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Ann Thorac Surg 2009;87:1539-1545. doi:10.1016/j.athoracsur.2009.02.013
© 2009 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Fluid Drainage and Air Evacuation Characteristics of Blake and Conventional Drains Used After Pulmonary Resection

Noriaki Sakakura, MDa,b,*, Takayuki Fukui, MDa, Shoichi Mori, MDa, Shunzo Hatooka, MDa, Kohei Yokoi, MDb, Tetsuya Mitsudomi, MDa

a Department of Thoracic Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
b Division of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan

Accepted for publication February 6, 2009.

* Address correspondence to Dr Sakakura, Division of Thoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan (Email: nskkr{at}med.nagoya-u.ac.jp).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: The Blake drain (BD) has recently begun to be used as a chest tube after pulmonary resection; however, its fluid drainage and air evacuation characteristics remain unclear. We compared the performance of the 19F BD with that of the 32F conventional drain (CD).

Methods: We studied 148 consecutive patients (74 with BD; 74 with CD) who underwent pulmonary resection. Postoperative drainage rates (daily drainage and total drainage) were analyzed to assess fluid drainage. Air evacuation was evaluated to determine whether subcutaneous emphysema or insufficient residual lung expansion developed when air leakage occurred. The BD group was initially managed with water seal or suction, whereas the CD group was managed with water seal. Furthermore, we experimentally measured the evacuation pressure required to expel a constant volume of air through various chest tubes to determine basic air evaluation performance of the tubes.

Results: Drainage rates on the operative day were significantly lower in the BD group than in the CD group, but were similar in both groups on the following day with greater variation in the water-sealed BD group. Among cases with air leakage, air evacuation insufficiency was more frequent in the BD group (16 of 22, 73%) than in the CD group (4 of 17, 24%; p = 0.004). The experiment revealed that air evacuation performance of the 19F BD was equivalent to that of the 12F CD, indicating that the BD requires higher intrathoracic pressure for air evacuation.

Conclusions: Suction is required for the BD to obtain fluid drainage performance comparable to that of the water-sealed CD. When air leakage occurs, air evacuation by the BD tends to be insufficient, irrespective of suction conditions.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
The Blake drain (BD) is a new type of drain equipped with four longitudinal grooves so that tissues do not completely occlude the grooves, thereby allowing efficient drainage (Fig 1, left). This silicone drain also inflicts little pain at the insertion site because it is small and soft. It has been widely used in thoracic surgery as a mediastinal drain after cardiac procedures [1–3]. The BD has recently begun to be used as a chest tube after pulmonary resection [4–7]; however, its fluid drainage and air evacuation characteristics remain unclear, and there are arguments for and against its use as a chest tube after pulmonary resection. There is a report of some complications arising from BD usage [8]. After pulmonary resection, the performance of a chest tube is greatly affected by respiration because of the presence of a residual space in the thoracic cavity. Efficient fluid drainage and air evacuation are both considered as the most important aspects of chest tube performance after pulmonary resection. Nevertheless, there have been no reports quantitatively discussing these two characteristics of the BD. In addition, detailed assessment of air evacuation characteristics is more difficult than that of fluid drainage. In fact, the concept of the drain's air evacuation performance itself has not yet been proposed. The purpose of the present study is to evaluate the performance of the BD used as a chest tube after pulmonary resection by comparing its fluid drainage and air evacuation characteristics with those of a conventional drain (CD).


Figure 1
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  		Fig 1. (Left) Features of the 19F Blake drain and cross-specific section profiles: AB, four longitudinal grooves; BC, transition portion; and CD, 19F single lumen. (Right) Position of the Blake drain used in this study. Arrowhead indicates the insertion site.

 

   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
This study was approved by the institutional review board of the Aichi Cancer Center Hospital. Patient consent regarding the use of the BD was waived because it has been previously used for pulmonary resection [4–7] and the purpose of this study was to evaluate the use of the BD and the CD in daily practice. Each patient was informed that their clinical data might be used for various studies, and consent was obtained on this basis.

Surgical Cases
We retrospectively studied 148 consecutive patients who underwent pulmonary resection at the Aichi Cancer Center Hospital between December 2005 and October 2006. Postoperatively, 74 patients were managed using the BD (BD group) and the remaining 74 patients were managed with the CD (CD group) (Table 1). Coincidentally, both drain groups had the same number of patients. Patients with pneumonectomy were excluded. All patients underwent a serratus anterior muscle-sparing thoracotomy accompanied by an anterior or a vertical axillary incision. Air leakage from the bronchial stump and residual lung parenchyma was checked by soaking the reinflated residual lung in warm saline solution under 30 cm H2O internal airway pressure, after which they were closed by appropriate sutures or sealant materials.


