Tube Thoracostomy Management Technique

The following questions are frequently asked in the context of chest-tube management.

What size chest drains should be used?

Use as large a tube that passes comfortably through the intercostal space. As a general rule, in an adult patient, 24-28 French is adequate for draining air, but 32-36 French may be necessary for draining fluid.

Can chest drains be clamped?

A bubbling drain should never be clamped, because the resultant pneumothorax can cause more problems for the patient. A check should be performed to confirm that all connections are secure; once this is done, the patient can be subject to all nursing procedures, movement, and physiotherapy with no clamps on the drain. ^[23]

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 before tube removal, as a trial of clamping for 4-6 hours to confirm that the air leak has stopped
• When it is necessary to reconnect 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’s condition.

Can a patient with a chest drain inserted be moved?

Patients with chest drains can be moved around as usual. All connections must be checked for security, and the underwater seal bottle must 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 should be between –10 and –20 cm H₂O (–2 to –3 kPa). Whereas a suction pressure as high as –25 cm H₂O may be needed for massive air leaks, a suction pressure of –5 cm H₂O is sufficient to help drain fluid contents out of the chest.

How long should chest drains be left in?

Apposition of the two 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 1 week, but it may take as long as 4-6 weeks.

If the air leak persists, the case should 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?

Artificially made one-way valve systems may be alternatives to underwater bottle drainage.

The flutter valve (Heimlich) 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, affording the patient greater mobility. The flutter valve can be used for pneumothorax only.

The intercostal drainage bag is a plastic bag built around a tube that reaches to its bottom. The bag is filled with fluid to the prescribed level, and this acts as the underwater seal. The tube, which is about 1 m long, is connected to the intercostal tube. As much as 200 mL of drainage can be collected before the contents must be drained and fresh fluid poured in to recreate the underwater seal. The bag can be strapped to the patient's thigh 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. ^[23]

Analgesia

Postprocedural pain control is of vital importance in the management of patients with chest tubes. Optimal pain control leads to better patient cooperation for chest exercise and physical therapy. No prospective trials are available in regard to standardizing the pain control regimen for these patients.

Typically, the recommended analgesic options in an alert patient are as follows:

• Opioids (eg, morphine) - Oral, intravenous [IV], or patient-controlled pumps
• Nonsteroidal anti-inflammatory drugs (NSAIDs; eg, ketorolac) - Oral or IV
• Intercostal nerve blocks or epidural analgesia for patients with associated rib fractures or postoperative indwelling chest catheters

At the time of chest tube removal, adequate analgesia should be considered for patient comfort. This can usually be achieved with a single systemic dose of an opioid or an NSAID, infiltration of a local anesthetic (eg, lidocaine) around the chest tube entry site, or both.

Breathing exercises and chest physiotherapy

Breathing exercises and chest physiotherapy are the main keys for achieving quick lung expansion and faster recovery. Incentive spirometry (eg, with the TriFlo incentive spirometer) provides the impetus for expanding the lung quickly. Upper-limb movements, especially at the shoulder, help restore the movements of the chest wall. Steam inhalations and nebulized bronchodilators may also encourage quick lung expansion.

Nursing management

In 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 level of comfort
• Ensure that the dressing is occlusive, and note whether the chest tube is on negative pressure or is to water seal

Keep the patient in a propped-up position (ie, 45-90°). The semi-Fowler position is useful for evacuating air (pneumothorax). ^[19]  The high Fowler position is useful for draining fluid (hemothorax). Adjust the 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. All joints must be well taped with adhesive. 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. The bottle should be erect and at least 100 cm below the level of the patient’s chest.

In addition to vital signs, the following items should be monitored routinely:

• Swinging or oscillation of the column of water in the water seal chamber
• Blowing or air bubbling in drainage chamber 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 may have closed
• Type and quantity of drainage - Inform the practitioner if drainage exceeds 70 mL/hr or if the quality of the drainage changes to frank blood

Never lift the drainage system above the level of the patient’s chest; doing so may cause fluid from the system to siphon back into the patient’s chest.

