It is a minimally invasive procedure in which a thin plastic tube is inserted into the pleural space.
It is also inserted between the chest wall and the lungs and can be attached to a suction device to remove excess fluid or air.
A chest tube can also deliver medications into the pleural space.
The name thoracostomy also knows it. It is used to remove air (pneumothorax) fluid (pleural effusion, blood, chyle) or pus (empyema) from the intrathoracic space, allowing the expansion of the lungs and the restoration of pressure negative in the thoracic cavity.
Appropriate chest drainage management is required to maintain respiratory function and hemodynamic stability. Chest drains can be routinely placed in the operating room or the emergency department and ward areas in emergencies.
Therapy for pleural space fluid and air accumulation can be daunting for those unfamiliar with stabilizing patients with pleural space disease. It requires identification that pleural drainage is necessary and, in some cases, rapid intervention.
History of pleural drainage
The concept of chest drainage or pleural drainage was first advocated by Hippocrates when he described the treatment of empyema by incision, cauterization, and insertion of metal tubes.
However, the technique was not widely used until the 1917 influenza epidemic to drain postpneumonic empyema, which was first documented by Dr. C. Pope in “Joel,” a 22-month-old baby.
The use of chest tubes in postoperative chest care was reported in 1922, and they were used regularly after thoracotomy in WWII. However, they were not routinely used for emergency tube thoracostomy after acute trauma until WWII. Korea.
Pneumothorax: A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall.
Symptoms generally include a sudden onset of sharp, one-sided chest pain and shortness of breath.
In a minority of cases, the amount of air in the chest increases when a one-way valve forms through an area of damaged tissue, leading to a tension pneumothorax.
This condition can cause a progressive worsening of oxygen shortage and low blood pressure.
Unless reversed by effective treatment, it can cause death. Very rarely can both lungs be affected by a pneumothorax?
Pleural effusion: Pleural effusion, also called water in the lung, is an excessive accumulation of fluid in the space between the lungs and the chest cavity.
The thin membranes, called the pleura, cover the outside of the lungs and the inside of the chest cavity. There is always a tiny amount of fluid within this lining to help lubricate the lungs as they expand within the chest during breathing.
Certain medical conditions can cause a pleural effusion. It is a severe condition associated with an increased risk of death.
Chylothorax: A chylothorax (or chyle leak) is a pleural effusion. It results from lymph formed in the digestive system called chyle that accumulates in the pleural cavity due to an interruption or obstruction of the thoracic duct.
Empyema: An empyema (from the Greek ἐμπύημα, “abscess”) is a collection or accumulation of pus within a naturally existing anatomical cavity. For example, pleural empyema is an empyema of the pleural cavity.
Hemothorax: A hemothorax is a pleural effusion in which blood collects in the pleural cavity. The term is heme (blood) in the chest.
If left untreated, the condition can progress to a point where a pool of blood begins to put pressure on the mediastinum and trachea, effectively limiting the amount that the heart’s ventricles can fill.
The condition can cause the windpipe to deviate or move to the unaffected side. When treated, the prognosis is usually excellent if it is traumatic, and if it is adequately treated, the patient has a perfect chance of survival.
An exception is if it was caused by an aortic rupture, which is a surgical emergency and usually fatal.
Hydrothorax: it is a type of pleural effusion in which the transudate accumulates in the pleural cavity.
This condition is more likely to develop secondary to congestive heart failure following increased hydrostatic pressure within the lungs. More rarely, hydrothorax can develop in patients with cirrhosis or ascites.
Hepatic hydrothorax is often challenging to manage in end-stage liver failure and is often unresponsive to therapy.
Devices used for pleural drainage
Tube pleural drainage is a standard procedure in which a line is placed through the chest wall into the pleural cavity primarily to drain air or fluid. Still, the tube can also instill agents to induce pleurodesis or treat empyema.
After esophagectomy, conventional drainage of the pleural cavity involves one to two large-bore drainage tubes connected to underwater bottles. After a transthoracic esophagectomy, vacuum drainage is an alternative to the traditional large-bore chest tube system.
Chest tubes are commonly made of transparent plastics such as PVC and soft silicone. Chest tubes are manufactured in various sizes measured by their outer diameter from 6 Fr to 40 Fr.
