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Ann Thorac Surg 1997;63:1497-1502
© 1997 The Society of Thoracic Surgeons

Collective Reviews

Thoracic Drainage

Edward R. Munnell, MD

Section of Thoracic and Cardiovascular Surgery, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma


   Abstract
Top
 Footnotes
 Abstract
Introduction
 The Beginning
 Open Drainage
 Thoracic Catheters
 Thoracic Drainage Systems
 Management Considerations
 Suction
 References
 
The evacuation of empyemas first performed centuries ago, marked the beginning of thoracic drainage. The subsequent acquisition of a greater knowledge of the anatomy, physiology, and pathology of the pleural space directed the design of thoracic catheters and drainage systems and the development of the methods by which they are used. Furthermore, a better understanding of the physics of vacuum and air flow brought about improvements in the use of suction with drainage. Today, thoracic catheters, chest drainage systems, and most vacuum sources are well designed and well made and incorporate components needed to achieve the best care of the pleural-mediastinal space. This review covers the development and important considerations in the current use of thoracic drainage.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
The Beginning
 Open Drainage
 Thoracic Catheters
 Thoracic Drainage Systems
 Management Considerations
 Suction
 References
 
Thoracic drainage systems are designed to remove air, liquids, and solids (fibrinous elements) from the pleural space or mediastinum, which collect there as a result of injury, disease, or surgical procedures. Twenty years ago there were roughly three dozen drainage systems and a variety of vacuum pumps available, and this often led to confusion regarding patient care. A study conducted in 1975 showed that the ideal system should meet the reasonable special needs of the users, be simple and inexpensive, and safely fulfill the physiologic and therapeutic needs of the patient [1].

A prerequisite of the reasonable use of chest tubes and drainage devices, however, is an understanding of the surgical anatomy, physiology, and pathology of the chest, pleural space, and mediastinum as well as the physics of suction drainage.


   The Beginning
Top
 Footnotes
 Abstract
 Introduction
 The Beginning
Open Drainage
 Thoracic Catheters
 Thoracic Drainage Systems
 Management Considerations
 Suction
 References
 
The open drainage of empyemas was performed frequently in the fifth century BC according to the writings of Hippocrates [2]. In the 15th century AD, Celsius described the performance of rib resection that included the use of a trocar and then a metal cannula for drainage, instruments similar to ones still available today [2]. The foundation of our present methods of thoracic drainage was reported in 1875 by Playfair [3]. In treating an empyema he solved the problem of pneumothorax by continuous subaqueous drainage of the pleural space (Fig 1Go). In 1910 Robinson [4] added suction to thoracic drainage by using vacuum air pumps. Later Lilienthal [5] described a simpler method that involved the use of a pair of bottles. Subsequent changes evolved as the result of the use of new materials and manufacturing techniques.



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  		Fig 1. . Water seal drainage of the pleural space, the technique developed by Playfair in 1873. (Reprinted from [2] by permission of Vantage Press.)

 

   Open Drainage
Top
 Footnotes
 Abstract
 Introduction
 The Beginning
 Open Drainage
Thoracic Catheters
 Thoracic Drainage Systems
 Management Considerations
 Suction
 References
 
Although it has its beginnings in antiquity, open thoracic drainage is still an integral part of the treatment of empyema or mediastinal infections. Once the infection is controlled, more definitive management of the cause and effects can then be instituted. On rare occasions, open drainage may need to be permanent, because of the nature of the pathologic condition or debility. Methods of open drainage include the precise placement of a large tube or multiple tubes, segmental rib resection at a dependent site followed by the placement of large tubes [5], the occasional addition of sump drainage with or without irrigation [6], and open skin-pedicle drainage (Eloesser flap) [7].


   Thoracic Catheters
Top
 Footnotes
 Abstract
 Introduction
 The Beginning
 Open Drainage
 Thoracic Catheters
Thoracic Drainage Systems
 Management Considerations
 Suction
 References
 
Chest tubes have witnessed their own evolution, starting with Playfair's caoutchouc (India gum rubber) tube, used in the late 1800s [2]; to red rubber tubes, first used in the 1920s [5], to designed plastic catheters, introduced in 1961 by Sherwood Medical (St. Louis, MO).

