Thorax 2003 58 Suppl IIii5357521ii59 1 BACKGROUND In current hospital practice chest drains are used in many different clinical settings and doctors in most specialities need to be capable of their safe insertion The emergency insertion of a large b ID: 66664
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BTSguidelinesfortheinsertionofachestdrainDLaws,ENeville,JDuffy,onbehalfoftheBritishThoracicSocietyPleuralDiseaseGroup,asubgroupoftheBritishThoracicSocietyStandardsofCareCommittee(SupplII):ii53±ii591BACKGROUNDIncurrenthospitalpracticechestdrainsareusedinmanydifferentclinicalsettingsanddoctorsinmostspecialitiesneedtobecapableoftheirsafeinsertion.TheemergencyinsertionofalargeborechestdrainfortensionpneumothoraxfollowingtraumahasbeenwelldescribedbytheAdvancedTraumaandLifeSupport(ATLS)recommenda-tionsintheirinstructor'smanualandtherehavebeenmanygeneraldescriptionsofthestepbystepmethodofchesttubeinsertion.Ithasbeenshownthatphysicianstrainedinthemethodcansafelyperformtubethoracostomywith3%earlycomplicationsand8%late.Intheseguidelineswediscussthesafeinsertionofchesttubesinthecontrolledcircumstancesusuallyencounteredbyphysicians.Asummaryoftheprocessofchestdraininsertionisshownin®g1.2TRAININGAllpersonnelinvolvedwithinsertionofchestdrainsshouldbeadequatelytrainedandsupervised.[C]Beforeinsertionofachestdrain,alloperatorsshouldhavebeenadequatelytrainedandhavecompletedthistrainingappropriately.Inallothercircumstances,insertionshouldbesupervisedbyanappropriatetrainer.ThisispartoftheSHOcorecurriculumtrainingprocessissuedbytheRoyalCollegeofPhysiciansandtraineesshouldbeexpectedtodescribetheindicationsandcompli-cations.Traineesshouldensureeachprocedureisdocumentedintheirlogbookandsignedbythetrainer.Withadequateinstruction,theriskofcomplicationsandpatientpainandanxietycanbereduced.Theseguidelineswillaidthetrainingofjuniordoctorsintheprocedureandshouldbereadilyavailableforconsultationbyalldoctorslikelytoberequiredtocarryoutachesttubeinsertion.3INDICATIONSChesttubesmaybeusefulinmanysettings,someofwhicharelistedinbox1.4PRE-DRAINAGERISKASSESSMENTRiskofhaemorrhage:wherepossible,anycoagulopathyorplateletdefectshouldbecorrectedpriortochestdraininsertionbutroutinemeasurementoftheplateletcountandprothrombintimeareonlyrec-ommendedinpatientswithknownriskfactors.[C]Thedifferentialdiagnosisbetweenapneumothoraxandbullousdiseasere-quirescarefulradiologicalassessment.Similarlyitisimportanttodifferentiatebetweenthepresenceofcollapseandapleuraleffusionwhenthechestradio-graphshowsaunilateralªwhiteoutº.Lungdenselyadherenttothechestwallthroughoutthehemithoraxisanabsolutecontraindicationtochestdraininsertion.tion.·Thedrainageofapostpneumonectomyspaceshouldonlybecarriedoutbyorafterconsultationwithacardiothoracicsurgeon.[C]Thereisnopublishedevidencethatabnormalbloodclottingorplateletcountsaffectbleedingcomplicationsofchestdraininsertion.However,wherepossibleitisobviousgoodpracticetocorrectanycoagulopathyorplateletdefectpriortodraininsertion.Routinepre-procedurechecksofplateletcountand/orprothrombintimeareonlyrequiredinthosepatientswithknownriskfactors.Forelectivechestdraininsertion,warfa-rinshouldbestoppedandtimeallowedforitseffectstoresolve.5EQUIPMENTAlltheequipmentrequiredtoinsertachesttubeshouldbeavailablebeforecommencingtheprocedureandarelistedbelowandillustratedin®g2.SterileglovesandgownSkinantisepticsolution,e.g.iodineorchlor-hexidineinalcoholSteriledrapesGauzeswabsAselectionofsyringesandneedles(21±25Localanaesthetic,e.g.lignocaine(lidocaine)1%or2%ScalpelandbladeSuture(e.g.