1. Thoracic Surgery On-Line Part 2 Chest Drains Tubing,Bottles and Suction

2. Chest Drains Needle aspiration Pigtails Straight Tubes (Blake Drains)

3. Chest Drains Needle aspiration: –Localise where air/fluid is –Local anaesthetic to chest wall. –Insert needle – usually long,large bore,with 3- way tap and tubing to jug placed on sterile area. –Aspirate and empty into jug – samples taken for culture,cytology,biochemistry – glucose,LDH,protein. –CXR to document post procedure situation

4. Chest Drains Pigtail Drains –Useful for draining air,not so good for thick fluid/pus –Easy to insert using introducer kit. –Can be ambulatory or to underwater seal drain system. –Always CXR after insertion to document post procedural situation.

5. Chest Drains Straight Chest drains – 20French/28/32. Bigger drains for thick fluid/pus Can be used for inserting talc slurry Better than pigtail for large airleaks. Training using manequin Always suture next to drain with 0-silk or similar,and tie onto drain to crimp it. Secure onto lower chest/abdo to prevent pulling on stitch.

6. Chest Drains When draining large effusions,when patient starts to cough,pinch drain off temporarily with fingers to stop drainage. Wait for patient to feel more comfortable,then release again. Possible to drain litres of fluid by this means without reexpansion pulmonary oedema.

7. Chest Drains Drains best positioned in dependant position in chest,but not always possible. Position mid-axillary line,5 th space. As fluid drains lung expands and fluid goes up and still drains. Obsession with low drains can lead to danger.

8. Chest Drains Sometimes drains best guided using ultrasound Especially left sided,where heart can be right across to the left,leaving a small space. Best to aspirate first,and perhaps insert finger before inserting drain.

9. Chest Drains Tubing is 6 foot long,to allow for mobilising Must be below patient at all times. If elevated,with inspiration fluid can be sucked up into the chest,infecting the pleural cavity.

10. Chest Drains Observations of chest drains: –Bubble – empty tubing of fluid and ask patient to take a big breath and cough.Observe drain bottle to see if air bubbles out. –Swing – the column of fluid will move up with inspiration and down with expiration.Swing may not be pronounced if lung is up against the drain holes. –Drainage – 24 hr drainage must be documented,as well as the type of fluid.

11. Chest Drains Removing chest drains: –Drains are removed 24 hours after any air leak stops –Drains are removed if they drain less than 100cc/24hr period. –After removing the whole lung,the drain is removed the next day no matter what,as the chest must be allowed to fill with fluid to replace the lung that was removed.

12. Chest Drains Suction Suction can be applied to drains in various ways: –Some drains have a control on the side which one dials up to regulate the suction from 10cm H 2 0 to 40cm H 2 0 –Others have fixed water columns with the suction regulated by the depth of the water – ie 10 – 30 cm H 2 0

13. Chest Drains Suction –With simple underwater seal drains with a rod under water,suction is applied in 2 ways: –1.By placing the finger over the end of the suction control and dialling it up to the desired suction pressure – 2-4 KpA (=the 2 previous examples of fixed suction)

14. Chest Drains Suction- The BEST WAY: –Optimum and correct useage of suction to a simple underwater system is to connect the tubing to the bottle outlet,and dial up the suction to 2 -3-4 KpA. –This means that despite any air leak,there is always a negative pressure in the system,thus achieving the aim to get the lung expanded.

15. Chest Drains Suction –Always have a portable Chest X Ray done with the patient on suction to confirm the system is working properly. –Taking off suction:ALWAYS disconnect from the BOTTLE.Never leave the system connected and turn the suction off at the wall – this effectively blocks the escape of air and causes a tension pneumothorax

16. Chest Drains Removing chest drains: –The patient is instructed in what is going to happen.Premed if thought necessary. –Position patient so the drain can esily be seen. –Prepare the airtight dressing.Remove the patient dressings,and cut stitch out of skin. –Ask patient to hold big breath in,and quickly pull drain out,covering it with the dressing. –Chest X Ray to confirm situation.Observe patient for respiratory distress. –Dressings can be removed 48hrs later,and changed daily after shower.

17. Chest Drains Removing drains –On occasions,the underlying lung will not expand,and there is a space in the chest. –When the drain is removed,this space will fill with fluid,so a purse string suture is used to hold the drain site closed so the fluid doesn’t leak and get infected. –If drainage is infected,the drain is not removed in one go,but gradually over a period of weeks,as will be discussed in another Part on Pleural Infections.

18. Chest Drains Heimlich valves and portable drains –From time to time,patients need to be ambulatory with chest drains in,with continuing air leaks. –Heimlich valves – like a finger of a rubber glove with a hole cut in the end,placed over the end of the chest tube- allow air through but not back into the drain.

19. Chest Drains Heimlich valves: –These “valves” are best if there is not much fluid drainage. –There may be a risk of tension pneumothorax if the drain kinks or falls out. –Therefore careful selection is required before allowing a patient home with this system –Can be used to fly patients in air ambulance.