Chest drainage | |
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Specialty | cardiothoracic surgery |
Chest drains are surgical drains placed within the pleural space to facilitate removal of unwanted substances (air, blood, fluid, etc.) in order to preserve respiratory functions and hemodynamic stability. Some chest drains may utilize a flutter valve to prevent retrograde flow, but those that do not have physical valves employ a water trap seal design, often aided by continuous suction from a wall suction or a portable vacuum pump.
The active maintenance of an intrapleural negative pressure via chest drains builds the basis of chest drain management, as an intrapleural pressure lower than the surrounding atmosphere allows easier lung expansion and thus better alveolar ventilation and gas exchange.
The so-called “central vacuum” was the first sub-atmospheric pressure device available. Sub-atmospheric pressure of around 100 cm of water column was historically generated at a central location in the hospital. This “central vacuum” was available throughout the entire hospital, as it was proved via a tubing system. It was referred to as “wall suction”.[ citation needed ]
Reduction valves that reduce the negative pressure to a therapeutically reasonable range were commercially available later. Due to this, multi-chamber suction – the use of three-chamber systems – was developed. In the 1960s, the first pumps (Emerson-Pump) were available. These and other systems launched later generated a fixed “negative pressure”. These pumps couldn’t compensate for an inadequate position of the collection chamber of a siphon. Since 2008, an electronically driven and regulated system is available, generating a “negative pressure” on demand.
External suction (previously referred to as active suction) is used to create a sub-atmospheric pressure at the tip of a catheter. As the atmospheric pressure is lower compared to the intrapleural pressure, the lack of external suction (which was previously referred to as passive suction) is used to drain air and fluids. [1] Traditional drainage systems are not able to suction sub-atmospheric pressure in the pleural space. These systems only allow for a regulation of pressure via the system itself but cannot regulate sub-atmospheric pressure in the pleural space.[ citation needed ]
Two different principles are used in chest drainage management: The Heber-Drain principle and the Bülau-Drain principle. The “Heber-Drain” is based on the Heber principle, which uses hydrostatic pressure to transfer fluid from the chest to a collection canister. It produces permanent passive suction. As the Heber drain is a classical gravity drain, the canister must be placed below chest level to be active. The difference in height between the floor and the patient bed determines the resultant sub-atmospheric pressure. With a difference, for example, of 70 cm in height, a pressure of minus 70 cm of water is created. A water seal component is always combined with a Heber-Drain.
The “Bülau-Drain” is based on the Bülau principle and creates a permanent passive suction within a closed system that is based on the Heber-Drain principle. The pulmonologist Gotthard Bülau (1835-1900) used this system in 1875 for the first time for the treatment of pleural empyema.[ citation needed ]
This type of drainage is mainly used in cardiac surgery. Mediastinal drains are placed behind the sternum and/or next to the heart. The main indication in these cases is the monitoring of post-operative bleeding. Whether these drains are used with active suction or not depends on factors such as personal preference and experience of the physician, individual patient-related factors etc...[ citation needed ]
Drainage of the pericardium can be achieved by puncture (transcutaneously) or surgically. In the first case, small-bore catheters not suitable for the drainage of blood (e.g. hemopericard) are used. Pericardial drains are mostly used with the help of gravity. As a pericardial drain is placed surgically, a largo bore drain is used with a decreased probability of clogging.[ citation needed ]
The simplest system that is sufficient for chest drainage is a one-chamber system. It uses either a Heber-drain or an active suction source and comprises a single collection canister. For active or passive air evacuation, a water seal component is attached. To ensure that all air is sucked out when using a Heber-drain, manual support might be needed. To prevent a pneumothorax or subcutaneous emphysema when the patient is not able to breathe out or cough out surplus air, the height between the patient bed and the ground might need adjustment. As air leaks are not always easy to observe, some one-chamber systems are limited when it comes to the treatment of huge air leaks, especially when the patient produces a lot of foam.