ª1ºsilk)Instrumentforbluntdissection(e.g.curved Box1Indicationsforchestdraininsertion ·Pneumothorax·inanyventilatedpatient·tensionpneumothoraxafterinitialneedle·persistentorrecurrentpneumothoraxaftersimpleaspiration·largesecondaryspontaneouspneumot-horaxinpatientsover50years·Malignantpleuraleffusion·Empyemaandcomplicatedparapneumonicpleuraleffusion·Traumatichaemopneumothorax·PostoperativeÐforexample,thoracotomy,oesophagectomy,cardiacsurgerySeeendofarticleforauthors'affiliationsCorrespondenceto:DrDLaws,DepartmentofThoracicMedicine,RoyalBournemouthHospital,CastleLaneEast,BournemouthBH77DW,UK;diane.laws@ Guidewirewithdilators(ifsmalltubebeingused)ChesttubeConnectingtubingCloseddrainagesystem(includingsterilewaterifunderwa-tersealbeingused)Equipmentmayalsobeavailableinkitform.6.CONSENTANDPREMEDICATIONPriortocommencingchesttubeinsertiontheproce-dureshouldbeexplainedfullytothepatientandconsentrecordedinaccordancewithnationalguide-lines.[C]Unlesstherearecontraindicationstoitsuse,pre-medication(benzodiazepineoropioid)shouldbegiventoreducepatientdistress.[B]Consentshouldbetakenandrecordedinkeepingwithnationalguidelines.TheGeneralMedicalCouncil(GMC)guidelinesforconsentstatethatitistheresponsibilityofthedoctorcarryingoutaprocedure,oranappropriatelytrainedindividualwithsuf®cientknowledgeofaprocedure,toexplainitsnatureandtherisksassociatedwithit.Itiswithintherightsofacompetentindividualpatienttorefusesuchtreatment.Inthecaseofanemergency,whenthepatientisunconsciousandthetreatmentislifesaving,treatmentmaybecarriedoutbutmustbeexplainedassoonasthepatientissuf®cientlyrecoveredtounderstand.Ifpossible,aninfor-mationlea¯etshouldbegivenbeforetheprocedure.Chestdraininsertionhasbeenreportedtobeapainfulpro-cedurewith50%ofpatientsexperiencingpainlevelsof9±10onascaleof10inonestudy,andthereforepremedicationshouldbegiven.Despitetheapparentcommonsenseofthisapproach,thereislittleestablishedevidenceoftheeffectfromthesemedications.PremedicationcouldbeanintravenousanxiolyticÐforexample,midazolam1±5mgtitratedtoachieveadequatesedationÐgivenimmediatelybeforetheprocedureoranintramuscularopioidgiven1hourbefore,althoughneitherdrughasbeenshowntobeclearlysuperior.BoththeseclassesofdrugsmaycauserespiratorydepressionandpatientswithunderlyinglungdiseasesuchasCOPDshouldbeobservedasreversalagentsÐforexample,naloxoneor¯umazenilÐareoccasionallynecessary.Whiletheuseofatropineaspartofpremedicationfor®bre-opticbronchoscopyhasbeenassessed,nocontrolledtrialofitsuseinchesttubeinsertionhasbeenidenti®ed,althoughitisadvocatedinsomecentres.Casereportsofvasovagalandadeathduetovagalstimulationfollowingtubeinsertionmaysupportitsuseaspremedication.Figure1Summaryofchestdraininsertionprocess. Indicationtoinsertchestdrain(section3) (section6) Premedication(section6) Confirmationofsiteofinsertionclinicallyandonradiography(section8) Positioningof(section7) Sizeofchestdrain(sections10and13) Aseptictechnique(section11)Localanaesthesia(section12)Bluntdissectionifrequired(section13.3.2) Securingdrainandsuture(section13.3.4) Underwaterseal(section14.2)Clampinginstructions(section14.1) Decisionresuction(section14.3) Removalofdrain(section14.5) Figure2Equipmentrequiredforinsertionofchestdrains. Laws,Neville,Duffy 