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  		Table 1 Patient Characteristics a
 
The BD used in this study was a 19F Blake drain hubless round (Ethicon, Inc, Somerville, NJ) and the CD was a 32F Toughsil thoracic drainage catheter (Sumitomo Bakelite, Inc, Tokyo, Japan). The BD was inserted at the upper anterior axillary line of the thoracotomy in the apical direction and looped toward the diaphragm (Fig 1, right). This is considered advantageous for air evacuation because the suction grooves of the BD are located close to the apical portion of the thoracic cavity [6]. The CD was inserted at the lower anterior axillary line of the thoracotomy in the apical direction. In both groups, each patient received either one BD or one CD by the insertion position described above. Based on the suction conditions used immediately after surgery, the BD group was divided into subgroups in which the drain was managed with water seal (WS-BD group; 44 patients) or –10 cm of suction (SUC-BD group; 30 patients), whereas the CD group was managed with water seal. The assignment of individual patients to the BD or CD group and the initial suction of BD was made at the discretion of the operating surgeon. Both drains were connected to a three-bottle drainage apparatus (Chest Drain Vac; Sumitomo Bakelite, Inc). The initial suction conditions were maintained until chest tube removal in cases that did not show air leakage. When air leakage occurred, postoperative tube management was conducted as follows: the water seal was changed to –10 cm of suction when subcutaneous emphysema increased or when expansion of the residual lung was obviously insufficient. Alternatively, the suction was changed to water seal when the air leakage tended to stop with the seal. These conditions were maintained as long as air evacuation was considered sufficient. The chest tube was removed when the measured daily drainage was less than 200 mL without air leakage. To assess the efficacy of fluid drainage, we analyzed postoperative daily drainage, total drainage, and the daily drainage rate (daily drainage divided by total drainage x 100 [%]). Air evacuation characteristics were evaluated to determine whether subcutaneous emphysema increased or insufficient residual lung expansion (air evacuation insufficiency) developed when air leakage occurred. A minimum of 2 thoracic surgeons and 2 nurses checked air leakage and subcutaneous emphysema three times per day. Subcutaneous emphysema was confirmed by daily chest radiographs and palpation of the patient's chest. Obvious subcutaneous emphysema extending to the contralateral chest wall was recorded.

Experimental Investigation of Air Evacuation Characteristics of Chest Tubes
To examine the basic air evacuation performance of chest tubes, which does not depend on physical and biologic factors, we experimentally measured the pressure required to expel a constant volume of air through various chest tubes (Fig 2). The portion with side holes for the CD, or that with grooves for the BD, was tightly connected to the outlet of a respirator (Servo-i Adult; Maquet Critical Care AB, Solna, Sweden), and the other end of the tube was connected to a three-bottle drainage reservoir (Chest Drain Vac; Sumitomo Bakelite, Inc) and water-sealed. When the respirator intermittently delivered a given quantity of air at a given velocity, the effect was similar to that when an air leakage occurred in the water-sealed portion. The required pressure was then displayed as the internal airway pressure on the respirator monitor. Air expulsion time was varied from 0.2 seconds to 3.0 seconds at intervals of 0.1 seconds. The volume of air expelled was 100 mL, which is a volume example of air evacuated from the thoracic cavity through a chest tube synchronized with respiration. The pressure was measured using 19F and 24F BDs (Blake Drain; Ethicon, Inc), 32F CD (Toughsil Thoracic Drainage Catheter; Sumitomo Bakelite, Inc), and four other CDs with different diameters (Argyle Trocar Aspiration Kit, 8F; Argyle Trocar Catheters, 12F, 16F, and 20F; Nippon Sherwood Medical Industries Ltd, Tokyo, Japan). The required evacuation pressure was measured 10 times for each condition using two of the same type tubes.


Figure 2
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  		Fig 2. Experimental evaluation of air evacuation characteristics of chest tubes. When a given quantity of air is delivered intermittently by the respirator at a given velocity, the required pressure is displayed as the internal airway pressure on the respirator monitor.

 
Statistical Analysis
The air evacuation insufficiency of surgical cases was evaluated with Fisher's exact test using StatView for Windows (version 5.0, SAS Institute, Cary, NC).