In a two-chamber system air and fluid are directed to a first collection canister. Gravity keeps the fluid in the first canister, whereas air is directed into a second canister. The air can either actively or passively be released via a water seal. Two-chamber systems are mainly used for patients with huge air leaks. These patients often produce foam due to protein rich surfactant that might enter the tubing toward the patient.[ citation needed ]
Early three-chamber systems used an extra glass bottle filled with water as a third water-vacuometer chamber in addition to a two-chamber system. The sub-atmospheric pressure was controlled with a pipe. The higher the pipe depth, the lower the generated pressure in the pleural space. These systems were used in times of the central vacuum and are not used anymore as they caused accidents and were not very ease to use. The mechanics of these systems depended on high flows (20l/min) for the system to be considered active.
In modern portable, digital chest drainage systems, the collection chamber is integrated into the system. During the suction process, fluid will be collected in the chamber and air discharged into the atmosphere. [2]
Digital chest drainage systems have many advantages compared to traditional, analogue systems:
Electronic systems do not apply permanent suction but monitor the patient very closely and are activated when needed. On average, after an uncomplicated lobectomy, an electronic pump is active for 90 minutes within 2.5 days.
The pleural cavity, pleural space, or interpleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication between the membranes, and also to create a pressure gradient.
A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve is formed by an area of damaged tissue, and the amount of air in the space between chest wall and lungs increases; this is called a tension pneumothorax. This can cause a steadily worsening oxygen shortage and low blood pressure. This leads to a type of shock called obstructive shock, which can be fatal unless reversed. Very rarely, both lungs may be affected by a pneumothorax. It is often called a "collapsed lung", although that term may also refer to atelectasis.
Pleurisy, also known as pleuritis, is inflammation of the membranes that surround the lungs and line the chest cavity (pleurae). This can result in a sharp chest pain while breathing. Occasionally the pain may be a constant dull ache. Other symptoms may include shortness of breath, cough, fever, or weight loss, depending on the underlying cause. Pleurisy can be caused by a variety of conditions, including viral or bacterial infections, autoimmune disorders, and pulmonary embolism.
A pleural effusion is accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung. Under normal conditions, pleural fluid is secreted by the parietal pleural capillaries at a rate of 0.6 millilitre per kilogram weight per hour, and is cleared by lymphatic absorption leaving behind only 5–15 millilitres of fluid, which helps to maintain a functional vacuum between the parietal and visceral pleurae. Excess fluid within the pleural space can impair inspiration by upsetting the functional vacuum and hydrostatically increasing the resistance against lung expansion, resulting in a fully or partially collapsed lung.
An exudate is a fluid emitted by an organism through pores or a wound, a process known as exuding or exudation. Exudate is derived from exude 'to ooze' from Latin exsūdāre 'to sweat'.
Pleural empyema is a collection of pus in the pleural cavity caused by microorganisms, usually bacteria. Often it happens in the context of a pneumonia, injury, or chest surgery. It is one of the various kinds of pleural effusion. There are three stages: exudative, when there is an increase in pleural fluid with or without the presence of pus; fibrinopurulent, when fibrous septa form localized pus pockets; and the final organizing stage, when there is scarring of the pleura membranes with possible inability of the lung to expand. Simple pleural effusions occur in up to 40% of bacterial pneumonias. They are usually small and resolve with appropriate antibiotic therapy. If however an empyema develops additional intervention is required.
Pleurodesis is a medical procedure in which part of the pleural space is artificially obliterated. It involves the adhesion of the visceral and the costal pleura. The mediastinal pleura is spared.
A chest tube is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substances such as air (pneumothorax), excess fluid, blood (hemothorax), chyle (chylothorax) or pus (empyema) from the intrathoracic space. An intrapleural chest tube is also known as a Bülau drain or an intercostal catheter (ICC), and can either be a thin, flexible silicone tube, or a larger, semi-rigid, fenestrated plastic tube, which often involves a flutter valve or underwater seal.
