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Chest drains and thoracotomy

  • Chest drain is a conduit to remove air or fluid from the pleural cavity
  • The fluid can be blood, pus or a pleural effusion
  • Allows re-expansion of the underlying lung
  • Must prevent entry of air or drained fluid back into the chest
  • A chest drain must therefore have three components
    • An unobstructed chest drain
    • A collecting container below chest level
    • A one-way mechanism such as water seal or Heimlich valve

Indications for chest drain insertion

  • Pneumothorax
    • In any ventilated patient
    • Tension pneumothorax after initial needle insertion
    • Persistent pneumothorax after simple aspiration
    • Large spontaneous pneumothorax in patients over 50 years
  • Malignant pleural effusion
  • Empyema and complicated parapneumonic pleural effusion
  • Traumatic haemopneumothorax
  • Post thoracotomy, oesophagectomy and cardiac surgery

Mechanism of action

  • Drainage occurs during expiration when pleural pressure is positive
  • Fluid within pleural cavity drains into water seal
  • Air bubbles through water seal to outside world
  • The length of drain below fluid level is important
  • If greater than 2-3 cms increases resistance to air drainage

Principles of a chest drain

Insertion

  • Unless emergency situation then pre-procedure chest x-ray should be performed
  • Drain usually inserted under local anaesthesia using aseptic technique
  • Inserted in 5th intercostal space in mid-axillary line
  • Inserted over upper border of rib to avoid intercostal vessels and nerves
  • Blunt dissection and insertion of finger should ensure that pleural cavity is entered
  • Used to be taught that:
    • To drain fluid it should be inserted to base of pleural cavity
    • To drain air it should be inserted towards apex of lung
  • Probably does not matter provided there is no loculation of fluid within pleural cavity
  • A large drain (28 Fr or above) should be used to drain blood or pus
  • Drain should be anchored and purse-string or Z-stitch inserted in anticipation of removal

chest drain

Does and don'ts of chest drains

  • Avoid clamping of drain as it can result in a tension pneumothorax
  • Drain should only be clamped when changing the bottle
  • Always keep drain below the level of the patient
  • If lifted above chest level contents of drain can siphon back into chest
  • If disconnection occurs reconnect and ask patient to cough
  • If persistent air leak consider low pressure suction
  • Observe for post-expansion pulmonary oedema

Removal

  • Remove drain as soon as it has served it purpose
  • For a simple pneumothorax it can often be removed within 24 hours
  • To remove drain ask patient to perform a Valsalva manoeuvre
  • Remove drain at the height of expiration
  • Tie to pre-inserted purse-string or Z-stitch
  • Perform a post-procedure chest x-ray to exclude a pneumothorax

Complications

  • "There is no organ in the thoracic or abdominal cavity that has not been pierced by a chest drain."
  • Early complications
    • Haemothorax
    • Lung laceration
    • Diaphragm and abdominal cavity penetration
    • Bowel injury in the presence of unrecognised diaphragmatic hernia
    • Tube placed subcutaneously
    • Tube inserted too far
    • Tube displaced
  • Late complications
    • Blocked drain
    • Retained haemothorax
    • Empyema
    • Pneumothorax after removal

Thoracotomy

  • A surgical incision into the chest
  • Used to gain access to thoracic organs
  • Approach depends on procedure planned

Anterior incision

  • Principle option is anterior thoracotomy
  • Used for:
    • Access to right middle lobe
    • Partial pericardectomy
  • Provides poor access for pulmonary and oesophageal resections

Lateral incisions

  • Options include:
    • Axillary thoracotomy
    • Lateral (muscle-sparing) thoracotomy
    • The 'French' incision
  • Used for access to mediastinum

Posterior thoracotomy

  • Option include:
    • Posterolateral thoracotomy
    • Posterior thoracotomy
  • Used for:
    • Pneumonectomy
    • Oesophageal surgery
    • Tracheal surgery

Bibliography

Laws D,  Neville E,  Duffy J et al.  BTS guidelines for the insertion of a chest drain.  Thorax 2003;  58(Suppl 2):  53-59.

Parry G W,  Morgan W E,  Salama F D.  Management of haemothorax.  Ann R Coll Surg Eng  1996;  78:  325-326.

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