In 1975 catheters were manufactured in many sizes, from 6F to 40F in 2F increments. However, once a study showed that the most popular sizes were 28F, 32F, and 36F for adults and 16F, 20F, and 24F for pediatric patients [1], manufacturers stopped making catheters in the rarely used sizes, which was of benefit to all. Polyethylene catheters (Intracath), small plastic tubes (14 to 18 gauge) [8], or J-shaped catheters [9] were recommended for use in neonates with spontaneous pneumothorax or pneumothorax after needle biopsy of the lung [10]. Currently, straight, right-angle, and trocar chest catheters as well as multichannel tubes for sump-irrigation drainage made of polyvinyl chloride, silicone elastomer, or silicone are available. Most have a radiopaque line, multiple inlet holes, and a flared end to allow for attachment to the drainage unit. Approximately 1,330,000 catheters are used annually in the United States at a total cost of $10.6 million (1995 data) [11].

Salient descriptions of the insertion sites and methods of chest tube insertion have been published by Fishman [12], Miller and Sahn [8], Symbas [13], Munnell [14], and Gregoire and Deslauriers [15]. Some of the considerations brought up by these authors merit emphasis. For example, a 14- or 16-gauge needle or angiocath can be inserted quickly in the second or third interspace in the midclavicular line for the management of a life-endangering pneumothorax [14]. Usually chest tubes are inserted in the third to sixth intercostal space in the anterior or midaxillary line and then directed cephalad for the evacuation of free air or posteriorly for the evacuation of fluid. In addition, during thoracotomy a right-angle tube can readily be directed toward the costophrenic angle, but the tube position should avoid possible occlusion by diaphragmatic motion.

Loculated fluids can be drained by a tube using the exploring needle as a positioning guide. Occasionally a high posterior loculation must be drained at a point midway between the medial border of the scapula and the spinous process of the seventh cervical vertebra [16].

Fundamentally the preparation for chest tube insertion includes thorough and ample skin sterilization with an antiseptic such as povidone iodine, sterile draping, and complete local anesthesia of all chest wall layers. Local anesthesia is often enhanced by a brief delay to allow for thorough diffusion of the anesthetic [14]. The importance of anesthesia was emphasized by Lilienthal [5], who in 1926 observed that "the first rule in puncturing the chest is to avoid pain." Whether it is a needle, blunt dissection, or a trocar being passing through rib interspaces, a further technique for reducing postprocedural pain is to hug the top edge of the lower rib during passage of the instrument, which minimizes injury to the intercostal vessels and nerves [12].

The debate over which technique should be used for insertion of a chest tube must be resolved by the person placing the chest tube, who must consider the positive and negative attributes of each technique. All of these are described in the following paragraphs.

  1. Today many believe that external trocars should not be used for tube insertion (Fig 2AGo) [12, 13, 15]. Nonetheless, a few surgeons employ this technique and trocars are shown in current instrument catalogs (Pilling 1993, V. Mueller 1988). However, the size of the cannula limits the size and style of the chest tube, and the chance puncture of intrathoracic or intraabdominal organs is a danger associated with this method.
  2. Perhaps the safest approach is to create an open thoracostomy with an incision and then bluntly develop a tract large enough to admit a finger so that the pleural space can be inspected and then a tube held in a Kelly clamp passed through the opening (Fig 2BGo) [13, 17]. However, this can often be painful and the opening is larger than that needed to accommodate the tube alone, with the result that leakage can occur. This technique is also, more time consuming than others, and pleural contents can be spilled during tube placement, with the consequence that a nosocomial infection could result while the drainage is initiated.
  3. Use of the trocar catheter is discouraged by some [12, 13], but its popularity depends on the operator's experience (Fig 2CGo). In addition, its safe use depends on attention to detail: the site, the space confirmed by aspiration, and strict attention to the control of the trocar (ie, immediately after penetration of the pleura, the trocar should be withdrawn about 3 cm before further advancement of the catheter) [8, 14]. The trocar remaining in the tube can facilitate tube positioning.
  4. A recent addition to chest tube technology is the Seldinger technique, in which tract-dilating obturators and a chest tube are passed over a J-wire guide (Cook Critical Care, Elletsville, IN) (Fig 2DGo) [18]. This is both a safe and cost-effective option.



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  		Fig 2. . Four methods of chest tube insertion (placement): (A) Trocar and cannula, (B) blunt dissection, (C) trocar chest tube, and (D) flexible guidewire, dilator, and obturator with a chest tube. (A, Reprinted by permission from Sloan H. Blunt chest trauma. Boston: Little, Brown, 1977. C, Reprinted from [12] by permission of Mosby–Year Book. D, Reprinted by permission of Cook Critical Care.)

