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Anaesthesia, 1993, Volume 48, pages 154-161

REVIEW ARTICLE

Pleural drainage systems

A . C. KAM. M . O’BRIEN AND P.C.A. KAM

Summary
The physics and the physiological principles of pleural or chest drainage systems are reviewed. The clinical managerne i t unrl
complications of pleural drainage are summarised.

Key words
Equipment; pleural, chest drainage systems.

Pleural or chest drainage is an essential aspect of the
management of the post-thoracotomy patient or the criti-
cally ill patient in the intensive care unit or accident and
emergency department. The primary aim of pleural drain-
age is the effective drainage of air, blood or fluids from the
pleural space to restore cardiorespiratory function by re-
expansion of the lung and the elimination of mediastinal
shift which may cause haemodynamic instability.
This review aims to summarise the basic physics, physio-
logical and clinical aspects of pleural drainage.
Historical uspects
Hippocrates [I] is credited for the first pleural drainage
when he drained an empyema with cautery and a metal
tube. However, it was not until the 1860s that Hunter [ I ]
revived the concept with the development of a hypodermic
needle for drainage purposes. Playfair [2] introduced the
idea of an underwater seal in 1875, and in 1876, Hewett [3]
described a closed drainage system for continuous siphon
drainage of a pleural empyema. In the same year, the first
use of suction on pleural drains was commented upon in an
unsigned editorial [4]. However, technical problems
discouraged the widespread use of pleural drainage until
1917 when it was successfully used to treat postinfluenzal
cmpyema during an epidemic. In 1922 Lilienthal [5] rein-
Physical and physiological principles of’ pleurul druinuge
The normal elastic lung is maintained fully expanded by the
outward recoil of the chest wall combined with the
capillary attractive forces between the visceral and parietal
pleura, generating a subatmospheric intrapleural pressure
of -2 cmHzO a t end-expiration and - 7 cmHzO at end-
inspiration. Any surgical or traumatic wound penetrating
the chest wall or collection of air or liquid in the pleural
space will disrupt the subatmospheric intrapleural pressure
and impair expansion of the lung. Drainage of air. blood or
fluid from the pleural space requires an airtight system to
maintain the subatmospheric intrapleural pressure.
The three essential components [6, 71 required to achieve
effective pleural drainage are: a pleural tube to evacuate air.
blood or fluid with minimal resistance; a one-way valve,
usually an underwater seal, allowing expulsion of air from
the pleural space and preventing the re-entry of air during
inspiration; and a collection chamber for blood or pleural
fluid.
Pleural tube and connecting drainage tube
Air in the pleural space is moist and flow tends to be
turbulent [8] and follows the Fanning equation where
n2r5P
Flow = ~ ~

troduced continuous closed pleural drainage in the post- fl

operative care of patients following routine thoracic (f = frictional factor) rather than Poiseuille’s Law
surgery. Major advances in the development of pleural
drainage systems occurred during the Korean and Vietnam
wars.

A.C. Kam, MB, BS, Resident Medical Officer, P.C.A. Kam, FRCAnaes, FFARACS. Senior Staff Specialist, Anaesthetics
Department, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2050. Australia, M. O’Brien, MB, BS.
FFARACS, Fellow in Anaesthesia, Royal Alexandra Hospital for Children, Camperdown NSW 2050, Australia.
Correspondence should be addressed to Dr P.C.A. Kam please.
Accepted I I May 1992.

0003-2409/93/020 I54 + 08 $OS.OO/O @ 1993 The Association of Anaesthetists of G t Britain and Ireland 154