Keep two (angled) clamps at the bed side.

Do not clamp a bubbling chest drain. ^[24]  All nursing procedures, patient movement, and physiotherapy are permitted without clamping the drain, with the drainage system kept below the patient’s chest level at all times. Clamp tubes only for procedures related to the tube or system (eg, changing, emptying, or reconnecting the tubing or the system).

Avoid kinks in the tubing. Teach the patient to look for kinks and to avoid sitting or lying on the tube(s).

"Milk" the tube(s) regularly to avoid blockage by fibrin plugs or clots. If fibrin plugs form, small doses (1 mg to 1 mL sterile solution dilution) of recombinant tissue plasminogen activator (r-tPA) may be used to restore patency. ^[25]

Change the connecting tube and drainage system as required, and replace them with sterile equivalents. Wash and disinfect equipment to remove all residue before sterilization.

When connecting two emerging chest tubes to a single drainage unit, use a Y-shaped connector—not a T-shaped connector, which causes kinks in the tubes. Additionally, be sure to equalize the lengths of the emergent tubes before the Y connector; this avoids kinking of unequal lengths of tube. ^[10]

Suction

Traditionally, all chest tubes have been connected to wall suction after placement; however, firm evidential support for this practice is lacking. The literature on the use of suction is conflicting, with some studies demonstrating early resolution of air leaks with suction and others showing that suction prolongs the resolution of air leakage and hence delays chest-tube removal. ^{[12, 13, 17, 18, 25]}

Additionally, only moderate-quality evidence supports the view that suction reduces the incidence of pneumothorax as compared with water seal in the postoperative period. ^{[12, 18]}  In a systematic review and meta-analysis comparing suction with water seal for tube thoracostomy after traumatic chest injury, suction appeared to have a positive effect on duration of chest-tube treatment, length of hospital stay, and persistent air leakage; however, the available data were limited, and the quality of evidence was (very) low to moderate. ^[26]

Regardless, the practice of connecting chest tubes to suction, at least during the initial 1-2 days, remains common. Of note, when suction is needed, it should be a constant low-pressure suction to fully remove the pleural contents without causing patient discomfort.

The recommended level of suction is –5 to –20 cm H₂O. (The –20 cm H₂O figure is based on convention, not research.)

Theoretically, suction can improve the speed at which air and fluid are removed from the chest. Greater negative pressure can increase the flow rate out of the chest, but it can also damage lung tissue.

Radiography

Daily chest radiographs are usually obtained to monitor and confirm the expansion of the lung; however, no first-class evidence exists to support this practice. There is evidence to suggest that routine postthoracostomy chest radiography does not significantly change management and that radiographic investigation should be guided by adverse clinical outcomes or procedural factors. ^[27]

Antibiotics

Antibiotics are not required during the presence of a chest drain for a simple pneumothorax or hydrothorax.

Cefazolin—a first-generation beta-lactam cephalosporin—can be used prophylactically to prevent the development of an empyema when a chest drain is used in thoracic trauma. ^[28]

Pearls

The underwater seal acts as a one-way valve through which air is expelled and prevented from reentering the pleural space during the next inspiration.

The collection chamber should be kept below the level of the patient’s chest at all times to prevent fluid from being siphoned into the pleural space.

The 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 may indicate a continuing bronchopleural air leak.

Clamping a pleural drain in the presence of a continuing air leak may result 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 system, a graduated air-leak meter (calibrated from 1 to 5) provides a way to measure the leak and monitor it over time. ^[15]

General recommendations regarding the criteria and timing of chest tube removal exist; however, level 1 studies to guide a uniform chest-tube removal practice are lacking. Several studies have presented institution-based protocols or algorithms to drive chest-tube removal decisions ^[6] ; however, the reliability of these algorithms has not been validated with prospective randomized controlled trials.