A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons to gain access to the thoracic organs, most commonly the heart, the lungs, or the esophagus, or for access to the thoracic aorta or the anterior spine. A thoracotomy is the first step in thoracic surgeries including lobectomy or pneumonectomy for lung cancer or to gain thoracic access in major trauma.
A pulmonary sequestration is a medical condition wherein a piece of tissue that ultimately develops into lung tissue is not attached to the pulmonary arterial blood supply, as is the case in normally developing lung. This sequestered tissue is therefore not connected to the normal bronchial airway architecture, and fails to function in, and contribute to, respiration of the organism.
A hemothorax is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury, but they may occur spontaneously due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to Pneumothorax, or rarely in association with other conditions.
A chylothorax is an abnormal accumulation of chyle, a type of lipid-rich lymph, in the space surrounding the lung. The lymphatics of the digestive system normally returns lipids absorbed from the small bowel via the thoracic duct, which ascends behind the esophagus to drain into the left brachiocephalic vein. If normal thoracic duct drainage is disrupted, either due to obstruction or rupture, chyle can leak and accumulate within the negative-pressured pleural space. In people on a normal diet, this fluid collection can sometimes be identified by its turbid, milky white appearance, since chyle contains emulsified triglycerides.
Thoracentesis, also known as thoracocentesis, pleural tap, needle thoracostomy, or needle decompression, is an invasive medical procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia. The procedure was first performed by Morrill Wyman in 1850 and then described by Henry Ingersoll Bowditch in 1852.
Esophageal rupture is a rupture of the esophageal wall. Iatrogenic causes account for approximately 56% of esophageal perforations, usually due to medical instrumentation such as an endoscopy or paraesophageal surgery. In contrast, the term Boerhaave syndrome is reserved for the 10% of esophageal perforations which occur due to vomiting.
A surgical drain is a tube used to remove pus, blood or other fluids from a wound, body cavity, or organ. They are commonly placed by surgeons or interventional radiologists after procedures or some types of injuries, but they can also be used as an intervention for decompression. There are several types of drains, and selection of which to use often depends on the placement site and how long the drain is needed.
A Jackson-Pratt drain is a closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites. The device consists of an internal drain connected to a grenade-shaped bulb or circular cylinder via plastic tubing.
A thoracostomy is a small incision of the chest wall, with maintenance of the opening for drainage. It is most commonly used for the treatment of a pneumothorax. This is performed by physicians, paramedics, and nurses usually via needle thoracostomy or an incision into the chest wall with the insertion of a thoracostomy tube or with a hemostat and the provider's finger,
Pulmonary hygiene, formerly referred to as pulmonary toilet, is a set of methods used to clear mucus and secretions from the airways. The word pulmonary refers to the lungs. The word toilet, related to the French toilette, refers to body care and hygiene; this root is used in words such as toiletry that also relate to cleansing.
A bronchopleural fistula (BPF) is a fistula between the pleural space and the lung. It can develop following pneumonectomy, lung ablation, post-traumatically, or with certain types of infection. It may also develop when large airways are in communication with the pleural space following a large pneumothorax or other loss of pleural negative pressure, especially during positive pressure mechanical ventilation. On imaging, the diagnosis is suspected indirectly on radiograph. Increased gas in the pneumonectomy operative bed, or new gas within a loculated effusion are highly suggestive of the diagnosis. Infectious causes include tuberculosis, Actinomyces israelii, Nocardia, and Blastomyces dermatitidis. Malignancy and trauma can also result in the abnormal communication.
In physiology, intrapleural pressure refers to the pressure within the pleural cavity. Normally, the pressure within the pleural cavity is slightly less than the atmospheric pressure, which is known as negative pressure. When the pleural cavity is damaged or ruptured and the intrapleural pressure becomes greater than the atmospheric pressure, pneumothorax may ensue.