"I
-
60
L /
P .
/ ..
d
0 2 4 6 8 10
Internal diameter (mm)
Fig. 1. Flows at - 10 cmHzO through 1.8 m length of tubes of
various diameters.
Consequently, flow has a relationship to the fifth power of
the radius of the drainage tube. From these physical
relationships, it has been demonstrated [9] that a tube with
a 6 mm internal diameter (ID) is the minimum required to
allow a maximum flow of 15.1 1.min-l of air (Fig. 1) at an
applied pressure of - 10 cmH,O. A tube with a 12 mm I D
allows air flows of 50-60 1.min-I with minimal resistance
and is favoured by a majority of thoracic surgeons [lo].
Effective pleural drainage also depends on the pressure
gradient between the pleural space and the drainage collec-
tion system. This is given by the relationship:
Pleural pressure-Pressure in collection system
Flow =
Resistance to flow
As the collection chamber is placed at a lower level than the
patient, the pleural space is the area of higher presssure and
the collection chamber is at a lower pressure. Therefore, the
pressure gradient between the pleural space and the collec-
tion chamber can be increased to enhance drainage by
lowering the level of the collection chamber below the
patient or by applying negative pressure to the collection
chamber.
Theoretically, if the collection chamber is placed 100 cm
below the patient, suction would not be required as the
hydrostatic column would generate a subatmospheric
pressure up to - 100 cmH,O [I 11. However, air pockets (91
produced by dependent loops of connecting tube between
the patient and the collection chamber, can break the
continuity of the liquid column, cause a loss of subatmos-
Fig. 2. Pleural pressure (P = (A
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Pleural drainage systems 155
Chest
T To collection
- chamber
-- - - - -f -
, '
.'
Extra pressure required for
airflow through fluid-filled
dependent loop
..
..
..
..
\
.. ,.
/. ..'
. . . .. .. . . . ..' ..: . .__ _ _ _ __
12
pheric pressure (Fig. 2 ) and thus may impede the flow of
air. Pressure in excess of the vertical height of the fluid
within the dependent loops is required for the flow of air
(Fig. 3).
One-way valve (underwater seal)
A one-way valve mechanism [12, 131 to expel air out of the
pleural space and prevent the re-entry of atmospheric air
into the pleural space is achieved by an underwater seal.
The underwater seal [6, 7, 91 consists of the distal end of
the drainage tubing submerged at about 2 cm below the
surface of sterile water or saline. During expiration or
coughing, air from the pleural space is expelled through the
tubing, and the depth at which the drainage tube is
submerged is the hydrostatic pressure to be overcome. In
addition, the underwater seal produces a siphon effect [I41
which enhances drainage.
During obstructed inspiration, large subatmospheric
pressures up to - 80 cmH,O may be generated so that fluid
in the collection chamber may be sucked up the tubing into
the pleural space; to prevent this, the collection chamber
should always be placed 100 cm below the chest.
Collection chamber
A large diameter collection chamber (approximately 20 cm
diameter) is desirable [I51 so that the volume of water
above the distal end of the submerged drainage tubing is
greater than the volume of the drainage tubing. This is to
prevent the loss of the underwater seal as water moves up
Vacuum
V
+ V)-(B + C + D)) during closed chest drainage.
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156 A.C. Kum, M . O'Brien and P.C.A. Kam