7PATIENTPOSITIONThepreferredpositionfordraininsertionisonthebed,slightlyrotated,withthearmonthesideofthelesionbehindthepatient'sheadtoexposetheaxillaryarea.Analternativeisforthepatienttosituprightleaningoveranadjacenttablewithapilloworinthelateraldecubitusposition.Insertionshouldbeintheªsafetriangleºillustratedin®g3.Thisisthetriangleborderedbytheanteriorborderofthelatissimusdorsi,thelateralborderofthepectoralismajormuscle,alinesuperiortothehorizontallevelofthenipple,andanapexbelowtheaxilla.8CONFIRMINGSITEOFDRAININSERTIONAchesttubeshouldnotbeinsertedwithoutfurtherimageguidanceiffreeairor¯uidcannotbeaspiratedwithaneedleatthetimeofanaesthesia.[C]Imagingshouldbeusedtoselecttheappropriatesiteforchesttubeplacement.[B]Achestradiographmustbeavailableatthetimeofdraininsertionexceptinthecaseoftensionpneumothorax.[C]Immediatelybeforetheproceduretheidentityofthepatientshouldbecheckedandthesiteandsideforinsertionofthechesttubecon®rmedbyreviewingtheclinicalsignsandthechestradiograph.Fluoroscopy,ultrasonography,andCTscan-ningcanallbeusedasadjunctiveguidestothesiteoftubeBeforeinsertion,airor¯uidshouldbeaspirated;ifnoneisforthcoming,morecompleximagingthanachestradiographisrequired.Theuseofultrasonographyguidedinsertionisparticularlyusefulforempyemaandeffusionsasthediaphragmcanbelocalisedandthepresenceofloculationsandpleuralthicken-ingde®ned.Usingrealtimescanningatthetimeofthepro-cedurecanhelptoensurethattheplacementissafedespitethemovementofthediaphragmduringrespiration.Thecom-plicationratefollowingimageguidedthoracocentesisislowwithpneumothoracesoccurringinapproximately3%ofcases.Successratesofimageguidedchesttubeinsertionarereportedtobe71±86%.Ifanimagingtechniqueisusedtoindicatethesitefordraininsertionbuttheprocedureisnotcarriedoutatthetimeofimaging,thepositionofthepatientatthetimemustbeclearlydocumentedtoaidaccurateinser-tionwhenthepatientreturnstotheward.Itisrecommendedthatultrasoundisusediftheeffusionisverysmallorinitialblindaspirationfails.9DRAININSERTIONSITEThemostcommonpositionforchesttubeinsertionisinthemidaxillaryline,throughtheªsafetriangleºillustratedin®g3anddescribedabove.Thispositionminimisesrisktounderlyingstructuressuchastheinternalmammaryarteryandavoidsdamagetomuscleandbreasttissueresultinginunsightlyscarring.Amoreposteriorpositionmaybechosenifsuggestedbythepresenceofalocule.Whilethisissafe,itisnotthepreferredsiteasitismoreuncomfortableforthepatienttolieonafterinsertionandthereisariskofthedrainForapicalpneumothoracesthesecondintercostalspaceinthemidclavicularlineissometimeschosenbutisnotrecom-mendedroutinelyasitmaybeuncomfortableforthepatientandmayleaveanunsightlyscar.Loculatedapicalpneumotho-racesarenotuncommonlyseenfollowingthoracotomyandmaybedrainedusingaposteriorlysited(suprascapular)api-caltube.1920Thistechniqueshouldbeperformedbyanopera-torexperiencedinthistechniqueÐforexample,athoracicsurgeon.Ifthedrainistobeinsertedintoaloculatedpleuralcollection,thepositionofinsertionwillbedictatedbythesiteoftheloculeasdeterminedbyimaging.10DRAINSIZESmallboredrainsarerecommendedastheyaremorecomfortablethanlargerboretubes[B]butthereisnoevidencethateitheristherapeuticallysuperior.Largeboredrainsarerecommendedfordrainageofacutehaemothoraxtomonitorfurtherbloodloss.