 
The insertion of a thoracic catheter is an invasive procedure and is therefore subject to iatrogenic complications. Chest wall pain is a procedural complication and can be prevented by adequate local anesthesia, choosing a chest tube that easily fits within the interspace, daily care of the chest tube site, the provision of adequate analgesia, and careful attention to technique during tube insertion [14]. The tube can be positioned into the axillary space, if one overlooks the fact that the bony thorax is a truncated cone with the smallest base at the thoracic inlet. Occasionally a nondraining tube is found to be located in an interlobar fissure, which is apparent only on a lateral chest x-ray study [19]. A tube site too low on the chest wall (usually below the sixth interspace) may lead to perforation of the diaphragm and even the spleen, liver, or stomach [13]. Injury to an intercostal artery, and/or an intercostal nerve or vein [20], and near-fatal hemorrhage resulting from puncture of the internal mammary artery have also been reported [21]. Other reported complications of thoracic catheter insertion include perforation of the heart, either an atrium [22] or ventricle [23]; of the aorta [24]; of the vena cava [25]; and of the lung [26], as well as phrenic nerve paralysis [27] and tension pneumothorax [28]. A subcutaneous emphysema may occur if one or more of the tube eyelet openings are situated outside the pleural space [15].


   Thoracic Drainage Systems
Top
 Footnotes
 Abstract
 Introduction
 The Beginning
 Open Drainage
 Thoracic Catheters
 Thoracic Drainage Systems
Management Considerations
 Suction
 References
 
The design of chest drainage systems must take into consideration the negative pressure (vacuum) of the pleural space created by the tendency of the elastic lungs to collapse, which is counterbalanced by the outward recoil of the chest wall. Normal intrapleural pressures, measured as the weight of a column water, are -8 cm H2O during inspiration and -3.4 cm H2O during expiration. During forced inspiration (with a closed glottis or blocked endotracheal tube) and forced expiration (coughing), these pressures may reach extremes, exceeding -54 cm H2O and +70 cm H2O, respectively [14].

The concept of the importance of using closed pleural drainage in all postoperative care was introduced by Lilienthal [5] in 1926, when he wrote about pulmonary resection for bronchiectasis. For many years most chest drainage involved the use of a single-bottle water trap, which he describes. Its major attributes were simplicity and low cost. Drawbacks of the technique included difficulty in measuring the drainage and increased resistance to drainage as fluid accumulated.

The time-honored arrangement of drainage bottles, usually called the three-bottle system (collection, water-seal, and manometer bottles), was described by Howe [29] in 1952 (Fig 3Go). This arrangement serves as the basis for almost all thoracic drainage systems in use today.



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  		Fig 3. . Three-bottle drainage system.

 
By the early 1970s there was an increasing diversity in the methods of draining the chest, stemming from the fact that there was about four dozen varieties of drainage systems from which to choose. These ranged from the original single-bottle water seal to a new unitized plastic system, which entered the market in 1968. Hospitals did not know what drainage systems to provide to meet the needs of their staff. At one physician's request, one vendor even supplied a 4,000-mL capacity bottle. All of this diversity complicated patient care, contributed to an increase in morbidity and possibly mortality, and increased hospital costs. In 1974 most of more than 300 thoracic surgeons who responded to a questionnaire indicated that they preferred a multiple "bottle" system, but 28% still relied on a single bottle with gravity [1]. Sampling ports and air leak meters were considered optional. It was also learned that most used commercially available plastic (59%) or glass (37%) units, and 4% preferred an in-house design.

In 1995 approximately 60,000 glass bottle systems were used, but this represents only 4.5% of the total market [11]. Currently there are four manufacturers that provide the bulk of plastic drainage units; these are available in nine styles, with or without an autotransfusion feature. During 1995 these manufacturers supplied 1.3 million drainage units to hospitals in this country at a cost of approximately $60 million [11]. These included Pleur-evac (Deknatel-Snowden-Pencer), Tucker, GA, Atrium (Atrium Medical Corp, Hudson, NH), ThoraKlex (recently acquired thoracic drainage products from Davol by Deknatel-Snowden-Pencer), and Sentinel Seal and Thoraseal (Sherwood Medical, St. Louis, MO). Most include necessary features: a manual high negative pressure release valve; an automatic high negative pressure release valve (at -40 cm H2O); a positive-pressure release valve (at +2 cm H2O); sampling ports; serrated, tapered catheter connectors; and air leak meters. Two brands have connecting-tube pinch clamps attached, but this carries the risk of leading to inadvertent clamping. The ability to size the chest catheter connector is desirable. Some nonsizable connectors have an 18F opening, so if, for example, a 36F chest tube is connected to this connector, the efficiency of the air flow is reduced and blood clots may become trapped. Therefore, for reasons of safety and function, it appears that pinch clamps should be eliminated and all connectors should be sizable.

