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Tube Thoracostomy, Management

Introduction
The mechanics of ventilation relate to the negative intrathoracic pressure that draws air
into the lungs during spontaneous respiration. This negative pressure is best maintained
in the pleural space, which is the potential space between the parietal and visceral layers
of the pleura. Collections of air, fluid, or blood in the pleural space not only compress the
lung tissue but also cause the pleural pressures to become positive, causing inappropriate
ventilation.

Chest drains are inserted to remove pathological collections of air or fluid in the pleural
space, to allow the re-creation of the essential negative pressures in the chest, and to
permit complete expansion of the lung, thereby restoring normal ventilation. Chest drains
are very simple and effective tools in the management of thoracic and pleural pathology.
They need proper safe insertion and correct management. Chest drains are lifesaving in
critical care.

Chest drainage systems work by combining the following 3 efforts:

• Expiratory positive pressure from the patient helps push air and fluid out of the
chest (eg, cough, Valsalva maneuver).
• Gravity helps fluid drainage as long as the chest drainage system is placed below
the level of the patient’s chest.
• Suction can improve the speed at which air and fluid are pulled from the chest.

Any catheter inserted through the chest wall to remove air or fluid from the pleural space
may be called a chest tube or chest drain. Crosswell Hewitt is credited as being the first to
use a chest drain, in 1876, when he used a red rubber catheter to drain an empyema
thoracis.[1 ]Ideally, the chest tubes (also called thoracic catheters) must be nontoxic,
nonthrombogenic, and soft but with thick resilient walls. The traditional red rubber tubes
have most of these features but, being opaque, tend to be quickly occluded by
encrustation and fibrinous secretions.

Today, chest tubes are made of clear plastic (vinyl or silastic). They are available in
varying diameters, sized in multiples of 4 on the French scale (eg, 12F, 16F, 20F, up to
36F). They have multiple side holes to allow effective drainage and have length markers
to help note the distance of the lowest hole from the skin surface. A radiopaque strip lines
the tube to help easy visualization on chest radiography.[2 ]Some tubes are mounted on
stylets or trocars that act as guides to help insertion and proper placement of tubes.
Improper management of inserted chest tubes results in premature removal or delayed
removal, both of which lead to increased hospital stay and costs.

When caring for and maintaining a patient with a chest tube, the following steps are
important: Keep chest tubes patent, note the presence of drainage and fluctuations, and
observe the patient's vital signs and levels of comfort. The chest dressing status and type
of suction must be noted.

Tube thoracostomy is the insertion of a tube (chest tube) into the pleural cavity to drain
air, blood, bile, pus, or other fluids. Whether the accumulation is the result of rapid
traumatic filling or insidious malignant seepage, placement of a chest tube allows
for continuous, large volume drainage until the underlying pathology can be more
formally addressed.

The list of specific treatable etiologies is extensive (see Indications), but without
intervention, patients are at great risk for major morbidity or mortality.

Indications
Indications for chest drains include the following:

• Pleural collection
o Pus (empyema)
o Blood (hemothorax)
o Chyle (chylothorax)
o Malignant effusions (pleurodesis)
• Postoperative
o Thoracotomy
o Video-assisted thoracic surgery (VATS)
• Pneumothorax
o Open or closed
o Simple or tension
• Hemothorax
• Hemopneumothorax
• Hydrothorax
• Chylothorax
• Empyema
• Pleural effusion
• Patients with penetrating chest wall injury who are intubated or about to be
intubated
• Considered for those about to undergo air transport who are at risk for
pneumothorax
Contraindications
When a chest drain is needed for any of the indications listed above, no absolute
contraindications exist for chest drain insertion.

Anesthesia
• Following chest tube placement, anesthesia is not required during the
management phase.
• For more information on chest tube placement, see Tube Thoracostomy.
• At the time of tube removal, 5 mL of 1% lidocaine hydrochloride is infiltrated
with a 24-gauge needle around the emerging tube from the chest wall.