[C]Theuseoflargeboredrainshaspreviouslybeen6821asitwasfeltthattherewasanincreaseinthefrequencyofdrainblockage,particularlybythickmalignantorinfected¯uid.Themajorityofphysiciansnowusesmallercatheters(10±14French(F))andstudieshaveshownthattheseareoftenaseffectiveaslargerboretubesandaremorecomfortableandbettertoleratedbythepatient.Thereremainsintensedebateabouttheoptimumsizeofdrainagecatheterandnolargerandomisedtrialsdirectlycomparingsmallandlargeboretubeshavebeenper-formed.Inpneumothoraces9Fcathetershavebeenusedwithsuc-cessratesofupto87%,althoughinafewpatientstheairleakseemstoexceedthecapacityofthissmallcatheter.Intheeventoffailuretodrainapneumothoraxduetoexcessiveairleakage,itisrecommendedthatalargerboretubebeinserted.Thereisnoevidencetosuggestthatsurgicalemphysemaratesvarybetweenthesizeofdrains.Ultrasonographicallyguidedinsertionofpigtailcathetersfortreatmentofmalignantpleu-raleffusionsforsclerotherapyhasbeenparticularlywellstud-iedwithgoodeffect.Theuseofsmallborepigtailcathetershasallowedoutpatienttreatmentofmalignantpleuraleffusionswhichhavenotrespondedtochemotherapy.Empyemasareoftensuccessfullydrainedwithultrasonicallyplacedsmallboretubeswiththeaidofthrombolyticagents.3435Inthecaseofacutehaemothorax,however,largeboretubes(28±30Fminimum)continuetoberecommendedfortheirdualroleofdrainageofthethoraciccavityandassessmentofcontinuingbloodloss.11ASEPTICTECHNIQUEAseptictechniqueshouldbeemployedduringcath-eterinsertion.[C]Prophylacticantibioticsshouldbegivenintraumacases.[A]Asachestdrainmaypotentiallybeinplaceforanumberofdays,aseptictechniqueisessentialtoavoidwoundsiteinfec-tionorsecondaryempyema.Althoughthisisuncommon,estimationsoftheempyemaratefollowingdraininsertionsfortraumaareapproximately2.4%.Whilethefullsteriletechniqueaffordedbyasurgicaltheatreisusuallyunneces-sary,sterilegloves,gown,equipmentandtheuseofsteriletowelsaftereffectiveskincleansingusingiodineorchlorhex-idinearerecommended.AlargeareaofskincleansingshouldFigure3Diagramtoillustratetheªsafetriangleº. BTSguidelinesfortheinsertionofachestdrain beundertaken.Inastudyofchesttubesinsertedintraumasuitesusingfullaseptictechnique,therewerenoinfectivecomplicationsin80cases.Studiesoftheuseofantibioticprophylaxisforchesttubeinsertionhavebeenperformedbuthavefailedtoreachsigni®cancebecauseofsmallnumbersofinfectiouscomplica-tions.However,ameta-analysisofthesestudieshasbeenper-formedwhichsuggestedthat,inthepresenceofchesttrauma(penetratingorblunt),theuseofprophylacticantibioticsreducestheabsoluteriskofempyemaby5.5±7.1%andofallinfectiouscomplicationsby12.1±13.4%.Theuseofprophy-lacticantibioticsintraumacasesisthereforerecommended.Theantibioticsusedinthesestudieswerecephalosporinsorclindamycin.Theuseofprophylacticantibioticsislessclearintheeventofspontaneouspneumothoraxorpleuraleffusiondrainageasnostudieswerefoundwhichaddressedthesecircumstances.Inonestudyonlyoneinfectiouscomplication(inthechesttubetrack)occurredinaseriesof39spontaneouspneumo-thoracestreatedwithchesttubes.12ANAESTHESIALocalanaestheticshouldbein®ltratedpriortoinser-tionofthedrain.[C]Localanaestheticisin®ltratedintothesiteofinsertionofthedrain.Asmallgaugeneedleisusedtoraiseadermalblebbeforedeeperin®ltrationoftheintercostalmusclesandpleu-ralsurface.Aspinalneedlemayberequiredinthepresenceofathickchestwall.Localanaestheticsuchaslignocaine(upto3mg/kg)isusuallyin®ltrated.Higherdosesmayresultintoxiclevels.Thepeakconcentrationoflignocainewasfoundtobe(thatis,alowriskofneurotoxiceffects)in85%ofpatientsgiven3mg/kgintrapleurally.Thevolumegivenisconsideredtobemoreimportantthanthedosetoaidspreadoftheeffec-tiveanaestheticarea.Theuseofadrenalinetoaidhaemostasisandlocalisetheanaesthesiaisusedinsomecentresbutisnotevidencebased.13INSERTIONOFCHESTTUBEChestdraininsertionshouldbeperformedwithoutsubstantialforce.