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Fluid Drainage Characteristics of Chest Tubes in Surgical Cases
Table 2 presents daily drainage from the operative day to postoperative day 2. No significant difference was observed in total drainage and duration of drainage among the groups, although total drainage in the SUC-BD group was relatively large. Figure 3 demonstrates alterations of daily fluid drainage rates, which allows detailed assessment of fluid drainage performance by quantifying the percentage of total drainage on each day. Drainage rates (mean ± standard deviation) on the operative day were significantly lower in the BD groups (WS-BD, 16% ± 16%; SUC-BD, 22% ± 14%) than that in the CD group (33% ± 17%). Mean drainage rates on the following day were similar in all groups, with a greater standard deviation in the WS-BD group (42% ± 23%) than in other groups (SUC-BD, 40% ± 16%; CD, 40% ± 13%). Suction was required for BD to obtain fluid drainage performance comparable with that of the water-sealed CD.


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  		Table 2 Fluid Drainage Characteristics in Surgical Cases a
 

Figure 3
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  		Fig 3. Fluid drainage characteristics in the water-sealed Blake drain (WS-BD), Blake drain with suction (SUC-BD), and conventional drain (CD) groups. Each column indicates the fluid drainage rate (mean ± standard deviation) for the day indicated, defined as daily drainage divided by total drainage x 100 (%).

 
Air Evacuation Characteristics of Chest Tubes in Surgical Cases
Air leakage occurred in 22 of 74 (30%) BD patients and 17 of 74 (23%) CD patients (p = 0.456), indicating no significant difference between the two groups. Among these, obvious subcutaneous emphysema or insufficient expansion of residual lung developed in 16 of 22 (73%) BD patients and 4 of 17 (24%) CD patients (p = 0.004). Suction conditions, therefore, had to be altered in 11 of 22 (50%) BD patients and 2 of 17 (12%) CD patients (p = 0.017), after which evacuation insufficiency did not improve in 5 of 11 (45%) BD patients and 0 of 2 (0%) CD patients (p = 0.487).

Chest radiographs of 2 patients considered to have markedly insufficient air evacuation are shown in Figure 4. Figure 4A shows a case of left upper lobectomy. Suctioning after surgery resulted in minor air leakage, but the water seal stopped the leak, thereby maintaining the seal. However, the next morning, the residual lung completely collapsed (tension pneumothorax). Immediate suction resulted in massive air evacuation. Figure 4B shows another case of left upper lobectomy. Suction was applied because air leakage and subcutaneous emphysema were both observed postoperatively. Although the air leakage was not extensive and was present mainly during forced expiration, subcutaneous emphysema gradually increased during the following days. As a countermeasure, the patient's BD was replaced with a 20F CD, after which severe and continuous air leakage became evident and subcutaneous emphysema decreased. This patient had a bronchopleural fistula.


Figure 4
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  		Fig 4. Chest radiographs of patients with insufficient air evacuation. (A) Left tension pneumothorax. (B) Bronchopleural fistula with marked subcutaneous emphysema.

 
Experimental Evaluation of Air Evacuation Performance of Chest Tubes
Each curve in Figure 5 indicates the pressure required to expel 100 mL of air through a particular type of chest tube during different air expulsion times, and each symbol indicated in the figure is the mean value measured for each condition. It was observed that the pressure required increased as the tube became thinner. Alternatively, the pressure required for air expulsion times of 0.3, 0.5, 1.0, and 2.0 second was 37, 27, 14, and 7 cm H2O, respectively, for the 19F BD and 13, 8, 5, and 3 cm H2O, respectively, for the 32F CD. The pressure required also increased as expulsion time shortened and the effect was more marked for the 19F BD than for the 32F CD. Furthermore, the curves for the 19F and the 24F BDs overlapped with those of the 12F and the 16F CDs, respectively. It was a physical experiment and was reproducible.


Figure 5
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  		Fig 5. Air evacuation performance of different chest tubes. The curves indicate the evacuation pressure required to expel 100 mL air through the tubes during the times indicated. (BD = Blake drain; CD = conventional drain.)

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Since the introduction of the 19F BD into daily practice for pulmonary surgery at the Aichi Cancer Center Hospital in October 2005, we have encountered several important cases illustrating its characteristics. Drainage requirements after pulmonary resection are fundamentally different from those after cardiac or other surgeries because both fluid drainage and air evacuation require consideration.