2
-
L
80 I 31 fluid trap and
underwater seal
60
01
2 21 fluid trap and
40
' underwater seal
.-
0 I1 fluid trap and
c
0 underwater seal
z 20
. Underwater seal only
-10 -20 -30
Subatmospheric pressure (crnH,O)
Fig. 4. Reverse airflow into pleural space during inspiration with
varying dead space volumes between pleural and underwater seal.
(adapted from Batchelder and Morris [9]).
the drainage tube during a deep inspiratory effort. Thus, a
large diameter collection chamber provides minimal resist-
ance to drainage of air (12, 151 and maintains the under-
water seal if a large inspiratory effort is made.
The work done by the patient to expel air down the
pleural drainagc system is determined by: the depth of the
underwater seal [16]; the volume of air that must be
displaced in the system (air dead space); and the calibre of
the vcnt in thc collcction chamber. The air dead space is
made up of the combined volume of the drainage tubing
and the collection chamber. The larger the air dead space,
the greater is the work required to expel air from the
pleural space. This is due to the 'compliance' of the system
so that reverse air flow within the system occurs during
inspiration (Fig. 4).This reverse flow in effect is added to
thc paticnt's own respiratory dead space [9] and can be
overcome by increased depth of respiration, thus increasing
respiratory work. This is an important consideration in
children. Addition of suction to the system would maintain
constant subatmospheric pressure in the tubing and help
overcome this hazard.
Practical aspects of pleural drainage systems
Pleural drainage systems [ 171 consist of the following com-
ponents: pleural drain o r catheter (also known as thoracic
catheter, chest drain, thoracostomy tube), connector(s).
connecting drainage tube, collection chamber. one-way
valve system (underwater seal), suction source.
Pleural drain or cutheter
Modern pleural drains or catheters are designed for drain-
age of air or blood with minimal resistance. The maximum
external diameter of a pleural drain is determined by the
distance between adjacent ribs of the patient. However, it is
the internal diameter of the pleural drain that dctermines
the resistance to air flow [9]. Various sizes of pleural drains
are available (Table I). For adults, the minimal ID of a
pleural drain should be 6 mm [9] and sizes 26-40 FG
(6-1 I mm ID) are recommended. For children. pleural
drain sizes 2-26 FG (2-6 mm ID) are recommended. For
infants, various drains (Table 2) have been
recommended [18]. As air flows may be as high as
600 m1.min-I in neonates with bronchopleural fistulae, the
PCS-830 and PCS-850 pigtail catheters (Cook Critical
Care) and the Argyle 10 FG pleural drains have been
recommended [ 181.
Pleural drains should be nonirritant, flexible,
nonkinking. noncollapsible and clcar to permit visualisa-
tion of clots or fibrin deposition. The inner surface should
be smooth and nonadherent with an incorporated radio-
opaque strip to outline the openings. Polyvinyl chloride
pleural drains are the most commonly used. Silicon rubber
pleural drains tend to have thicker walls and are more
collapsible, expensive and thus less popular, whilst vulca-
nised red rubber pleural drains are more irritant and
promote the formation of a fibrous track, hence are most
suited for the drainage of chronic empyemae.
The distal end is usually a square hole [ I I] as it is least
likely to be obliterated by tissue. Whether multiple open-
ings improve drainage is debatable, as side holes lying

Table 1. Sizes of pleural drainage tubes.

External Approx internal

Size: FG diameter; mm diameter; mm Length; cm Suitability

6 2 < 2.0 23 Infant

10 3.1 2.5 23 Infant
20 6.7 5.0 40 Child
26 8.7 6.0 51 Adult
28 9.3 7.5 51 Adult
32 10.7 9.0 51 Adult
36 I2 10.0 51 Adult
40 13.3 11.0 51 Adult