Equipment
Equipment

• Chest drainage bottles (see description of drainage system below)


• Adequate length (1.5 – 2 m) of sterile, transparent, plastic tubing (eg,
vinyl/silastic)
• Appropriate sterile connectors
• Adhesive tape
• Angled clamps (2) for clamping the tube when needed
• Distilled water to fill in the drainage bottle

Drainage system

The typical drainage system consists of 3 bottles: (1) underwater seal bottle, (2) trap
bottle, and (3) suction regulator bottle.

• Underwater seal bottle (shown below)


The underwater drainage bottle.

o The underwater seal bottle is the most important element in pleural drainage. It is
essentially an extension of the chest tube underwater; a low-resistance, one-way
valve for the evacuation of pleural contents.
o The underwater seal is a conduit for the expulsion of air and fluid from the chest
against minimal resistance. When intrapleural pressure rises (eg, expiration,
coughing), air is forced out of the lungs through the mouth, and free contents of
the pleural space are forced out through the chest tube and into the underwater
seal drainage bottle. The underwater seal is also an anti-reflux valve. Re-entry of
air into the pleural space when intrapleural pressures become negative (eg,
inspiration), is blocked by the underwater seal. Water can be drawn up the tube
only to the height equal to the negative intrathoracic pressure (usually up to -20
cm of water). Therefore, the apparatus must be kept far enough below the patient
to prevent water from being sucked up into the chest (100 cm is sufficient).[4 ]The
water in this tube is referred to as the "column" of water; it reflects the changes in
intrathoracic pressure with each inspiration and expiration.
o The end of the tube in the underwater seal bottle must remain covered with water
at all times. When a broad-based bottle (eg, Tudor-Edwards) and a narrow tube
are used, elevation of the water column in the tube lowers the level in the
reservoir by only a very small amount, keeping the seal intact.
o The end of the tube must not be kept too far below the surface of water because
the resistance to expulsion of air from the chest is equal to the length of tubing
that is underwater. Keeping the tip of the tube 2-3 cm below the surface of water
should be enough to act as a constant valve.
o The whole system is placed erect, 100 cm below the level of the patient’s chest.
This placement aids gravity drainage of chest contents into the bottle and prevents
reentry of fluid into the chest during the upward swing of the fluid in the tube
during inspiration.

Trap bottle (shown below)

The trap bottle.

• When excessive fluid drains from the chest, the level of fluid in the underwater seal is
raised. This increases resistance to further outflow of fluid from the chest.
• To decrease this resistance, a trap bottle is introduced between the chest tube and the
underwater seal. The trap bottle collects the fluid draining out of the chest, while the air
passes on to the second bottle. This keeps the underwater seal at a constant level.
• Suction regulator bottle (shown below)
The suction bottle.

o Suction hastens the expansion of the lung. Another bottle is needed to


introduce suction regulation to this system.
o The suction regulator bottle has a 3-hole stopcock.
 Short tubes are passed through 2 of the holes. One short tube
connects to the underwater seal bottle’s vent tube and the other
short tube connects to the suction source.
 An atmospheric vent runs through the 3rd hole, passing below the
level of water in this bottle.
o When suction is applied, air is drawn down the atmospheric vent in this
bottle, equal to the pressure inside the bottle that is decreased by the
vacuum. Under stronger vacuum, airflow through the atmospheric vent
commences, and air bubbles through the water in the bottle, but the level
of suction in the bottle remains the same.
o This constant level of low pressure suction is now transmitted to the
underwater seal bottle and then into the pleural cavity, thus aiding
evacuation of contents there, allowing a quicker reexpansion of the
underlying lung. The maximum force of suction is determined by the
depth of the atmospheric vent underwater in the suction regulation bottle.
[2 ]

 To obtain a suction of -20 cm of water, set the tip of the tube 20


cm below the surface of the fluid.
 Now, increase the vacuum gradually until air bubbles gently and
constantly through the atmospheric vent in the water during both
phases of respiration.
 A constant pressure of -20 cm of water is now transmitted to the
underwater seal and on to the chest drain.
o The role of suction is now being debated. Some schools of thought say
suction delays the sealing of air leaks from the underlying lung.[9 ]

Multifunction chest drainage system

The multiple bottles and numerous connections of the typical 3-bottle system result in a
bulky bedside device, which can be prone to accidental disconnections and blocks in the
system. In addition, sterility is difficult to maintain in such a system. These systems,
therefore, have been largely replaced by commercially produced, disposable plastic
multifunction units (eg, Codman, Pleurovac, Atrium) that fit into a single box and work
on the same principles, as shown below.