All but two of these systems have water manometers to adjust the vacuum. ThoraKlex is a completely waterless system with a one-way valve and vacuum limiter, whereas the Pleur-evac A-6000 has a dry suction control with a conventional underwater seal. Users should be aware, however, that these devices need more air flow from the vacuum source for them to function.

A collecting system was introduced in the mid-1970s that was designed exclusively for use in pneumonectomy patients. This unit provides balanced drainage with an intrapleural pressure of approximately -6 cm H2O [30]. However, the 1975 study mentioned earlier revealed that diverse practices were used for drainage of the pneumonectomy space, including no drainage, water seal with or without clamping of the connecting tube, the rare use of suction drainage, and balanced drainage [1]. Each year, however, a few more pneumonectomy drainage units are used.

Other thoracic drainage devices are the Denver pleural peritoneal shunt (Denver Biomaterials, Evergreen, Co) and the Heimlich valve (Becton-Dickinson, Franklin Lake, NJ). The Denver shunt is an integrated, compressible one-way valve designed to move pleural fluid into the abdomen, especially for palliation in patients with malignant pleural effusions and persistent chylothorax. Occasionally, however, the shunt becomes occluded (15%) [31].

The Heimlich valve was introduced in 1968 and is a flutter valve that is especially useful when emergency transport is anticipated [32]. The valve must be connected to some type of collection container. Tension pneumothorax resulting from reversal of the Heimlich valve has been reported [33]. Nevertheless, this device has a place in pleural drainage, if carefully used. More than 23,000 are sold each year [11].


   Management Considerations
Top
 Footnotes
 Abstract
 Introduction
 The Beginning
 Open Drainage
 Thoracic Catheters
 Thoracic Drainage Systems
 Management Considerations
Suction
 References
 
In recent years, numerous thorough discussions of chest drainage management have appeared in the literature [8, 12, 14, 15, 34]. Some subjects, because of their frequency of occurrence or seriousness, deserve particular emphasis.

One of these is that too often the connecting tube is allowed to hang so that it droops below the top of the collection container and a resulting fluid-filled loop causes the suction drainage to stop. Excess tubing should therefore be coiled on the bed and the tube should go straight from the patient to the collection system located on the floor. Fluid oscillations in the water seal synchronous with respiration (tidaling) confirm the presence of intrapleural pressures and tube patency. This motion stops when the lung is expanded or the system is blocked (clotting, kinking). If the amplitude of tidaling is increased, this indicates the existence of a large, empty intrapleural space; it may also be seen after lung resection or in the presence of atelectasis or incomplete lung expansion resulting from other reasons. A chest tube should never be clamped, except momentarily in the event of a disconnection or unit breakage or to locate a leak in the drainage setup. Irrigation of a chest catheter or drainage tube should be discouraged but occasionally must be done if blood clot blockage is suspected or when an instillation is done for pleurodesis. The possibility of infection (empyema) resulting from these maneuvers should be borne in mind. The foaming of serosanguineous fluid in the collection chamber can be controlled by adding one ounce (30 mL) of alcohol or Mylicon (simethicone). Stripping of the connecting tube is discouraged. Vacuums of up to -400 cm H2O have been reported to result from stripping [35], and little benefit is achieved from it [36]. Reexpansion pulmonary edema is infrequent and usually seen in the setting of lung collapse resulting from pneumothorax or effusion of several days' duration [37]. When this is encountered, slow, intermittent reexpansion of the lung is recommended (as was recommended in 1818 by Zang) [2]. In patients with large air leaks and high suction, fluid in the water seal and manometer chambers will evaporate, leading to the lowering of fluid levels with a loss of the water seal or reduced suction, or both.

A few surgeons attach two chest tubes to separate drainage units. Although occasionally this may be prudent (eg, loculated collections of different substances), this increases the cost and is cumbersome. A better method is to connect the chest tubes to a Y-connector and then to a single drainage unit or to use a dual-chamber collection unit. Both are simpler and cheaper to use and have the added advantage of providing the same amount of suction to the chest tubes.


   Suction
Top
 Footnotes
 Abstract
 Introduction
 The Beginning
 Open Drainage
 Thoracic Catheters
 Thoracic Drainage Systems
 Management Considerations
 Suction
References
 
Early pleural drainage using a water-seal bottle relied on the vacuum created by the fluid column (gravity) in the connecting tube, together with a pleural pressure change, decreased negativity with expiration, and even positivity with coughing or straining, to remove the pleural fluid. However, as fluid collects in this trap bottle, the resistance to drainage increases, such that in the event of a continued air leak the potential exists for a tension pneumothorax to develop [14, 15].

