vertical tube.

During normal breathing the water level in the vertical tube oscillates, signalling that the tubes are patent and
functioning correctly.

11. If liquid drains out of the chest it may be trapped in a dependent loop of tubing, damping the oscillation of
the level in the vertical tube. Doubly clamp the tube emerging from the chest, disconnect the tubing distal to
this, elevate the drain tube to allow the liquid to run into the bottle, then reconnect the tubes and take off
the double clamps. Check that oscillation is now normal.
12. You can estimate the amount of liquid draining from the chest by marking the initial water level in the
bottle and subsequently comparing the mark with the water level.
13. If air leaks rapidly into the pleural cavity, bubbling will continue in the bottle and the lung cannot re-
expand. Check, and if necessary correct, any leakage around the chest drain. If not, connect the open tube
emerging from the bottle to a vacuum pump set to maintain the pressure in the bottle at slightly below
atmospheric pressure. This results in an increase in bubbling but eventually the lung will re-expand, seal
against the parietal pleura, and the bubbling will cease. While you are applying suction do not expect to see
any oscillation.
14. Intrapleural drains usually seal off and fail to function after 48 hours. You may now cut the stitch attaching
the chest drain and withdraw it, tightening, as you do so, the loose stitch to seal off the hole.
It is often valuable to apply suction as you gently withdraw the drain so that any last fluid collection
is removed. Now tie the loose suture and apply a dressing.

ABSCESSES AND CYSTS

These are eminently suitable for drainage (see Ch. 12). After you have evacuated the contents the discharge will be small,
but continue drainage to allow the cavity to shrink and become partly or completely obliterated. Depending on the site and
size of the cavity, you may use open or closed drainage.

EXTERNAL FISTULAS

1. An external fistula opens on the body surface. Some produce little discharge and do not need to be drained. Others need to
be excised or laid open and prevented from bridging over by applying packs.

2. Some fistulas, especially those carrying digestive juices from the gastrointestinal tract, may produce voluminous discharge
which is usually intensely irritant to the skin or excoriating (L ex = off + corium = skin). The discharge can often be
collected in a stoma bag. Cut an accurate hole in the karya gum backing to the stoma bag attachment ring, to fit closely
around the discharge site. Clean and dry the skin around the stoma and apply the gum carefully to the skin. The stoma bag
ring may have hooks to which you can attach an encircling belt. Clip on the stoma bag. This can be removed as necessary
without disturbing the backing ring. In some cases the bag may be emptied from time to time, without removing it, through a
tap at the bottom, or by removing and replacing a clip on a spout.

3. Less successful is a box that fits over the stoma, to which suction can be applied to maintain the seal. It works better in
theory than in practice.

4. Occasionally you may be able to pass a Foley-type catheter into the fistulous track, gently inflate the catheter balloon to
seal the passage, and allow the catheter to drain into a bag.

NEGATIVE PRESSURE WOUND HEALING

1. A number of devices have been developed to exert suction on open wounds. It is claimed that they act by
removing discharged fluids and debris and encourage epithelialization.
2. The principle on which the devices work is that
the wound is filled with a plastic foam shaped to
the surface of the defect, in which is buried a tube connected to a vacuum pump. Alternatively the suction
tube may be wrapped in gauze. Over the area a plastic sheet is laid and sealed round the edge to the skin
with adhesive (Fig. 11.10).
Fig. 11.10 Negative pressure wound healing. The wound is filled with plastic foam shaped to fully occupy it. A tube is buried within the
foam. The area is now sealed with plastic film which is stuck to the surrounding skin with adhesive. The tube is connected to a suction
pump.

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Handling drains

3. Suction of about 100–130 mmHg is applied by a suction pump.

4. Wound exudate is removed and possibly bacteria
and loose slough. Various claims are made such as oedema is reduced, blood flow is increased, phagocytes
REFERENCE

1. Armstrong DG, Lavery LA. Negative pressure wound therapy after partial diabetic foot amputation: A multi- centre, randomized
controlled trial. Lancet 2005;366:1704–1710.

and fibroblasts are promoted, and growth factors are increased. A wide variety of conditions have been treated using the
method including diabetic foot.1 Improved healing is claimed, although the Cochrane Reports have not identified any clear
advantage.