Table 2. Pleural drains for infants [I81

~~~

External diameter; Resistance to

Device FG Length I 1.min-I flow

Pigtail vascular catheter 8 I10 High

Pigtail vascular catheter 5-6 65 Moderate
PCS-830 pigtail catheter 8.3 40 Low
(Cook)
PCS-850 pigtail catheter 8.5 25 Low
(Cook)
Standard thoracostomy 10 23 Low
tube
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Pleural drainage systems 157

Table 3. Connecting tube for pleural drains.

Internal Approximate
diameter; mm Length: cm volume; ml Flow capacity

6 180 503 Moderate

9.5 180 127 High
12 I80 203 High
4 Underwater
seal tube
against the chest wall are more likely to be obliterated
compared to those facing the lung [ 171. The proximal end
of the pleural drain is slightly bevelled and flared to facili- c . . . 1
Sterile water or saline .> . . 2cm
tate connection to the connecting drainage tubing. . .. .
, '_

, . . .
I .

Connectors
Connectors used to join the pleural drain to the connecting
drainage tube should be streamlined [I31 with an I D greater
than 6 mm [I71 to prevent obstruction by blood clots. Clear underwater seal also acts as a monitor for intrapleural
plastic connectors are desirable to enable visualisation. pressure changes and bronchopleural air leaks 16, 71 if all
Serrations on the outer surface of the connectors reduce the connections in the system are airtight. Oscillations of the
risk of disconnection. The connectors may be straight or water level within the drainage tube reflects intrapleural
Y-shaped for connection to multiple pleural drains. pressure changes. Absence of oscillations suggests: obstruc-
tion of the drainage system by clots, fibrin or kinks; loss of
subatmospheric pressure due to fluid-filled dependent
Connecting drainage tubing loops; or complete re-expansion of the lung.
The connecting drainage tube connects the pleural drain to There are several disadvantages of the one-bottle system.
the collection chamber. It should be clear, flexible, As the collection chamber is filled with blood or fluid, the
nonkinking, noncollapsible and lightweight to reduce drainage tube becomes submerged to a greater depth
drag and discomfort to the patient. The optimal resulting in an increased resistance to drainage. Some
dimensions [9, 10. 161 of the connecting drainage tube are commercial designs have a spillover chamber which main-
1.8 m long, with I D 9.5 mm to 12 mm to provide minimal tains a constant depth at which the drainage tube is
resistance to drainage (Table 3). Dependent loops should submerged. If large volumes of air and blood are drained,
be avoided as collection of blood or fluid in the loops froth occurs in the collection chamber making measure-
would reduce the applied suction pressure. ment of the volume of drainage difficult. Antifoam may be
added to the water to reduce froth formation. Retrograde
flow of water or fluid in the collection chamber into the
Collection systenis patient's pleural space may occur if the chamber is held
The desirable features [I71 of a collection system are:
airtight connections; secure connections to prevent acci-
dental disassembly; nonbreakable, rigid and noncollapsible Table 4. Characteristics of 'one-bottle' pleural drainage systems.
and lightweight material; foolproof system of assembly and
Advantages Disadvantages
attachment to prevent accidental reverse application; built-
in monitor to visualize adequate flow or suction. 1. Simple I . Increasing
Collection systems consist essentially of a collection 2. Cheap resistance to
chamber. an underwater seal (one-way valve) and suction drainage as
attachment or control system. Collection systems may be bottle fills
Single chamber for 2. Froth formation
classified into two groups: gravity drainage systems or collection and leading to
suction drainage systems. However, in current practice, underwater seal overflow and
suction may be applied to gravity drainage systems measuring
converting them into suction drainage systems to reduce problems
some of the problems with pure gravity drainage. Various Systems used:
arrangements have evolved over the last 40 years but the (a) Glass bottle 1. Simple I. Breakable
2. Cheap 2. Heavy
basic operating principles are the same.
3. Inconvenient for
transport
(b) Plastic bottle. I. Simple, cheap
Gravity drainage systems e.g. Meraseal 2. Nonbreakable
(Tuta) 3. Lightweight
One-bottle s ~ * s t m (i Table 4) (c) Argyle 'Single' I. Small dead 1. Limited capacity
This is the simplest drainage collection system (Fig. 5 ) seal (moulded space (approx
plastic) 60 ml)
where the drainage tube extends into a sterile plastic or 2. Constant 2. High resistance
glass bottle so that it is submerged 2 cm under the level of underwater seal to high air flows
sterile water or saline. thus acting as an underwater seal by geometric (not suitable for
and collection chamber. An exit vent allows the escape of designed spill- bronchopleural