Chest drain multipurpose unit.


Chest drain multipurpose model Oasis (Atrium Medical Corporation, Hudson, NH).

• Multifunction chest drainage systems have been designed primarily for


management of chest tubes after cardiothoracic surgery and chest trauma.
• Multichamber bottles are provided, incorporating both functional and safety
features. They combine patient protection with effective drainage, accurate fluid
loss measurement, and clear detection of air leaks.
• The multifunction systems allow single or multicatheter drainage and are suitable
for both gravity-assisted and suction-assisted drainage. The unit has a latex-free
patient tube and a filtered water seal to prevent contamination.
• Units with 3 or 4 chambers are also available, which provide 2 independent
collection chambers, an automatic positive pressure relief vent, and a filtered
negative pressure valve.[10 ]
• Each multifunction chest drainage system contains the following:
o Collection chamber: Fluids drain directly into this chamber, which is
calibrated in mL.
o Water seal: This is a one-way valve, U-tube design that can monitor air
leaks and changes in intrathoracic pressure.
o Suction control chamber: This chamber is also a U-tube; the narrow arm is
the atmospheric vent, and the large arm is the fluid reservoir. The system
is regulated, and controlling negative pressure is easy. The suction
chamber also helps monitor intrathoracic pressure.
 For gravity drainage without suction, the level of water in the
water seal chamber equals the intrathoracic pressure.
 For suction-assisted drainage, the level of water in the suction
control chamber plus the level of water in the water seal chamber
equals the intrathoracic pressure.

Positioning
• Emergent and elective chest drains are usually placed in the triangle of safety
(shown below), an area delineated by the anterior border of latissimus dorsi, the
lateral border of pectoralis major, and a horizontal line lateral at the level of the
nipple, or about the 5th intercostal space. This corresponds to an insertion area
between the midaxillary and anterior axillary lines at the level of the nipple. See
eMedicine topic Tube Thoracostomy for a detailed description of chest tube
insertion.
The triangle of safety

• Major obtrusive dressings around the chest tube are unnecessary and potentially
dangerous. They can give rise to kinking of the tube, therefore rendering the tube
useless and potentially allowing the accumulation of air and the formation of a
tension pneumothorax.
• The correct taping of the emerging chest tube from the patient is with a
"mesentry" fold of adhesive tape that holds the tube to the trunk of the patient.
This allows some side-to-side movement of the tube, prevents kinking of the tube
as it passes through the chest wall, and is far less painful to the patient than taping
the tube directly to the chest wall.

Multifunction chest drainage system setup

• Follow the manufacturer’s instructions for adding water to the chambers. This is
usually 2 cm in the water seal chamber and 20 cm in the suction control chamber.
• Connect the 6-ft patient tube to the thoracic catheter.
• Connect the drain to vacuum.
• Slowly increase vacuum until gentle bubbling appears in the suction control
chamber.
• Be sure not to allow too much bubbling in the suction control chamber.
o Excessive bubbling is not needed clinically in 98% of patients.
o Vigorous bubbling is loud and disturbing to most patients.
o Vigorous bubbling also causes rapid evaporation in the chamber, which
lowers the level of suction.

Technique
Management of chest drains

Analgesia

• Chest drains are painful for the patient. Adequate analgesia (orally, rectally, or
parenterally) helps the patient cooperate better for the chest exercises and
physiotherapy.
• Patients whose chest tubes were inserted postoperatively or who have associated
rib fractures need stronger forms of analgesia, such as patient-controlled
anesthesia (PCA) with diluted opioids or even an epidural catheter for direct
delivery of the analgesic medication.
Breathing exercises and chest physiotherapy

• Breathing exercises and chest physiotherapy are the mainstays for the quick
expansion of the lung.
• Incentive spirometry (eg, TriFlo incentive spirometer) gives the patient the
impetus to expand the lung quickly.
• Upper limb movements, especially at the shoulder, help restore the movements of
the chest wall.
• Steam inhalations and nebulized bronchodilators also encourage quick lung
expansion.

