P. Nandi
University Queen Mary Department Hospital of Surgery

Chest tubes and bottles are some of the simplest devices used in the practice of medicine. Yet they are often misunderstood, sometimes misused and are a mystery to medical students, nurses and some practising doctors. An outline of the indications of their use will be given and consider some of the problems that may arise. Aim of chest drains is to evacuate air, fluid, pus or blood from the pleural space effectively and as quickly as possible.
Dangers of Collection in the Pleural 1. Pneumothorax: Space

Free air in the pleura is absorbed into circulation within a few days unless new air is added. But excessive air within the chest occupies space and restricts lung expansion resulting in reduction of lung function and causing dyspnoea. Any pneumothorax occupying twenty percent or more of the hemithorax should be drained. If a tension penumothorax develops, patient’s life may be in danger from cardio respiratory embarrassment. 2. Pleural effusion: Free fluid within the chest also occupies space and causes reduction of lung function. 3. Empyema: Pyothorax or pus in the chest will evoke inflammatory and fibrotic response and cause encapsulation of the lung in a thick scar. This restricts Iung expansion leading to decrease in pulmonary function. Tension pyothorax may develop and the patient may be acutely ill from septicaemia and respiratory distress. 4. Haemothorax: Blood in pleural cavity can be absorbed provided it is not excessive in amount, clotted or infected. Massive haemothorax will cause shock and respiratory embarrassment.
Water Seal (Fig. 1 & 4)

in the chest bottle. 29. Saline will be lifted a few centimeters up the tube by negative inspiratory intrathoracic pressure. lung collapse. This is done by connecting the chest drain to a glass straw which is immersed under saline contained in a bottle. 1977 In order to evacuate fluid or air effectively from the pleural space. Any fluid in a dependent loop of tubing will obstruct flow and d. especially to an air leak (Fig. a. Others use a smaller water seal apparatus. Expiration then forces the air and fluid into the bottle. Lung Resections After operations involving removal of part or parts of lung. it is necessary to ensure one-way flow through the chest drain. collapse or the patient may lie on it. two drains must be inserted in the chest. Drains following Chest Surgery 1. An obstructed or small size air vent permits pressure to build up C. The flow of air or fluid out of the hemithorax must be unimpeded. The apical drain which reaches the apex of the hemithorax is meant for drainage of free air.42 THE BULLETIN OF THE HONG KONG MEDICAL ASSOCIATION VOL. Infant’s pleural cavity cannot absorb enough air from the large tube and straw or blow enough air to-get negative inspiratory pressure which is needed for full lung expansion. Some centres advocate removal of intrapleural catheter on mild suction while lungs are being inflated by the anaesthetist at the end of thoracotomy. This is safer as it permits drainage of fluid and air that may collect during the postoperative period. Infant’s chest drain straw generally shows a high fluid level and minimal fluctuation. 2 & 3). Routine use of chest tubes and water seal drainage in a postoperative infant is somewhat controversial. narrow tube and pencil size straw should be used in children. The basal drain is placed in the lower part of the chest with the last hole above the level of the dome of diaphragm and it drains out fluid or blood that may . The following can significantly restrict air and fluid evacuation from the chest tube and lead to dyspnoea. embarrassment of circulation and death. but air cannot reenter the submerged tube tip. create back pressure. A full bottle with glass straw tip deep under the fluid surface. but not up to the bed level from the floor. Therefore. Too narrow or too soft tubing may spontaneously kink or b. Water Seal in Infants Use of large diameter tube and straw can cause persistent air space in the chest because these have a considerable air capacity and may obstruct evacuation of air or fluid during expiration. Passage through a narrow tube or straw cannot be as free as through a good size tube and under saline straw.

Chest Tube Suction Use of suction to chest bottles is somewhat controversial. it is safer not to use it. a cracked or loose connector. are connected directly to the air vent of the water seal bottle. the upper one reaching the back of manubriau sterni. 3. Others do not use suction and feel that it is hazardous. Pneumonectomy Only one basal drain is necessary after pneumonectomy. Following Open Heart Surgery Open heart operations are usually done through a vertical sternotomy and in most cases. If a pleura is accidentally opened an additional drain is inserted in to the chest from the lateral chest wall. If there is any doubt about the efficacy of the suction device. There are different ways of applying suction to chest bottles.with small multiple leaks suction may promote healing by drawing the leaking areas against other lung and chest wall surfaces. chest tube suction is very useful. Closed mitral valvotomy. It is important to remember that use of suction on water seal drain is never life saving. pleura is not opened. Conditions where Chest Tube Suction is Useful A. Wall suction is usually applied through a three or two bottle system (Fig.g. Under these circumstances. Many surgeons always use chest bottle suction and maintain that it is essential. Operations other than Lung Resection e. Pneumothorax (i) When a patient has a large air leak . (ii) A persistent small air leak or an unusually large one for the situation being dealt with suggest some leak in the water seal system. 4.g.g. suture and division of patent ductus arteriosus. Both drains should be placed anterior to the midaxillary line. a leaky rubber tube or a glass straw which is not long enough to enter the water seal . two drains (an upper and a lower) are left in the anterior mediastinum. Only a basal drain is necessary. If a drain is placed behind this line. e. the patient will lie on it which causes discomfort to him and may block it.CHEST TUBES AND WATER SEAL DRAINAGE 43 collect. There is a slight danger that some air leaks could be kept open by excessive early suction on a small or inelastic residual lung. Two drains are also necessary after transthoracic oesophageal resection. 5). Thoracic pumps. Robert’s Pump. e. 2. When properly applied. especially if a suction device used cannot maintain negative pressure in the bottle throughout all phases of respiration and coughing.