Chest tubes, like most catheters, are measured on a French catheter scale. For adults, 20 Fr to 40 Fr (6.7 to 13.3 mm OD) are commonly used, and 6 Fr to 26 Fr for children.
Conventional chest tubes feature multiple drainage fenestrations in the line section within the patient, distance markers along with the box, and a radiopaque stripe delimiting the first drainage hole.
Chest tubes are also provided in right angle, trocar, flare, and tapered for different drainage needs. Also, some chest tubes are covered with heparin to help prevent thrombus formation, although this effect is controversial.
The chest tube has an end port (proximal, toward the patient) and a series of side ports. The number of side holes is generally six on most chest tubes.
The tube length with side holes is the effective drain length (LDE). In chest tubes designed for pediatric cardiac surgery, the effective drainage length is shorter, usually having only four side holes.
Channel-style chest drains, also called Blake drains, are so-called Silastic drains made of silicone and feature open grooves that reside within the patient.
Drainage is believed to be achieved by capillary action, allowing fluids to travel through the open slots in a closed cross-section, containing the liquid and allowing suction through the tube.
Although these chest tubes are more expensive than conventional ones, in theory, they are less painful.
Chest drainage system
Generally, a chest drainage system collects chest drainage (air, blood, effusions). Most commonly, drainage systems use three chambers based on the three-bottle system.
The first chamber allows fluid that drains from the chest to collect. The second chamber functions as a ‘water seal,’ which acts as a one-way valve that allows gas to escape but not re-enter the hood.
Air bubbling through the water seal chamber is standard when the patient coughs or exhales but may indicate, if continuous, a pleural or system leak that needs to be critically evaluated.
It can also indicate an air leak from the lung. The third chamber is the suction control chamber. The height of the water in this chamber regulates the negative pressure applied to the system.
Gentle bubbling through the water column minimizes evaporation of the fluid and indicates that the suction is being regulated at the height of the water column. In this way, the increase in wall suction does not increase the negative pressure of the system.
Newer drain systems eliminate the water seal with a mechanical check valve, and some also use an automatic regulator to regulate suction pressure.
Systems that employ both are called “dry” systems, while systems that retain the water seal but use a mechanical regulator are called “wet-dry” systems.
Systems that use a water seal and a water column regulator are called “wet” systems. Dry systems are advantageous as effluents from wet systems can spill and mix with blood, requiring the replacement of the system.
Even the newer systems are smaller and more ambulatory, so the patient can be sent home for drainage if indicated.
Recently digital or electronic chest drainage systems have been introduced. An onboard motor is used as the vacuum source, an integrated suction control canister, and a water seal.
These systems monitor the patient and alert if the measured data is out of range. Due to the digital control of negative pressure, the system can objectively quantify the presence of a pleural or system leak.
Digital drainage systems allow clinicians to mobilize patients early, even for those on continuous suction, which is difficult to achieve with the traditional suction water seal system.
Recently published clinical data indicate that the application of such systems can also reduce complications.
Chest tube insertion is a standard procedure usually done to drain accumulated air or fluids from the pleural cavity.
Small-bore chest tubes (≤14F) are generally recommended as first-line therapy for spontaneous pneumothorax in non-ventilated patients and pleural effusions in general, with the possible exception of hemothorax and malignant effusions (for which pleurodesis is planned immediately).
Large gauge chest drains can be helpful for large air leaks as well as post-ineffectiveness testing with small gauge drains. Chest tube insertion should be image-guided, either by bedside ultrasound or, less frequently, by computed tomography.
The so-called trocar technique should be avoided. Instead, a blunt dissection (for tubes> 24 F) or the Seldinger technique should be used.
All chest tubes are connected to a drainage system device: a flutter valve, underwater seal, electronic systems, or vacuum bottles for indwelling pleural catheters (IPCs).
The classic three-bottle drainage system requires either wall suction (external) or gravity drainage (“water seal”) (the former is not routinely recommended unless the latter is not practical).
The optimal time for tube removal remains controversial; however, the use of digital drainage systems facilitates informed and prudent decision-making in this area.
A drainage suppression test before tube removal is generally not recommended.
Pain, blocked drain, and accidental displacement is common complications of small-gauge drains; the most feared complications include organ damage, hemothorax, infections, and re-expansion pulmonary edema.