Nursing management

• Keep the patient in a propped-up position (ie, 45-90°).


o The semi Flower's position is useful to evacuate air (pneumothorax).[12 ]
The high Flower's position is useful to drain fluid (hemothorax).
o Adjust tubing to hang in a straight line from the chest tube to the drainage
chamber, avoiding excess length and loops.
• Check that all connections are secure.
o All joints must be well-taped with adhesive.
o A single layer of tape across the long axis of each joint holds better than
layers of circular tape over the joint. This prevents disconnection and the
subsequent loss of the negative pressure.
• Always ensure the correct position of the underwater seal bottle.
o The bottle should be erect and at least 100 cm below the level of the
patient’s chest.
o The tip of the glass tube that connects to the chest drain should be at least
2 cm below the fluid level in the bottle (and not more than 7 cm below the
fluid level).
• In addition to vital signs, the following items need to be monitored every 4 hours:
o Swinging or oscillation of the column of water in the glass tube connected
to the chest drain
o Blowing or air bubbling in drainage bottle with quiet respiration and on
coughing (Bubbling of air indicates that the lung is still leaking air. The
cessation of bubbling during both quiet respiration and coughing indicates
that the air leak in the lung has closed.)
o Type and quantity of drainage (Inform practitioner if drainage is >100
mL/h or if frank blood.)
• Never lift the drainage bottle above the level of the patient’s chest, as fluid from
the bottle may siphon off into the patient’s chest.
• Keep 2 clamps (angled) at the bed side.
• Do not clamp a bubbling chest drain.
o All nursing procedures, patient movement, and physiotherapy are
permitted without clamping the drain.
o Clamp tubes only for procedures related to the tube or bottle (eg, to
change the tube or bottle, to empty the bottle, to reconnect an accidental
disconnection of the tube at any of the joints).
• Avoid kinks in the tubes. Teach the patient to look for kinks and to avoid sitting
or lying on the tubes.
• "Milk" the tubes frequently to avoid blockage by fibrin plugs or clots.
• Change the connecting tube and bottle at least once every 48 hours, and replace
them with sterile equivalents. Wash and disinfect equipment to remove all residue
before sterilization.
• Connection of 2 emerging chest tubes to a single drainage unit should be done
through a Y-shaped connector (not a T-shaped connector, which causes kinks in
the tubes). Also, equalizing the length of the emergent tubes before the Y
connector is important. This avoids kinking of unequal lengths of tube.

Suction

• When suction is needed, it should be a constant low-pressure suction to fully


remove the pleural contents without causing pain to the patient.
• The recommended level of suction is -5 to -20 cm of water. (The measurement of
-20 cm of water is based on convention, not research.)
• Higher negative pressure can increase the flow rate out of the chest, but it can also
damage tissue.
o Suction can improve the speed at which air and fluid are pulled from the
chest.
o However, recent research has shown that suction may actually prolong air
leaks from the lung by pulling air through an opening that would
otherwise close on its own.

Radiography

• Serial chest radiographs are needed to monitor and confirm the expansion of the
lung.

Antibiotics

• Antibiotics are not needed during the presence of a chest drain for a simple
pneumothorax or hydrothorax.
• The antibiotic cephalexin can be used to prevent the development of an empyema
when a chest drain has been used in thoracic trauma.

