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Ann Thorac Surg 1998;66:299-300
© 1998 The Society of Thoracic Surgeons

Correspondence

Outpatient chest tubes

Kieran G. McManus, FRCS(I)a, Gary M. Spence, FRCS(I)a, James A. McGuigan, FRCS(Ed)a

a Thoracic Surgery, Royal Victoria Hospital, Belfast, Northern Ireland, United Kingdom, BT12 6BA

To the Editor

We congratulate Dr Ponn and associates for their article on outpatient chest tube management [1] and commend them for their use of outpatient pleural drainage. The introduction of the Heimlich valve, which allows this therapy, was indeed a landmark in the treatment of persistent pleural drainage. The fact that chest tube drainage systems must have no obstruction to either the afferent or efferent ports results in the Heimlich valve having a problem with management of the fluid discharge from the efferent end of the valve. This can amount to 200 mL per day in an otherwise uncomplicated pleural drain. Placing a gauze sponge over the end of the efferent tube does prevent a certain amount of soiling of clothing and bedding, but it is difficult for patients to handle hygenically.

A method of overcoming this problem is the use of the Ambulatory Chest Drainage System (Portex Limited, Hythe, UK), which incorporates a "nonstick," vertically oriented flutter valve device within a drainage bag (Fig 1). The bag has a specially designed exhaust vent, which allows fluid to collect within the bag without spilling on clothing or bedding. The flexible polyvinyl chloride bag can be worn inconspicuously under clothes.



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  		Fig 1. Portex Ambulatory Chest Drainage System.

 
We have changed from using the Heimlich valve to the Portex bag system over the last 8 years, initially for inpatient use [2], but more recently in the outpatient management of prolonged air leak or prolonged drainage of empyema. Over a recent 18-month period in 1995 and 1996 we performed an audit of our outpatient use of the Ambulatory Chest Drainage System. Twenty-three patients (14 men, 9 women; age range, 20 to 74 years; mean age, 49 years) were discharged home with the Portex bag once their lung had been demonstrated to remain adequately expanded without suction. They were reviewed on a weekly basis until the air leakage or drainage had stopped. In total 25 pleural cavities were drained; 16 for persistent air leak, 2 after traumatic hemopneumothorax, 6 after postpneumonic empyema, and 1 after malignant pleural effusion. The mean duration of underwater seal drainage before discharge from the hospital was 12.4 days (range, 1 to 36 days; median duration, 9 days). The mean duration of outpatient drainage with the flutter valve apparatus was 14.1 days (range, 4 to 54 days; median duration, 8 days). No deaths were attributable to the method of drainage used. There was no incidence of tension pneumothorax or infection. Patient acceptance was favorable in all cases. Two patients required a further operation. One of these was a pregnant woman with a previous history of pneumothorax who underwent elective pleurectomy after successful cesarian section delivery. The other patient, an elderly man with a secondary pneumothorax whose air leak was not eliminated by conservative management, underwent open bullectomy and pleurectomy, but died as a result of adult respiratory distress syndrome. The chest drain was found to have been placed in the interlobar fissure, preventing spontaneous resolution of the air leak.

In conclusion, we recommend outpatient chest tube management in carefully selected patients who have been fully educated on the management of the drainage system. The Portex Ambulatory Chest Drainage System provides a more satisfactory, hygienic, controlled drainage system than the traditional Heimlich valve.

References

  1. Ponn R.B., Silverman H.J., Federico J.A. Outpatient chest tube management. Ann Thorac Surg 1997;64:1437-1440.[Abstract/Free Full Text]
  2. Graham A.N.J., Cosgrove A.P., Gibbons J.R.P., McGuigan J.A. Randomised clinical trial of chest drainage systems. Thorax 1992;47:461-462.[Abstract/Free Full Text]



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