General Guidelines for chest drain insertion:
BTS Guidelines: http://thorax.bmj.com/cgi/content/full/58/suppl_2/ii53
Before inserting chest drain:
Confirm the indication and the site
Confirm the timing of the procedure: Does it need to be done as an emergency or can it wait?
Does the doctor performing the procedure have enough training and familiarity with the equipment?
Ultrasound guidance is strongly advised when inserting a drain for fluid
Post-thoracic surgery, Pneumothorax, Pleural effusion, Chylothorax, Empyema, Hemothorax
Refractory coagulopathy, lack of cooperation by the patient, and diaphragmatic hernia.
Minor complications: Subcutaneous emphysema, haematoma or seroma, anxiety, shortness of breath (dyspnea), and cough after removing large volume of fluid.
Major complications: Haemorrhage, infection, reexpansion pulmonary edema, injury to the liver, spleen, diaphragm, heart, lung, or thoracic aorta.
National Patient Safety Agency (npsa):
Chest Drains post-cardiac surgery:
Usually the pleura is not opened for valve operations so there will be a mediastinal and pericardial drain. The mediastinal drain lies in front of the heart (and the pericardium if it was closed) whilst the pericardial drain positioned under the diaphragmatic surface of the heart. Sometimes the mediastinal drain acts as a pleural as well, the side holes are in front of the heart whilst the tip of the tube lies high in the pleural space.
Those patients undergoing coronary artery bypass surgery may have the pleura opened and if both internal mammary arteries are used there will be both left and right pleural drains. More commonly the left internal mammary artery is used. Dissection of this may involve opening the left pleura which will necessitate an appropriate drain. The pleural drain is often curved and placed towards the left base in order to drain fluid.
All patients have chest drains inserted following heart surgery. These are rigid tubes of polyvinyl chloride and are used to drain the mediastinal and pleural spaces of fluid and air, to prevent incomplete expansion of the lung and to monitor blood loss postoperatively, thereby preventing cardiac tamponade, tension pneumothorax and pleural effusion.
It is not necessary to routinely empty chest drain tubes the morning following surgery as this gives the impression that drainage is artificially high. However the emptying of tubes should be performed’only when specifically indicated, for example the day of surgery in the context of heavy blood loss in order to prevent the tubes from becoming blocked and thereby causing cardiac tamponade. Note the milking of drains is not without complication, the negative pressure generated may lead to injury to adjacent tissues, perpetuation of air leaks and hypoxia.
Chest tube clearance methods:
Milking, is compression of the tube using twisting or squeezing to move fluid within the tube.
Fan folding , involves folding sections of the tube over each other and squeezing.
It is proposed that milking and fan folding produce some positive pressure during the twisting, squeezing or fan folding process followed by negative pressure when the tubing is released.
Tapping, is a gentle rhythmical tapping of the tube with forceps to facilitate drainage of blood down the narrow section of the chest tube.
Stripping, involves using either fingers or hand held rollers to compress a length of tubing proximally to distally whilst maintaining the compression. It is proposed this action produces negative pressure which draws fluid and clots out of the chest.
In clinical practice all of the above are used on an as needed basis rather than routinely.
Another very effective technique is to clamp the chest tube closest to the patient and disconnect at the point between tube and bottle thus letting blood clots drain out. Once completed unclamp the tube as quickly as possible. This serves to keep the drainage system patent.
The drains are usually removed in the following order; pericardial,left pleural, and mediastinal. If an air leak occurred after pleural drain removal it would be drained by the mediastinal drain.
Chest Drains post-Thoracic surgery:
Pleurovac (Chest Drainage System)
A three chamber device is typically used to drain chest tube contents (air, blood, effusions). The first chamber is a collecting chamber. The second is the "water seal" chamber which acts as a one way valve. Air bubbling through the water seal chamber may indicate a pleural or system leak that should be evaluated critically. The third chamber is the suction control chamber. The height of the water in this chamber determines the negative pressure of the system. Bubbling should be kept a gentle bubble to limit evaporating the fluid. Increased wall suction does not increase the negative pressure of the system.