In many centers, indwelling pleural catheters represent first-line palliative therapy for malignant pleural effusions. The optimal drainage frequency for indwelling pleural catheters has not been formally agreed upon or officially established.
Why is pleural drainage done?
Therapeutic thoracentesis, or pleural effusion drainage, is performed to relieve symptoms of pleural effusion. These commonly include shortness of breath, chest pain, or a dry cough.
Thoracentesis can also help stop the cycle of inflammation that can occur with pneumonia-associated (parapneumonic) stroke. This can help the spill resolve faster.
The fluid drained from the spill can be sent for analysis and can provide clues to the cause of the fall.
How does pleural drainage work?
Drainage of a pleural effusion (thoracentesis) involves inserting a needle into the pleural space so that fluid can be aspirated (suctioned). This relieves pressure on the lungs and makes breathing easier. Thoracentesis is best suited for collections of free-flowing pleural fluid.
Thicker pleural effusions may not drain quickly through the thoracentesis needle, such as those associated with some pneumonia. In these cases, a tube thoracostomy may be necessary.
Thoracentesis is performed under local anesthesia by a doctor in a hospital or operating room on the same day. Before the procedure, you can expect to have a chest X-ray, CT scan, or chest ultrasound.
Blood tests are used to confirm that your blood is clotting normally. Thoracentesis can be done during a hospital stay or as an outpatient procedure so that you can go home afterward.
You will be asked to change into a hospital gown when you arrive for the procedure. You will sit on the edge of an armless chair or a bed. A technician will help you bend forward so that your arms and headrest are on a small table in front of you.
It is essential to remain as still as possible during the procedure. The technician will clean the skin on your side and back with an antiseptic, which may feel cold.
Your doctor will check the preparations and give you a local anesthetic injection. You can expect the injection to sting, but only for a moment. A small area of your back, between your ribs, will go numb.
After the area is numb, your doctor will insert a hollow needle between your ribs so that excess fluid can drain into the collection jars. As the fluid drains, you may experience discomfort or a strong urge to cough.
The procedure generally takes about 15 minutes to complete. The fluid is then sent to a lab for analysis of pleural fluid.
What should you expect during the procedure?
Drainage of a pleural effusion is a simple procedure performed at the patient’s bedside. It does not require general anesthesia. Before drainage is completed, a chest X-ray will usually be ordered to confirm the presence of pleural effusion and establish the precise location.
Ultrasound can also be used during the procedure to guide needle insertion. Typically, patients are asked to sit upright during the process. It is crucial to remain still so that the needle is inserted correctly.
An antibacterial solution will be used to clean the skin around the needle insertion site. This is usually between the ribs at the back of the chest. A local anesthetic is injected into your back to help reduce discomfort.
Next, a larger needle or catheter is inserted at the same point, going deeper into the chest wall and the pleural space. This needle can be attached to a flexible plastic tube and vacuum bottles, which collect the fluid as it drains from the pleural space.
The needle or catheter will be removed, and a sterile dressing will be applied over the insertion site to help prevent infection. If the patient develops a cough or chest pain during the procedure, it should be stopped immediately.
After the procedure, another chest x-ray may be ordered to check for the presence of a pneumothorax or to determine if the fluid was successfully drained.
What are the risks?
Although invasive, thoracentesis is considered a minor procedure and does not require special follow-up care. The risks of pleural drainage include:
Pneumothorax: This complication occurs in about one in ten cases. Many are very mild and do not require treatment; some may require placement of a tube thoracostomy to drain the air.
Re-expansion of pulmonary edema: With the drainage of large volumes of fluid, there is a slight chance that the lungs may react poorly to rapid re-expansion, and the air spaces may fill with fluid.
This is an infrequent complication, but it can be fatal. Patients who have a bleeding disorder or who take blood-thinning medications such as warfarin may have an increased risk of bleeding during the procedure. Always inform your healthcare provider if this applies to you.
There is also a risk that the thoracentesis will not be successful or that the drained fluid may accumulate again. This is particularly common in pleural effusions associated with malignancy.
A small pneumothorax will heal on its own, but a more significant pneumothorax usually requires hospitalization and placement of a chest tube.
Aftercare for a pleural drain
Once the procedure is complete and the needle is removed, the technician will apply pressure to the wound to control bleeding. They will then apply bandages, which they will wear for the next day.