is not inserted far enough into pleural space – one or more of holes in
chest tube will be outside pleural space
– Air enters from atmosphere
– In debilitated patients – with poor tissue turgor – negative pleural pressure will
cause air to enter pleural space around chest tube at insertion site
– Leaks in the system.

53. HOW TO DIFFERENTIATE- AIR
LEAKS
– Measuring the level of pco2 in the air coming from chest tube
– Collected in syringe – blood gas analyzer
– Pco2 >20mmHg (Bronchopleural fistula)
– Pco2 <10mmHg (Atmospheric air)

54.  If a chest tube for pneumothorax is clamped, this should be under
the supervision of a respiratory physician or thoracic surgeon, the
patient should be managed in a specialist ward with experienced
nursing staff, and the patient should not leave the ward
environment.
 If a patient with a clamped drain becomes breathless or develops
subcutaneous emphysema, the drain must be immediately
unclamped and medical advice sought.

55. COMPLICATIONS
 Injury to the neurovascular bundle in the ICS
 Injury to lung parenchyma
 Injury to diaphragm and consequent injury to
intraperitoneal structures may occur
 Injury to heart and other vessels
 Massive bleeding
 Re expansion pulmonary oedema due to rapid
evacuation of fluid from the pleural cavity
 Empyema
 Skin excoriation and inflammation
 Subcutaneous emphysema & subcutaneous haematoma

57. REMOVAL OF THE DRAIN
 Original indication
 Clinical progress
 Daily drainage should be <100ml.
 There should be no air leak
 No fresh or altered blood should be draining from chest tube
 Radiological status-lung should be fully expanded.
 End expiration/valsalva

58. REPOSITIONING CHEST
DRAINS
 Use imaging assistance
 Avoid pushing & pulling drains
 Best is a fresh insertion
 Avoid a previous site, choose a new one

59. Procedure for chest tube removal
 Gather supplies and explain procedure to patient
 The clinician will remove the dressing and sutures
 During peak exhalation, the clinician will remove the chest tube in one quick
movement
 Immediately apply a sterile gauze dressing containing petroleum to prevent
air from entering pleural space
 Monitor patient’s respiratory status
 Arrange for chest X-ray to confirm lung reexpansion
 Monitor patient’s respiratory status and SpO2 for 1-2 hours after removal

60. PATIENTS REQUIRING ASSISTED
VENTILATION
 During the insertion of a chest tube in a patient on a high
pressure ventilator (especially with positive end
expiratory pressure (PEEP), it is essential to disconnect
from the ventilator at the time of insertion to avoid the
potentially serious complication of lung
penetration, although as long as blunt dissection is carried
out and no sharp instruments are used, this risk is
reduced.

62. RECOMMENDATIONS FOR SAFE PRACTICE
OF CHEST DRAIN INSERTION
1. Site: safe triangle in the midaxillary line
2. Imaging to be used to select appropriate site of insertion
3. USG guided insertion can ensure safety placement
4. Do not use substantial force
5. Small bore drains to be placed under imaging guidance
with a guide wire(dissection not required)
6. Blunt dissection for large tube bore
7. CXR available at time of insertion except in case of tension
pneumothorax
BTS GUIDELINESS