over column fistula)
pleural air from the chamber into the atmosphere. The
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158 A.C. Kum. M . O'Brien and P.C.A. Kum

re-expansion of the lung. The work required to expel

patient
pleural air is increased and may be significant in children.
In addition, the siphon effect due to the underwater seal is
lost, reducing the efficiency of drainage. The drainage
efficiency is dependent on the pressure difference between
Underwater
seal tube
>
the pleural space and the collection chamber, which is
0 limited. Applying subatmospheric pressure to the collection
0 chamber will increase the pressure difference between the
0 pleural space and the collection chamber, thereby
L
, . .. .
/ L /
enhancing the drainage efficiency.
. . ;.. .
.. . . . .. . . .. . .
I

. . . .
. .
. . I . . I
. . .
.
Suction drainage systems
Underwater Drainage collection
seal chamber chamber (fluid trap) Suction increases the pressure difference between the
Fig. 6. 'Two-bottle' system.
pleural space and the collection chamber by drawing air
from the chamber, causing a decrease of the pressure within
the collection chamber.
above the level of the patient [15], which may be prevented Suction devices used for pleural drainage should have the
by an antireflux float valve. following features [lo, 17, 191: control of subatmospheric
pressure and a pressure gauge (0 to -60 cmH,O) incor-
Two-bottle system (Table 5 ) porated; high potential flow (approx 20 I.min-l at
- 10 cmH,O); constant subatmospheric pressure; an exit
The disadvantages of the one-bottle system may be reduced vent to the underwater seal so that the drainage system
by the two-bottle system [6, 7, 171. Blood or fluid is drained remains vented when the suction device is turned off.
into a collection chamber or fluid trap and air flows into a In general, high pressure high flow suction devices are
separate underwater seal chamber, thus ensuring that the preferred although the suction is limited to -20 cmH,O in
underwatcr seal is kept at a fixed constant level (Fig. 6). An clinical use [lo]. Low pressure systems capable of gener-
exit vent at the underwater seal chamber allows any pleural ating between - 15 and -20 cmH,O pressure and flow
air to escape into the atmosphere. between 5 and 10 I.min-' include the Stedman, Gomco and
However, the collection chamber (or fluid trap) forms an Thermovac systems. High pressure high flow systems, e.g.
extension of the patient's pleural air space (pneumothorax) Emerson and Sorensen system, are capable of pressures of
and increases the total air dead space [6, 71. The extra air -60 cmH,O with flows of > 20 I.min-I. When selecting a
dead space in the collection chamber is compressible, suction system, the suction level should be selected so that
moving in and out of the pleural cavity during inspiration a subatmospheric pressure greater than the end-expiratory
and expiration, thereby creating an air lock and impeding pleural pressure ensures effective drainage of the pleural
space.
Table 5. Characteristics of 'two-bottle' pleural drainage systems. Wall-mounted suction devices either from a pipeline
vacuum system or Venturi suction system may be used so
Advantages Disadvantages long as there are control and pressure gauges to regulate
and monitor the level of suction. It should be noted that
General features:
Two chambers I . Constant 1. Fluid trap wall-mounted suction systems d o not provide an exit vent
underwater seal increases pleural when they are turned off. Therefore, the drainage systems
air dead space should be disconnected from such wall-mounted suction
(a) Collection 2. No froth 2. Increased patient devices when they are turned off.
(fluid trap) formation work to evacuate
pleural space High volume suction may be required for large
(b) Underwater 3. Limited capacity pulmonary air leaks with broncho-pleural fistulae, creating
seal for high flows excessive tracheal air velocity which may make the patient
Systems used: acutely short of breath [13].
(a) Two glass I . Simple I . Heavy and If suction from a single source is applied to two drainage
bottles breakable systems simultaneously, the subatmospheric pressure trans-
2. Cheap
2. Not
transportable mitted to the respective drains will differ if there is a large
air flow through one but not the other [19]. This can result
(b) Argyle Sentinel I . '3-column' High resistance in a mediastinal shift if the drains are on different sides of
Seal spillover design to large flow
to reduce air drainage (max. the chest [19]. If both drains are on the same side of the
dead space flow 2.3 I.min-' chest, it will be of little consequence.
2. Antiretlux float at -20 CmHzO
valve to preserve suction)
underwater seal Three-bottle suction drainage system (Table 6 )