Tube removal

• This must be individualized to the patient, taking into consideration the reason for
the chest tube placement, whether or not the patient has had a pulmonary
resection, and whether the patient is mechanically ventilated.
• Timing of tube removal
o The timing of tube removal depends on clinical and radiological evidence
of complete expulsion of all contents of the pleural cavity with complete
expansion of the lung.
 Minimal drainage should have occurred over the previous 24 h.
 When the patient coughs or performs the Valsalva maneuver, no
air leak should ensue.
 The chest radiograph should confirm complete expansion of the
lung.
 The swing in the fluid level in the tube in the underwater seal
bottle should be minimal, relating to the normal negative pressures
in the chest during the phases of respiration.
o Generally, for pneumothorax, a trial period of tube clamping for 6 hours is
done.
 A repeat chest radiograph is then taken. If this shows complete
expansion of the lung, it confirms that the lung leak has sealed and
that a proper adhesion between the layers of the pleura has
occurred.
 The tube may be safely removed at that time.
• Method of tube removal
o Tube thoracostomy removal is a sterile procedure that requires a
practitioner and an assistant.
o Before removal, give the patient a bolus dose of analgesia. Infiltrating 5
mL of 1% lidocaine hydrochloride with a 24-gauge needle around the
emerging chest drain can increase patient comfort.
o Cut loose the securing stitch while the tube is being supported.
o Free the mattress (sealing) stitch that was inserted and kept long at the
time of tube insertion. If this stitch is not in position, place a vertical
mattress stitch with strong suture material (NW 3397 of Ethicon) across
the center of the incision.
o Hold the ends of the mattress suture ready to tie a knot.
o Instruct the patient to cease respiration in either expiration or inspiration
(incidence of pneumothorax after tube removal is not different).[14 ]Gently
ease out the tube while simultaneously tying the knot to close the track.
o Apply a soft dressing.
o If the stitch breaks or cuts through, simply compress the oblique track and
apply an occlusive dressing.[10 ]
• Follow-up radiography
o A chest radiograph is repeated 4 hours after the removal of the tube
thoracostomy.
o The results of this radiograph should confirm that no air has entered the
chest and that the lung continues to remain fully expanded.

Pearls
• The underwater seal acts as a one-way valve through which air is expelled from
the pleural space and prevented from reentering during the next inspiration.
• Retrograde flow of fluid may occur if the collection chamber is raised above the
level of the patient’s chest. The collection chamber should be kept below the level
of the patient’s chest at all times to prevent fluid being siphoned into the pleural
space.
• Absence of fluid oscillations may indicate obstruction of the drainage system by
clots or kinks, loss of subatmospheric pressure, or complete reexpansion of the
lung.
• Persistent bubbling indicates a continuing bronchopleural air leak.
• Clamping a pleural drain in the presence of a continuing air leak results in a
tension pneumothorax.
• The water seal is a window into the pleural space. It reflects the pressure in the
pleural space and exhibits bubbling if air is leaving the chest. In the multifunction
chest drainage systems, a graduated air leak meter (graduated 1-5) provides a way
to measure the leak and monitor over time.

Complications
Troubleshooting chest drain management

• Column is not oscillating: If the column of fluid in the tube that connects the chest
drain to below the water level in the drainage bottle is not oscillating, the tube has
been blocked. All efforts must be made to restore patency of the tube by
squeezing, milking, and even flushing the drainage tubing. Restoration of patency
is confirmed by a respiration-related swing in the draining tube.
• Tubes got disconnected: This is no great disaster. Reconnect the tubes and ask the
patient to cough; any air that has entered the chest is forced out.
• Tube has been pulled out: If the tube has been pulled out, it needs to be
repositioned. Using all sterile precautions, position a new tube into the chest and
secure it properly. The new tube should not be inserted through the same hole. A
new thoracostomy is used, and the initial site is sealed with a vertical mattress
suture.
• Leak around the tube: A leak around the tube indicates a partial block in the
draining system. If all blocks have been removed and the leak around the tube
persists, a single suture may need to be placed along the side of the tube to narrow
the wound and seal the leak. Use of tapes and heavy dressings to occlude such
leaks is not useful.
• Underwater seal bottle broken: A broken bottle has to be replaced immediately
with a fresh bottle with a 2-hole stopcock, and the underwater seal must be
recreated. Then ask the patient to cough. Any air that has entered the chest is
forced out.