Kejriwal and Newman [4] initially evaluated the use of the 19F BD in pulmonary surgery. In their study, the BD was inserted at the caudal site of the thoracotomy so as to lie in the posterior paravertebral recess. They reported that 3 of 37 patients required insertion of an alternative tube because of tube dislodgement, persistent air leakage, or bronchopleural fistula, whereas the BD seemed to be comfortable for the remaining 34 patients. Terzi and coworkers [5] conducted a randomized prospective study in 50 patients with flexible spiral drains (a type of BD) and 50 patients with CDs. They used either two 19F spiral drains or two CDs for each patient and reported that the drainage duration was significantly shorter in the spiral drain group than in the CD group and that the former experienced less pain than the latter. Ishikura and Kimura [6] adopted another insertion method for the 19F BD. They reported that there were no major complications in the 30 patients who underwent pulmonary resection and that the duration of drainage was significantly shorter with the BD than with the CD; moreover, a cosmetic advantage after removal of the BD was recognized. Recently, Icard and colleagues [7] introduced a new 24F BD and reported that no patients experienced complications related to this drain. In these reports, the BD was considered a safe and acceptable device for most types of pulmonary surgery. In contrast, Clark and colleagues [8] reported a complication that arose from using the 19F BD; after a wedge resection of the apical pulmonary bullae followed by talc dispersion, the BD became completely occluded and life-threatening intrathoracic bleeding was not recognized. They warned that the smallness and flexibility of the BD might lead to kinking and that thrombotic occlusion attributable to hypercoagulability after pulmonary surgery might also prevent it from functioning. Thus, it is necessary to elucidate quantitative fluid drainage and air evacuation characteristics of the BD.

The use of the BD resulted in relatively large variation in fluid drainage (Fig 3), which tends to prevent the acquisition of accurate information about postoperative conditions within the thorax. Moreover, suction was required when using the BD to obtain performance comparable with that of the water-sealed CD. One possible reason for such variation in drainage is that positioning of the BD may greatly affect its drainage performance. Effective fluid drainage by gravity could be difficult to achieve with the position used in this study. Basically, from a structural viewpoint, the grooves of the BD can work effectively suctioning the exudative fluid. Because both fluid and air are present in the intrathoracic residual space, the grooves may not function successfully despite suctioning. An alteration in the position of the BD can then be considered. We now consider that suction is a minimum requirement for using the BD and have not used it with a water seal after this study.

On the other hand, a quantitative evaluation of air evacuation insufficiency is difficult. Although we adopted a position that is considered advantageous for air evacuation, evacuation insufficiency (indicated by subcutaneous emphysema or insufficient residual lung expansion) evidently occurred more frequently in the BD group than in the CD group, irrespective of suction conditions. The tendency for subcutaneous emphysema to occur may be associated with the serratus anterior muscle-sparing thoracotomy. However, we have never experienced a tension pneumothorax using the water-sealed CD. It should be noted that air leakage in the BD group tended to be less severe than that observed in the CD group. Recognizing the gravity of these results, we conducted an experiment to determine the basic evacuation performance of the chest tube itself.

To evaluate the air evacuation performance of a chest tube, it is necessary to consider the volume of air expelled from the thoracic cavity through the tube in synchrony with expiration, expulsion time, fluid dynamic equivalent diameter of the tube, and suction effect. The larger the volume of air to be evacuated at one time or the shorter the air expulsion time, the higher the evacuation pressure required, which in turn results in a high intrathoracic pressure load exerted on the chest wall. Use of a thinner chest tube makes this effect more noticeable, and when intrathoracic residual air is evacuated in a very short period, for example, while coughing, sneezing, or loud phonation, the intrathoracic pressure significantly increases. Conversely, when air is expelled softly during slow respiration, the pressure remains low. Figure 5 quantitatively demonstrates this point. The curve for the 19F BD overlaps with that for the 12F CD, indicating that the basic air evacuation performance of the 19F BD is comparable with that of the 12F CD. The figure also demonstrates that the curve for the 24F BD is equivalent to that of the 16F CD. This is considered to be because the grooves and the transition portion of the BD have a thinner fluid dynamic equivalent diameter than the single-lumen part of the tube. Furthermore, we thoracic clinicians tend to think that suction can solve the problem of such intrathoracic pressure elevation; however, despite suctioning, all the curves in Figure 5 move downward in parallel according to the suction pressure. Thus, suctioning does not necessarily result in a performance equal to that obtained with a thick chest tube. A good countermeasure would be to close the chest wall to make it as airtight as possible and to support the chest externally using a chest band to prevent subcutaneous emphysema.