[C]Insertionofachesttubeshouldneverbeperformedwithanysubstantialforcesincethisriskssuddenchestpenetrationanddamagetoessentialintrathoracicstructures.ThiscanbeavoidedeitherbytheuseofaSeldingertechniqueorbybluntdissectionthroughthechestwallandintothepleuralspacebeforecatheterinsertion.Whichoftheseapproachesisappro-priatedependsonthecathetersizeandisdiscussedbelow.13.1Smallboretube(8±14F)Insertionofasmallboredrainunderimageguidancewithaguidewiredoesnotrequirebluntdissection.SmallborechesttubesareusuallyinsertedwiththeaidofaguidewirebyaSeldingertechnique.Bluntdissectionisunnecessaryasdilatorsareusedintheinsertionprocess.Afterin®ltrationwithlocalanaesthesia,aneedleandsyringeareusedtolocalisethepositionforinsertionbytheidenti®cationofairorpleural¯uid.Aguidewireisthenpasseddownthehuboftheneedle,theneedleisremoved,andthetractenlargedusingadilator.Asmallboretubecanthenbepassedintothethoraciccavityalongthewire.Thesehavebeensuccessfullyusedforpneumothorax,effusions,orloculatedempyemas.15234213.2Mediumboretube(16±24F)MediumsizedchestdrainsmaybeinsertedbyaSeldingertechniqueorbybluntdissectionasoutlinedbelow.Astheincisionsizeshouldaffordasnug®taroundthechesttube,itisnotpossibletoinserta®ngertoexplorethepleurawheninsertingthissizeoftube.Explorationwitha®ngerisfelttobeunnecessaryfortheelectivemedicalinsertionofthesemediumsizedchesttubes.13.3Largeboretube (24F)Bluntdissectionintothepleuralspacemustbeperformedbeforeinsertionofalargeborechestdrain.[C]13.3.1IncisionTheincisionforinsertionofthechestdrainshouldbesimilartothediameterofthetubebeinginserted.ted.Oncetheanaesthetichastakeneffectanincisionismade.Thisshouldbeslightlybiggerthantheoperator's®ngerandtube.Theincisionshouldbemadejustaboveandparalleltoarib.13.3.2BluntdissectionManycasesofdamagetoessentialintrathoracicstructureshavebeendescribedfollowingtheuseoftrocarstoinsertlargeborechesttubes.Bluntdissectionofthesubcutaneoustissueandmuscleintothepleuralcavityhasthereforebecomeuniversalandisessential.Inoneretrospectivestudyonlyfourtechnicalcomplicationswereseenin447casesusingbluntdissection.UsingaSpencer-Wellsclamporsimilar,apathismadethroughthechestwallbyopeningtheclamptoseparatethemuscle®bres.Foralargechestdrain,similarinsizetothe®nger,thistrackshouldbeexploredwitha®ngerthroughintothethoraciccavitytoensuretherearenounder-lyingorgansthatmightbedamagedattubeinsertion.creationofapatenttrackintothepleuralcavityensuresthatexcessiveforceisnotneededduringdraininsertion.13.3.3PositionoftubetipThepositionofthetipofthechesttubeshouldideallybeaimedapicallyforapneumothoraxorbasallyfor¯uid.However,anytubepositioncanbeeffectiveatdrainingairor¯uidandaneffectivelyfunctioningdrainshouldnotberepositionedsolelybecauseofitsradiographicposition.[C]Inthecaseofalargeboretube,aftergentleinsertionthroughthechestwallthetrocarpositionedafewcentimetresfromthetubetipcanaffordsupportofthetubeandsohelpitspositioningwithoutincurringorgandamage.Asmallerclampcanalsobeusedtodirectthetubetoitsdesiredposition.Ifpossible,thetipofthetubeshouldbeaimedapicallytodrainairandbasallyfor¯uid.However,successfuldrainagecanstillbeachievedwhenthedrainisnotplacedinanidealsoeffectivelyfunctioningtubesshouldnotberepositionedsimplybecauseofasuboptimalradiographic13.3.4SecuringthedrainLargeandmediumborechestdrainincisionsshouldbeclosedbyasutureappropriateforalinearincision.incision.