and avoid reflux The safest method of regulating suction pressure is to add a
of water into
chest control bottle between the underwater seal and the suction
3. Positive pressure device. This was used in the three-bottle system developed
vent (2 cmH,O) at the Massachusetts General Hospital in 1945 [17].
in underwater Essentially, it consists of a suction control chamber
seal chamber
connected to a two-bottle system (Fig. 7).
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Pleural drainage systems 159

Air From patieni

Suction control Underwater seal Fluid trap

chamber chamber
Fig. 7. ‘Three-bottle’ system.

Table 6. Characteristics of ‘three-bottle’ pleural drainage systems. The suction control chamber consists of: inlet connected
to the vent of the underwater seal chamber of the two-
Advantages Disadvantages
bottle system; outlet connected to the suction device; and a
General features: control tube which is open to the atmosphere at one end
Three chambers ‘Constant’ I . Loss of constant but immersed approximately 20 cm underwater at the
(a) Collection subatmospheric suction pressure other end. When suction is applied, air is drawn from the
chamber (fluid pressure control for with surges of drainage chambers and also from the atmosphere through
trap) easy visualisation high drainage
(b) Underwater seal and monitoring the control tube. The depth to which the control tube is
(c) Suction control submerged determines the maximum level of subatmos-
2. No exit vent at pheric pressure [6, 71. Continuous bubbling will occur in
suction control the third bottle resulting in noise. The major disadvantages
chamber,
subatmospheric
of the three-bottle system are: greater complexity; noise due
pressure build-up to continuous bubbling, and lack of an exit vent if suction
if suction fails or fails. If the suction system fails, the entire system is not
obstructs vented and a pneumothorax may result.
3. Noisy
Systems available:
(a) Thoradrain 111 I . Compact Expensive Four-bottle suction drainage system (Table 7)
(moulded plastic) 2. Unbreakable The four-bottle system consists of a fourth bottle or safety
3. Relief valve at
underwater seal underwater seal connected to the collection chamber (fluid
chamber trap) of the three-bottle system (Fig. 8). The safety under-
4. Antireflux valve water seal will vent the entire system and relieve any
to preserve pressure build-up should there be a failure of suction.
underwater seal
5. Baffle to prevent Various commercial compact moulded plastic drainage
mixing units are available.
(b) Atrium 2002 1. Suction pressure Expensive
control to Resistance of suction drainage systems
regulate pressure
and reduce noise The resistance of commercially available pleural drainage
2. Negative float systems vary considerably. A recent study [I I] demon-
valve-controlled
release of strated that the maximal flow capacity in four devices
extreme ranged from 2.3 1.min-’ to 35.5 I.min-’ with -20 cmH,O
subatmospheric suction. The Thoraklex and Sentinel Seal systems had
intrathoracic higher resistance due to the narrow calibre of the suction
pressure
port and were unable to cope with air leaks of over

Table 7. Characteristics of ‘four-bottle’ pleural drainage system.

Patient
General features: four chambers $c+lon
(a) Collection chamber (fluid trap)
(b) Underwater seal chamber
(c) Suction control chamber
(d) Auxillary safety underwater seal to vent pressure build-up in c
system 0 0

c 0 0
System available: 0
Argyle ‘Double Seal’ chest drainage unit 0
I , Restricted flow orifice to maintain constant suction
2. Pressure relief vent at suction control chamber I U U u
3. Ball-valve mechanism to preserve underwater seal Safety Fluid trap Underwater seal Suction control
4. Auxillary ‘Safety Seal’ to prevent any positive pressure underwater seal chamber battle
build-up (4th bottle)
5. Suitable for paediatric and adult patients
Fig. 8. ‘Four-bottle’ system.

I .

160 A.C. Kam, M. O’Brien and P.C.A. Kam
5 I.min-’. The Emerson and Pleur-evac systems had lower
resistance and were capable of handling air flows of
35.5 I.min-l and 34.0 1.min-l respectively. The study also
showed that - 20 cmH,O suction provided optimal drain-
age and increasing it to -40 cmH,O did not significantly
alter flow through the drains.
Waterless variations
Some pleural drainage systems have incorporated a simple
flutter valve to function as a one-way valve instead of an
underwater seal. Heimlich [20] described a simple dispos-
able flutter valve consisting of leaflets with flattened ends
that open for air and liquid to drain out and close together
to prevent entry of air into the pleural space.
Mechanical screw type valves, which vary the size of the
opening to the suction device, have been used to replace the
suction control bottle (e.g. Argyle Sentinel Seal,
Thora-Klex). However, as the valve is narrow, it can
handle only limited volumes of air. A carefully calibrated