We should also consider that the smallness and flexibility of the BD might lead to its kinking or dislodgement as suggested in previous reports [4, 8]. In the case shown in Figure 4A (tension pneumothorax), although a detailed cause for the air evacuation insufficiency could not be determined, such characteristics might lead to this insufficiency.

It is crucial for a chest tube used after pulmonary surgery to evacuate fluid and air without resistance rather than operate by means of a suction mechanism. Complete fluid drainage by suction is not always required, and exudation of pleural effusion into the resected space does not pose a problem. If there is no air leakage, residual air does not pose a problem either. This is why the management technique of water sealing exists. Considering that almost all patients in the CD group could be managed with a water seal, and on the basis of reports indicating that air leakage tends to be treated better with a water seal than with suction [9, 10] and that an alternative tube management strategy combining water seal with suction is superior [11], it is considered necessary that water sealing can function sufficiently and suctioning, if required, also works effectively.

Although pain at the insertion site is one of the evaluative variables, we did not include it in the study for the reason that we intended to emphasize the fluid drainage and air evacuation performance of the BD and the CD. Moreover, the section of the study involving surgical cases did not have a randomized design and therefore has some possible limitations; however, the relevant points have been thoroughly discussed.

Overall, as Cerfolio [12] suggested, any chest tube used after pulmonary resection may need to have appropriate thickness and rigidity. Suction is the minimal requirement for the 19F BD to achieve fluid drainage performance comparable with that of a thick water-sealed CD. When air leakage occurs, air evacuation with the BD tends to be insufficient, irrespective of suction conditions. The experimental investigation demonstrated that the basic air evacuation performance of the 19F and the 24F BDs is almost equivalent to that of the 12F and the 16F CDs, respectively. Therefore, it is very important for us to be well versed with these characteristics when using the BD as a chest tube after pulmonary resection.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Obney JA, Barnes MJ, Lisagor PG, Cohen DJ. A method for mediastinal drainage after cardiac procedures using small silastic drains Ann Thorac Surg 2000;70:1109-1110.[Abstract/Free Full Text]
  2. Lancey RA, Gaca C, Vander Salm TJ. The use of smaller, more flexible chest drains following open heart surgery Chest 2001;119:19-24.[Abstract/Free Full Text]
  3. Frankel TL, Hill PC, Stamou SC, et al. Silastic drains vs conventional chest tubes after coronary artery bypass Chest 2003;124:108-113.[Abstract/Free Full Text]
  4. Kejriwal NK, Newman AJ. Use of a single silastic chest drain following thoracotomy: initial evaluation Aust N Z J Surg 2005;75:710-712.
  5. Terzi A, Feil B, Bonadiman C, et al. The use of flexible spiral drains after non-cardiac thoracic surgery. A clinical study. Eur J Cardiothorac Surg 2005;27:134-137.[Abstract/Free Full Text]
  6. Ishikura H, Kimura S. The use of flexible silastic drains after chest surgery: novel thoracic drainage Ann Thorac Surg 2006;81:331-334.[Abstract/Free Full Text]
  7. Icard P, Chautard J, Zhang XD, et al. A single 24F Blake drain after wedge resection or lobectomy: a study on 100 consecutive cases Eur J Cardiothorac Surg 2006;30:649-651.[Abstract/Free Full Text]
  8. Clark G, Licker M, Bertin D, Spiliopoulos A. Small size new silastic drains: life-threatening hypovolemic shock after thoracic surgery associated with a non-functioning chest tube Eur J Cardiothorac Surg 2007;31:566-568.[Abstract/Free Full Text]
  9. Cerfolio RJ, Bass C, Katholi CR. Prospective randomized trial compares suction versus water seal for air leaks Ann Thorac Surg 2001;71:1613-1617.[Abstract/Free Full Text]
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  12. Cerfolio RJ. Closed drainage and suction systems. Development and types of chest tubes. In: Patterson GA, Cooper JD, Deslauriers J, Lerut AEMR, Luketich JD, Rice TW, editors. Pearson's thoracic and esophageal surgery. 3rd edition. Philadelphia, PA: Churchill Livingstone/Elsevier; 2008. pp. 1147.

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