Tube Thoracostomy Management Periprocedural Care

In current practice, commercial chest tube kits are readily available. However, in resource-limited settings, the following equipment is necessary for optimally managing patients with chest tubes:

• Chest drainage bottles (see below)
• Adequate length (1.5-2 m) of sterile, transparent, plastic tubing (eg, vinyl or 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

Chest drainage systems work by combining the following three efforts:

• Expiratory positive pressure from the patient helps push air and fluid out of the chest (eg, cough, Valsalva maneuver)
• Gravity helps fluid drain 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

The typical drainage system consists of three bottles or chambers, as follows:

• Underwater seal chamber (see the first image below)
• Trap bottle or reservoir chamber (see the second image below)
• Suction regulator chamber (see the third image below)

Underwater seal bottle

The underwater seal chamber is the most important element in pleural drainage. It acts as a low-resistance one-way valve for the evacuation of pleural contents. When intrapleural pressure rises (eg, with expiration or coughing), the free contents of the pleural space are forced out through the chest tube and into the underwater seal drainage chamber. ^[8]  Hence, a single-chamber system is optimal only for a pneumothorax. The presence of hemopneumothorax or hydropneumothorax necessitates the use of a three-chamber drainage system.

Reentry of air into the pleural space when intrapleural pressures become negative (eg, with inspiration) is blocked by the underwater seal. The water in this tube is referred to as the "column" of water; its movements reflect the changes in intrathoracic pressure with each inspiration and expiration.

The end of the tube in the underwater seal chamber 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. The end of the tube must not be kept too far below the water surface, because the resistance to expulsion of air from the chest is equal to the length of tubing that is under water. The standard recommendation is to keep the tip of the tube 2-3 cm below the water surface. ^{[9, 10]}

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 chamber is introduced between the chest tube and the underwater seal. The trap chamber 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. ^[11]

Suction regulator bottle

A third chamber is introduced to the system to provide suction, which is thought to hasten lung expansion.

The suction regulator chamber has a three-hole stopcock. Short tubes are passed through two 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 third hole, passing below the level of water in this bottle.

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.

This constant level of low-pressure suction is now transmitted to the underwater seal bottle and then into the pleural cavity, thereby aiding evacuation of contents with a uniform pressure. The maximum force of suction is determined by the depth of the atmospheric vent underwater in the suction regulation bottle. ^[10]

To obtain a suction of –20 cm H₂O, set the tip of the tube 20 cm below the surface of the fluid. Then, 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 H₂O is now transmitted to the underwater seal and on to the chest drain.

The role of suction is now being debated, with some studies favoring the use of suction versus others not favoring the use of suction in patients with chest tubes, for prevention of postoperative air leakage and pneumothorax. ^{[12, 13]}

Multifunction chest drainage system

Contemporary chest tube kits contain a three-chamber system incorporated into one multifunction chest drainage system. The multiple bottles and numerous connections of the typical three-bottle system result in a bulky bedside device, which can be prone to accidental disconnections and blockages. In addition, sterility is difficult to maintain. These systems, therefore, have been largely replaced by commercially produced disposable plastic multifunction units (eg, Codman, Pleurovac, and Atrium [see the image below]) that fit into a single box and work on the same principles.

The kits are designed to incorporate the functions and improve on the safety features of the traditional three-bottle drainage system. They offer patient protection with effective drainage, accurate fluid loss measurement, and assistance in detecting air leaks.

The multifunction systems allow single-catheter 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.

Each multifunction chest drainage system contains the following:

• A collection chamber - Fluids drain directly into this chamber, which is calibrated in milliliters
• The middle chamber (the water seal) - This is a one-way valve, with a U-tube design that can monitor air leaks and changes in intrathoracic pressure
• A suction control chamber - This chamber is also a U-tube, with the narrow arm serving as the atmospheric vent and the large arm as the fluid reservoir; the water level in this chamber, and not the suction regulator, regulates the amount of suction pressure, and thus, controlling negative pressure is relatively easy ^[14]

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. ^[15]

Dry suction systems

Suction systems in present use are dry suction systems incorporating a dry suction regulator with fully calibrated water seal drainage. ^[14]

Digital suction systems

Multifunction chest drainage systems with digitally calibrated and regulated suction mechanisms are available. ^{[16, 17, 18]}  These systems are characterized by the following:

• Ability to regulate the intrapleural pressure by presetting the device for a required length of time or frequency (eg, continuous vs intermittent)
• Ability to quantify air leak precisely, thus reducing interobserver variability and decreasing chest tube duration as well as length of hospital stay ^{[16, 17, 18]}
• Ability to store information on the pattern and quantity of drainage over time and to retrieve that information in a graphical or numeric manner ^[16]

Anesthesia

After chest-tube placement, anesthesia is not required during the management phase. For more information on placement of a chest tube, see Tube Thoracostomy. ^[7]

At the time of tube removal, in an adult, 5 mL of 1% lidocaine hydrochloride is infiltrated with a 24-gauge needle around the emerging tube at the chest wall. Alternatively, premedication with oral or intravenous (IV) narcotic medication can be considered before chest-tube removal.

Positioning

Patient positioning

Keep the patient in a semirecumbent position (ie, 45-90°). The semi-Fowler position is useful to evacuate air (pneumothorax). ^[19]  The high Fowler position is useful for draining fluid (hemothorax).

Adjust tubing to hang in a straight line from the chest tube to the drainage chamber, avoiding excess length and loops.

Drainage system positioning

Regardless of the type of drainage system used, it should always be placed erect and approximately 100 cm below the level of the patient’s chest. This placement aids gravity drainage of chest contents into the drainage system and prevents reentry of fluid into the chest during inspiration. ^{[8, 20, 21]}

Chest-tube site dressing

In the authors' view, major obtrusive dressings around the chest tube are unnecessary and potentially dangerous. They can potentially kink the tube, thereby obstructing the tube and potentially allowing reaccumulation of air or liquid.

The correct taping of the emerging chest tube from the patient is with a "mesentery" 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.

A prospective randomized controlled study by Wood et al compared three dressing types and procedures after chest-tube placement: (1) gauze-and-tape dressing changed daily, (2) gauze-and-tape dressing changed every 3 days, and (3) silicone foam dressing changed every 3 days. ^[22] Patients with silicone foam dressings reported less pain at the insertion site than did those with gauze-and-tape dressings, and patients with daily dressing changes reported significantly more pain with dressing removal than did those with dressing changes every 3 days. The silicone foam dressing was associated with better skin integrity than the gauze-and-tape dressing.

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 1.5- to 2-m patient tube to the thoracic catheter. Connect the drain to the vacuum.

Slowly increase vacuum pressure until gentle bubbling appears in the suction control chamber. Be sure not to allow too much bubbling in the suction control chamber. Vigorous bubbling is loud and disturbing to most patients, and it causes rapid evaporation in the chamber, which lowers the level of suction.