In current practice, chest-tube removal guidelines are individualized on the basis of the institution's or surgeon's preference. Main considerations include the following ^[6] :

• Initial indication for chest-tube placement
• Whether the patient is mechanically ventilated
• Daily chest-tube output
• Presence of an air leak
• Full expansion of lungs on chest radiographs

The timing of tube removal depends on clinical and radiologic evidence of complete drainage of all abnormal contents of the pleural cavity, as well as complete expansion of the lung.

Minimal drainage should have occurred over the previous 24 hours. Level 1 recommendations state that this should be less than 2 mL/kg/day or less than 200-300 mL over a 24-hour period in adults. ^[29]  Studies have also suggested that removal of chest tubes with 400-450 mL/day of fluids is also safe. ^{[16, 18]}

Additionally, no air leak should be present—that is, no bubbling should be seen in the air-leak chamber during forced expiratory maneuvers (eg, Valsalva maneuver) or cough. 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. Evaluation for air leak by means of this nonobjective method falls prey to interobserver variability.

Digital drainage systems have the advantage of accurately measuring the presence of air leak and thereby eradicating interobserver variability. ^{[16, 17]} These devices are gaining increasing popularity and are the subject of ongoing research on tube thoracostomy management. Additionally, they may play a useful role in younger pediatric patients who are unable to perform forceful expiratory maneuvers or cough on demand; however, this possibility has not yet been well studied.

The values determining safe chest-tube removal in patients who are connected to the newer digital drainage systems are as follows ^[18] :

• < 50 mL/min in 12 hours or
• < 20 mL/min in 8 hours

In adult patients with pneumothorax, a trial period of tube clamping ^[30] for 6 hours may be performed. A repeat chest radiograph is then obtained. Complete expansion of the lung seen on the repeat chest radiograph confirms that the lung leak has sealed (output < 200 mL/day) and that proper adhesion between the layers of pleura has occurred (no identifiable air leak). The tube may be safely removed at that time.

In the authors’ pediatric surgery practice, after a 24- to 48-hour period of wall suction, patients may be placed on a 24-hour period of water seal without suction. After this latter period, if no air leak is present, the chest tube is discontinued and a follow-up chest radiograph obtained to confirm complete lung expansion and rule out a recurrent pneumothorax. A residual pneumothorax smaller than 10% of the original size does not warrant any intervention; however, a larger pneumothorax may suggest persistent or missed air leakage and may necessitate replacement of a chest drainage catheter.

Tube thoracostomy removal is a sterile procedure that requires a practitioner and an assistant. Before removal, the patient should be given a dose of analgesia. In adults, subcutaneous infiltration of 5 mL 1% lidocaine hydrochloride with a 24-gauge needle around the emerging chest drain can increase patient comfort.

Cut loose the securing stitches while the tube is being supported. Free the mattress (sealing) stitch that was inserted and kept long at the time of tube insertion. If this stitch is not in position, consider placing a vertical mattress stitch with a nonabsorbable suture material (eg, silk) across the center of the incision.

Hold the ends of the mattress suture ready to tie a knot. Instruct the patient to hold the breath at either deep inspiration or expiration (the incidence of pneumothorax after tube removal is not different). ^{[31, 32]}  Gently ease out the tube while simultaneously tying the knot to close the track.

Apply a soft dressing with petrolatum gauze underneath a pad of 4 × 4 gauze pieces. Apply silk or foam tape. If the stitch breaks or cuts through, simply compress the oblique track and apply the occlusive dressing described above.

A chest radiograph is repeated 4 hours after the removal of the tube thoracostomy. The results of this radiograph should confirm that no air has entered the chest and that the lung continues to be fully expanded.

In a systematic review and meta-analysis of 29 studies that included 4981 tube thoracostomies for traumatic indications, Hernandez et al reported an overall median complication rate of 19%. ^[33] Complication subtypes included the following:

• Insertional (15.3%)
• Positional (53.1%)
• Removal (16.2%)
• Infectious/immunologic (14.8%)
• Malfunction (0.6%)

Troubleshooting for chest tube management is summarized in Table 1 below. ^{[34, 35]}

Table 1. Troubleshooting Chest Drain Management ^{[34, 35]} (Open Table in a new window)