Chest drain complications

• Blocked tube due to poor positioning: Sometimes the tube gets trapped in the
major fissure of the lung. If this occurs, the tube needs to be withdrawn and
reinserted.
• Cardiac dysrhythmia: The tube may abut the mediastinum and occasionally cause
cardiac irregularities. First, try withdrawing the tube 2-3 cm. If this does not
resolve the problem, the tube may need to be reinserted at a separate location.
Medical management of the arrhythmia is also needed.
• Persistent pneumothorax: If a pneumothorax persists, check for obstructions or
leaks. Clear any obstructions and seal any leaks in the drainage system. If no leak
or obstruction is found, apply suction of up to -20 cm of water to the drainage
system.
• Failure of the lung to fully reexpand: This is rarely due to blockage of the tubes,
and change of tubes seldom helps. The common causes of nonexpansion of the
lung are as follows:
o Bronchial blockage leading to collapse, usually by retained sputum
(Fiberoptic bronchoscopy helps clear secretions and rule out other causes
of bronchial obstruction [eg, tumor].)
o The presence of a fibrinous "peel" (cortex) over the lung (This is the
thickened visceral pleura over the collapsed lung tissue and is usual in
cases of delayed treatment of an empyema. A decortication is the best way
to deal with this problem.)
• Infections: Infections occur rarely with chest drains but can range from wound
infection to empyemas. They reflect breaks in sterility and incorrect management
of the chest drain.
• Re-expansion pulmonary edema: This is also a rare chest drain complication and
is seen when large effusions are drained in a short period of time. It is best
prevented by gradual decompression.

Frequently Asked Questions


What size chest drains should be used?

Use as large a tube as will pass comfortably through the intercostal space. By rule of
thumb, in an adult patient, 24-28F is adequate to drain air, but 32-36F may be necessary
to drain fluid.

Can chest drains be clamped?

Never clamp a bubbling drain, as the resultant pneumothorax can cause more problems to
the patient. Check that all connections are secure, and then the patient can be subject to
all nursing procedures, movement, and physiotherapy with no clamps on the drain.[15 ]

When are chest drains clamped?

Drains are clamped only in the following situations:

• When the draining tubes and underwater seal bottle are to be changed
• Just prior to tube removal, as a trial of clamping for 4-6 hours, to confirm that the
air leak has stopped
• When reconnecting an accidentally disconnected tube that resulted in loss of the
underwater seal.
• If the drain is clamped, it should be unclamped as soon as possible by the same
individual who put the clamp on. Clamps are sometimes overlooked when
patients are handed over during shift changes of medical personnel. Clamps that
are not removed lead to deterioration of the patient.

Can a patient with a chest drain inserted be moved?

Yes, patients with chest drains can be moved around as usual. All connections have to be
checked for security, and the underwater seal bottle has to be kept erect at a level of about
100 cm below the patient’s chest.

What suction pressure should be applied?

As a general rule, suction pressures need to be between -10 and -20 cm of water (-2 to - 3
kPa). While up to 25 cm of water suction pressure is needed for massive air leaks, 5 cm
of suction pressure is sufficient to help drain fluid contents out of the chest.

How long should chest drains be left in?

Apposition of the 2 layers of the pleura is essential to seal air leaks and reduce the
drainage. All air leaks eventually stop if the lung can be kept fully expanded constantly.
This usually occurs within a week, but it may take as long as 4-6 weeks.

If the air leak persists, the case needs to be reviewed by a thoracic surgeon. If significant
discharge is evident, but the lung seems to be adherent, conversion to open tube drainage
may be needed.

Do alternatives to underwater bottle drainage exist?

Yes; artificially made one-way valve systems may be alternatives to underwater bottle
drainage.

• The flutter valve (Heimlich): This is a one-way system created with a plastic
diaphragm, which allows air to escape from the chest and yet maintains expansion
of the lung. It is attached to the chest drain and strapped to the patient’s side,
allowing greater mobility of the patient. The flutter valve can be used for
pneumothorax only.
• The intercostal drainage bag: This is a plastic bag built around a tube that reaches
to the bottom of the bag. The bag is then filled with fluid to the prescribed level,
and this acts as the underwater seal. The tube, which is about 1 meter long, is
connected to the intercostal tube. This bag can now collect up to 200 mL of
drainage before the contents have to be drained and fresh fluid poured in to
recreate the underwater seal. The bag can be strapped to the thigh of the patient
and must always be kept erect. If fluid is draining but air is not leaking, a simple
Urosac can be attached to the end of the intercostal tube.

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