spring mechanism has been designed to overcome this
problem (e.g. Pleur-evac series).
The waterless variations have several advantages in being
more compact, quiet in operation, and easy to transport.
Indications for pleural drainage
The indications for pleural drainage are: pneumothorax:
> 20% size, symptomatic, tension, traumatic; haemoth-
orax; pleural effusion; empyema; post-thoracotomy; bron-
chopleural fistula.
In the management of a pneumothorax, the size, symp-
toms, underlying pulmonary pathology and the use of
intermittent positive pressure ventilation guide therapeutic
intervention. Persistent air leaks and the failure of the lung
to re-expand suggest the use of suction.
The use of pleural drains in patients with bronchopleural
fistulae [21-241 may be both useful and detrimental [25].
Air leaks may range from I to 10 I.min-’ [ll]. A large
diameter pleural drain ( > 6 mm ID) is necessary for effec-
tive drainage of air and any infected material. If suction is
applied, closure and healing of the bronchopleural fistula
may be prevented [25] and appropriate pressure cycling of
ventilators used in such patients may be interfered
with [26-281.
The use of pleural drains in the post-pneumonectomy
patient [17, 191 is controversial. In the first postoperative
day, the pleural drain should be clamped and released
intermittently every 2 4 h to drain blood or fibrin. Suction
of pleural drains in the post-pneumonectomy patient is
absolutely contraindicated as it predisposes to a medias-
tinal shift which may cause cardiovascular embarrassment.
Care of patients with pleural drains
Proper care of pleural drains is essential to safeguard the
patient from complications that may arise while the pleural
tube is in-situ.
Position
The semi-sitting position with the collection chamber and
underwater seal approximately 100 an below the chest will
promote drainage by gravity. Fluid-filled dependent loops
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of connecting drainage tube must be avoided as they reduce
the pressure gradient between the pleural space and collec-
tion chamber.
Milking or stripping
The value of ‘milking’ or stripping of pleural drains to
maintain their patency and dislodge clot obstruction is
controversial [29]. Milking of pleural drains and tubes
mechanically dislodges and pushes clots or fibrin along the
tubing. It also creates a subatmospheric pressure within the
drain as the compressed segment is released and re-
expands. This negative pressure may exceed - 100 cmH,O
when 10cm of tube is stripped with rollers and exceed
-400 cmH,O when 45 cm is stripped, and may cause
pulmonary trauma [30]. Gentler techniques, by squeezing
hand over hand along the tubing and releasing between
each squeeze or by fan-folding several sections of tubing
and squeezing them have been recommended to dislodge
any clots in the tube.
Transport of patient
Under normal circumstances, the pleural drains should be
clamped when patients are moved to prevent any fluid from
being sucked or poured into the pleural cavity. The collec-
tion chamber should always be kept below the level of the
chest. However, clamping of the pleural drain can risk the
development of a tension pneumothorax in the presence of
a continuing air leak.
Monitoring [6, 71
Observation of synchronous oscillations or fluctuations of
the underwater seal suggests that the drainage is functional.
If blockage of the tube is suspected, gentle stripping may be
carried out. Alternatively, the proximal tube may be
clamped and the distal tube irrigated to dislodge the clots
or debris. Sequential clamping along the tube may be used
to detect the site of air leaks.
Complications
Various complications have been reported in the
literature [31]. Pulmonary lacerations are more likely in
patients with stiff lungs or pleural adhesions. Intercostal
artery bleeding, splenic, liver and stomach lacerations are
associated with poor techniques of insertion of pleural
drains. Unilateral pulmonary oedema is a well-described
complication of rapid drainage of large pleural effusions or
pneumothorax. Large pleural effusions should be drained
slowly [I] at a rate of not more than 1 1 over the first
30 min to avoid re-expansion pulmonary oedema.
Intrapleural infection after pleural drain placement is not
infrequent ( < 3%). The use of prophylactic antibiotics
with pleural drain placement is controversial. In the
absence of trauma and with a good aseptic technique,
prophylactic antibiotics are perhaps not required.
Conclusion
The selection of a pleural drainage system should be deter-
mined by the clinical requirements. An understanding of
the physiological principles and the physical characteristics
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Pleural drainage systems 161

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