Chest drain A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) 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 substance ...

s are surgical drains placed within the

pleural space 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 bet ...

to facilitate removal of unwanted substances (

air The atmosphere of Earth is the layer of gases, known collectively as air, retained by Earth's gravity that surrounds the planet and forms its planetary atmosphere. The atmosphere of Earth protects life on Earth by creating pressure allowing for ...

blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the c ...

fluid In physics, a fluid is a liquid, gas, or other material that continuously deforms (''flows'') under an applied shear stress, or external force. They have zero shear modulus, or, in simpler terms, are substances which cannot resist any shear ...

, etc.) in order to preserve respiratory functions and

hemodynamic Hemodynamics or haemodynamics are the dynamics of blood flow. The circulatory system is controlled by homeostatic mechanisms of autoregulation, just as hydraulic circuits are controlled by control systems. The hemodynamic response continuously mo ...

stability. Some chest drains may utilize a

flutter valve A flutter valve (also known as the Heimlich valve after its inventor, Henry Heimlich) is a Check_valve, one-way valve used in respiratory medicine to prevent air from travelling back along a chest tube. One can also use a Chest_drainage_managemen ...

to prevent retrograde flow, but those that do not have physical valves employ a water trap seal design, often aided by continuous

suction Suction is the colloquial term to describe the air pressure differential between areas. Removing air from a space results in a pressure differential. Suction pressure is therefore limited by external air pressure. Even a perfect vacuum cannot ...

from a wall suction or a portable vacuum pump. The active maintenance of an intrapleural

negative pressure Negative pressure may refer to: * Negative value of a Pressure#Negative pressures, pressure variable * Negative room pressure, a ventilation technique used to avoid contaminating outside areas * Negative pressure ventilator, also known as an iron ...

via chest drains builds the basis of chest drain management, as an intrapleural pressure lower than the surrounding

atmosphere An atmosphere () is a layer of gas or layers of gases that envelop a planet, and is held in place by the gravity of the planetary body. A planet retains an atmosphere when the gravity is great and the temperature of the atmosphere is low. A s ...

allows easier

lung The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...

expansion and thus better

alveolar Alveolus (; pl. alveoli, adj. alveolar) is a general anatomical term for a concave cavity or pit. Uses in anatomy and zoology * Pulmonary alveolus, an air sac in the lungs ** Alveolar cell or pneumocyte ** Alveolar duct ** Alveolar macrophage * ...

ventilation Ventilation may refer to: * Ventilation (physiology), the movement of air between the environment and the lungs via inhalation and exhalation ** Mechanical ventilation, in medicine, using artificial methods to assist breathing *** Ventilator, a ma ...

and

gas exchange Gas exchange is the physical process by which gases move passively by Diffusion#Diffusion vs. bulk flow, diffusion across a surface. For example, this surface might be the air/water interface of a water body, the surface of a gas bubble in a liqui ...

History

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”. Reduction

valve A valve is a device or natural object that regulates, directs or controls the flow of a fluid (gases, liquids, fluidized solids, or slurries) by opening, closing, or partially obstructing various passageways. Valves are technically fittings ...

s that reduce the

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.

Suction process

External

(previously referred to as active suction) is used to create a sub-atmospheric pressure at the tip of a

catheter In medicine, a catheter (/ˈkæθətər/) is a thin tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. Cath ...

. As the atmospheric pressure is lower compared to the

intrapleural 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 be ...

pressure, the lack of external suction (which was previously referred to as passive suction) is used to drain air and fluids. 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.

Drain types

Heber- and Bülau- Drain principles

Two different principles are used in chest drainage management: The Heber-Drain principle and the

Bülau A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) 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 substance ...

-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 In physics, gravity () is a fundamental interaction which causes mutual attraction between all things with mass or energy. Gravity is, by far, the weakest of the four fundamental interactions, approximately 1038 times weaker than the stro ...

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 Pulmonology (, , from Latin ''pulmō, -ōnis'' "lung" and the Greek suffix "study of"), pneumology (, built on Greek πνεύμων "lung") or pneumonology () is a medical specialty that deals with diseases involving the respiratory tract.

Gotthard Bülau (1835-1900) used this system in 1875 for the first time for the treatment of

pleural empyema 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 ...

Mediastinal drain

This type of drainage is mainly used in

cardiac surgery Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease (for example, with coronary artery bypass grafting); to corr ...

Mediastinal The mediastinum (from ) is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is an undelineated region that contains a group of structures within the thorax, namely the heart and its vessels, the esophagu ...

drains are placed behind the

sternum The sternum or breastbone is a long flat bone located in the central part of the chest. It connects to the ribs via cartilage and forms the front of the rib cage, thus helping to protect the heart, lungs, and major blood vessels from injury. Sh ...

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...

Pericardial drain

Drainage of the

pericardium The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong connective tissue (fibrous pericardium), and an inner layer made of ...

can be achieved by puncture (transcutaneously) or surgically. In the first case, small-bore

s 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.

Chest drainage systems

One-chamber-system

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 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 ...

subcutaneous emphysema Subcutaneous emphysema (SCE, SE) occurs when gas or air accumulates and seeps under the skin, where normally no gas should be present. ''Subcutaneous'' refers to the subcutaneous tissue, and ''emphysema'' refers to trapped air pockets resembling t ...

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.

Two-chamber-system

In a two-chamber system air and fluid are directed to a first collection canister.

Gravity In physics, gravity () is a fundamental interaction which causes mutual attraction between all things with mass or energy. Gravity is, by far, the weakest of the four fundamental interactions, approximately 1038 times weaker than the stro ...

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 Surfactants are chemical compounds that decrease the surface tension between two liquids, between a gas and a liquid, or interfacial tension between a liquid and a solid. Surfactants may act as detergents, wetting agents, emulsifiers, foaming ...

that might enter the tubing toward the patient.

Multi-chamber-system

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.

Digital systems

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

. Digital chest drainage systems have many advantages compared to traditional, analogue systems: * Mobility: enhanced mobility increases the quality of life and accelerates the recovery. * Real time data collection: air leaks and fluid production can be tracked in real time by following the

paddle-wheel A paddle wheel is a form of waterwheel or impeller in which a number of paddles are set around the periphery of the wheel. It has several uses, of which some are: * Very low-lift water pumping, such as flooding paddy fields at no more than abo ...

-principle in ml/min * Objective data measurement: discrepancies in evaluation of the clinical course are significantly lower when using an electronic system compared to classical systems. * Double lumen tubing: allows for a separation of fluid and air, sub-atmospheric pressure is measured via the thinner of the two tubes. This allows one to monitor the sub-atmospheric pressure very close to the pleural space; therefore, the system works correctly, irrespective of where it is placed. Data measured next to the

comes quite close to the real pressure within the

* Shortened drainage time: Healing is a dynamic process. On average, one day less is needed for chest drainage time when using electronic systems after anatomic resections * Increased safety, reduced workload: alarm features increase safety of the treatment and reduce the workload of nursing staff Electronic systems do not apply permanent suction but monitor the patient very closely and are activated when needed. On average, after an uncomplicated

lobectomy Lobectomy means ''surgical excision of a lobe''. This may refer to a lobe of the lung (also simply called a lobectomy), a lobe of the thyroid (hemithyroidectomy), a lobe of the brain (as in anterior temporal lobectomy), or a lobe of the liver (h ...

, an electronic pump is active for 90 minutes within 2.5 days.

References

External links

* {{DEFAULTSORT:Chest drainage management systems Emergency medical procedures Intensive care medicine Pulmonology Thoracic surgical procedures