the chest tubes must be unclamped as soon as the process of lifting the patient has been completed especially if there is an air leak. If the tubes are kept clamped or forgotten to be released while being transported the patient may develop tension penumothorax and be in serious trouble. Eventually by fibrosis and contraction the mediastinum. The chest tube is usually unclamped for a few minutes every hour. The siphoning can be avoided by raising the chest bottle to bed level before unclamping the tube. thus breaking the siphon. The pressure change can also result from a siphon effect if the tube is opened while submerged in pleural fluid. This situation - . e. The clotted blood may also cause postoperative cardiac tamponade. Suction is never applied to a chest drain in a patient who has a pneumonectomy.g. diaphragm and ribs surrounding the residual pneumonectomy space becomes relatively immobile.THE BULLETIN OF THE HONG KONG MEDICAL ASSOClATlON VOL. the chest drain is usually kept clamped because removal of a lung leaves an empty space filled with air or air and fluid. This empty hemithorax is subject to considerable pressure variation with respiration and especially with cough. (a) In a pneumonectomy patient. the chest drains should be milked as frequently as necessary. Pleural Effusion or Haemothorax B Suction is routinely applied to drain out fluid or blood from the chest as quickly as possible. with simultaneous venting of air into the tubing by a hollow needle to drain all fluid from the tube into the bottle. Suction on chest drain in pneumonectomy patient will cause mediastinal shift resulting in cardiorespiratory embarrassment which may be fatal if not corrected immediately. 1977 system during negative inspiratory pressure resulting in persistent partial lung collapse. After Open Heart Operations C. If such air leak cannot be easily occluded chest bottle suction should be applied. (b) When the drainage bottle or bottles have to be raised to level of the patient. Care and Removal of Chest Drains Never Clamp Chest Tubes except in Two Conditions 1. while moving a patient from bed to trolley or vice versa. 29. To ensure patency. Such sudden pressure changes can cause significant mediastinal oscillation and cardiac arrhythmia. Blood clots inside will block the drain and also cause increased fibrinolysis which in turn will provoke more bleeding. Suction is applied immediately to evacuate the blood as quickly as possible so that it does not get a chance to clot inside.

(a) Air leak (bubbling) has stopped for over twenty-four hours. When the fluid level in the bottle rises several centimeters above the tip of the straw the bottle should be changed especially if there is air leak. It is extremely dangerous to clamp the chest tubes or worse still to remove them before sending such a patient to the operating theatre. Special devices are available for effective milking. Hard plastic tubes are difficult or impossible to milk. The chest tube and the water seal drain must be left in situ under these circumstances. tubes can be milked by using two clamps applied down the tube in succession. A chest tube in a pneumonectomy patient is usually removed in twenty-four to forty-eight hours. The drain site should also be stitched in a child below twelve years of age. (b) Fully expanded lung as shown in chest x-ray. Foaming Problem 4. in a day. This cannot be emphasised too strongly. This can be controlled by a silicone antifoam spray or by adding ethanol in the bottle from time to time. as back pressure may develop under these conditions. Removal of Chest Drains 5. e. If these are not available. the drain site after removal of the tube should be stitched. Milking of Tubes 3. Amount of Drainage Daily or hourly increments in fluid level by drainage are noted from the scale on the side of the bottle and recorded on a chart as chest fluid drainage. It is important to avoid formation Of a fistulous fluid track to skin. Milking will expel tissue or clot from the chest tube and this will permit better drainage. The bottles on wheels will facilitate ambulation of the patients. Therefore. These criteria can be applied to any condition for which chest drains have been inserted. Chest tubes can be taken out when the following conditions are satisfied.g. It may be two to six days before these conditions are met. pleural effusion or after chest surgery. But it is desirable to have most chest surgical patients walk On second postoperative day.CHEST TUBES AND WATER SEAL DRAINAGE 2. Small clots that may be pushed back into the chest can be absorbed. Foaming in the chest bottle can be a nuisance in situations of high volume air leak. (c) Serous drainage from the tube is down to 50 to 80 ml. . often arises when a patient suffering from persistent spontaneous pneumothorax is ‘being taken to operating theatre for surgery. spontaneous pneumothorax.

1977 LEGENDS Figure 1 : Water Seal Drainage System. Rubber stopper . under saline surface. smaller in children. Straw tip not to be more than 1 .should be well-seated or taped down to stabilise the straw.THE BULLETIN OF THE HONG KONG MEDICAL ASSOCIATION VOL. 29. Bottle size . I- DRNIAGE DO NOT I FIGURE .1 L or 2L (for postoperative cases).2 cm. It should be air tight if suction is to be applied.

Inset shows the tube direct from bed to the bottle without any loop. FIGURE 3 . Figure 3 : Loops between the fixing pin and the patient allows adequate patient mobility in bed.CHEST TUBES AND WATER SEAL DRAINAGE 47 Figure 2 : There must be no dependent loop with fluid in it.

2) WATER SEAL BOTTLE (NO. WALL SUCTION VACUUM BREAKER STRAW - BOTTLE VACUUM BREAKER BOTTLE (NO.1977 Figure 4 : Chest drain wrongly connected to the air vent instead of to the under saline straw. 1) (NO. 2. Result . 29.48 THE BULLETIN OF THE HONG KONG MEDICAL ASSOCIATION VOL. Bottle no. instead.vigorous bubbling and the bottle is emptied on the floor. 3 can be omitted and suction applied to Bottle no. 3) . Figure 5 : Three Bottle Suction System.

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