During World War II it was found that the best management of chest trauma required suction drainage. However, there was no agreement as to how much suction should be used. Some favored low suction (-10 cm H2O) [38] and others high suction (-40 cm H2O) [39]. The most common suction pressure is -20 cm H2O, which probably evolved from the fact that when a commonly used gallon glass bottle was filled to near where the bottle tapered at its neck and the end of the vent tube was positioned about 2 cm from the bottom of the bottle, so that the tube was submerged about 20 cm, which in turn controlled the pressure of the vacuum in the system.

As pulmonary resection became more common, so did postoperative air leaks. In 1957 Perkins [38] noted that the volume of air flow "has been given insufficient attention" and that lung expansion had been treated by increasing the negative pressure rather than by using a pump capable of removing a minute volume of air that exceeded the minute volume of the air leak. The following year, Roe [39] also stressed the importance of high-flow vacuum using regulated wall suction systems rather than portable pumps.

In 1961 Batchelder and Morris [40] found that the rate of postthoracotomy air leaks ranged from 3.6 to 16.0 L/min. Interestingly, the patient with the latter leak survived what would usually have been a lethal bronchopleural leak.

Perhaps in response to these reports, J. H. Emerson Co (Cambridge, MA) introduced a portable pleural suction pump in 1955 capable of a regulated negative pressure of up to -60 cm H2O and air flows of up to 50 L/min (when used with Emerson collection units). However, users must exercise caution when using this system in a patient with a large air leak, because of the ease which it can generate high air flow suction that may lead to hypoxemia [41].

Using a laboratory model simulating a bronchopleural fistula, Rusch and colleagues [42] in 1988 found that three drainage systems did not have an adequate flow capacity and only one could handle a high-flow air leak (35 L/min). The design of the study did not take into account that the waterless manometer unit needs more wall suction to function properly and that the simulated air leak was much higher than is usually seen clinically. Nevertheless, this stimulated manufacturers to modify drainage units so that greater air volumes could be moved.

Finally, variations in the mixed diameters of the components of vacuum systems, as well as thoracic drainage setups, influence the air flow capabilities in managing large volume air flow drainage and waterless manometer valving drainage devices [8, 40] so the design of these systems must consider gas and fluid dynamics (Poiseuille's and Fanning's laws).

The pitfalls of suction drainage are simple: too little, too much, and the inexperience of the users. If there is too little flow through the system, the likelihood of tension pneumothorax, atelectasis, fluid accumulation, and infection increases [38]. If there is too much flow through the system, air leaks may be perpetuated, increased air stealing may lead to hypoxia [41], and rarely lung may be trapped within the chest catheter openings [43].

These problems associated with chest drainage are more likely to occur in patients with massive air leaks, such as occur in the setting of traumatic airway disruption; after some types of pulmonary resection; in patients with ruptured bullae or a pneumothorax associated with Pneumocystis carinii; and occasionally in those suffering from barotrauma. High flow can be produced in most water manometer–style drainage systems by blocking the air vent of the manometer, thereby creating regulated "straight wall suction." Both waterless manometer systems and the portable electric vacuum system have high-flow capabilities. When an air leak persists or increases, the lung remains poorly expanded, and the patient's condition is deteriorating, there is a strong urge to "turn up the suction to pull the lung up against the chest wall," which at times is correct. However, increasing the suction (the negative pressure and flow) may only increase the magnitude of the bronchopleural fistula [44]. Recovery depends on reversing the pulmonary edema, the atelectasis, or any other underlying lung disorder responsible for the acute respiratory failure (R. Peters, personal communication). Actually, the lowest level of chest tube suction that maintains some lung inflation is the most desirable [41]. Patients with air leaks greater than 500 mL/breath (normal tidal volume) usually do not survive [45]. The treatment for a high-flow bronchopleural fistula, in addition to conventional chest drainage, may include mechanical ventilation to ensure adequate air exchange [41], high-frequency jet ventilation [46], intermittent inspiratory chest tube occlusion [47], and independent lung ventilation [48].


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 The Beginning
 Open Drainage
 Thoracic Catheters
 Thoracic Drainage Systems
 Management Considerations
 Suction
 References
 
Address reprint requests to Dr Munnell, Department of Cardiothoracic Surgery, University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK 73190.


   References
Top
 Footnotes
 Abstract
 Introduction
 The Beginning
 Open Drainage
 Thoracic Catheters
 Thoracic Drainage Systems
 Management Considerations
 Suction
 References
 

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