·ªPursestringºsuturesmustnotbeused.[C]TwosuturesareusuallyinsertedÐthe®rsttoassistlaterclosureofthewoundafterdrainremovalandthesecond,astaysuture,tosecurethedrain.Thewoundclosuresutureshouldbeinsertedbeforebluntdissection.Astrongsuturesuchasª1ºsilkisappropriate.621ªmattressºsutureorsuturesacrosstheincisionareusuallyemployedand,whateverclosureisused,thestitchmustbeofatypethatisappropriateforalinearincision(®g4).Compli-catedªpursestringºsuturesmustnotbeusedastheyconvertLaws,Neville,Duffy alinearwoundintoacircularonethatispainfulforthepatientandmayleaveanunsightlyscar.Asutureisnotusu-allyrequiredforsmallgaugechesttubes.Thedrainshouldbesecuredafterinsertiontopreventitfallingout.Varioustechniqueshavebeendescribed,butasimpletechniqueofanchoringthetubehasnotbeenthesub-jectofacontrolledtrial.Thechosensutureshouldbestoutandnonabsorbabletopreventbreaking(e.g.ª1ºsilk),anditshouldincludeadequateskinandsubcutaneoustissuetoensureitissecure(®g4).Largeamountsoftapeandpaddingtodressthesiteareunnecessaryandconcernshavebeenexpressedthattheymayrestrictchestwallmovementorincreasemoisturecollection.Atransparentdressingallowsthewoundsitetobeinspectedbynursingstaffforleakageorinfection.Anomentaltagoftapehasbeendescribedwhichallowsthetubetoliealittleawayfromthechestwalltopreventtubekinkingandtensionattheinsertionsite(®g5).14MANAGEMENTOFDRAINAGESYSTEM14.1ClampingdrainAbubblingchesttubeshouldneverbeclamped.[C]Drainageofalargepleuraleffusionshouldbecontrolledtopreventthepotentialcomplicationofre-expansionpulmonaryoedema.[C]Incasesofpneumothorax,clampingofthechesttubeshouldusuallybeavoided.[B]Ifachesttubeforpneumothoraxisclamped,thisshouldbeunderthesupervisionofarespiratoryphy-sicianorthoracicsurgeon,thepatientshouldbemanagedinaspecialistwardwithexperiencednurs-ingstaff,andthepatientshouldnotleavethewardenvironment.[C]Ifapatientwithaclampeddrainbecomesbreathlessordevelopssubcutaneousemphysema,thedrainmustbeimmediatelyunclampedandmedicaladvicesought.[C]Thereisnoevidencetosuggestthatclampingachestdrainpriortoitsremovalincreasessuccessorpreventsrecurrenceofapneumothoraxanditmaybehazardous.Thisisthereforegenerallydiscouraged.Clampingachestdraininthepresenceofacontinuingairleakmayleadtothepotentiallyfatalcom-plicationoftensionpneumothorax.Abubblingdrainthereforeshouldneverbeclamped.However,manyexperi-encedspecialistphysicianssupporttheuseoftheclampingofnon-bubblingchestdrainsinsertedforpneumothoraxtodetectsmallairleaksnotimmediatelyobviousatthebedside.Byclampingthechestdrainforseveralhours,followedbyachestradiograph,aminorairleakmaybedetected,avoidingtheneedforlaterchestdrainreinsertion.IntheACCPDelphiconsensusstatementabouthalftheconsensusgroupsupportedclampingandhalfdidnot,andthisseemssimilartotheUKspreadofopinion.Drainclampingisthereforenotgenerallyrecommendedforsafetyreasons,butisacceptableunderthesupervisionofnursingstaffwhoaretrainedinthemanagementofchestdrainsandwhohaveinstructionstounclampthechestdrainintheeventofanyclinicaldeteriora-tion.Patientswithaclampedchestdraininsertedforpneumothoraxshouldnotleavethespecialistwardarea.Therehavebeenreportsofre-expansionpulmonaryoedemafollowingrapidevacuationoflargepleuraleffusionsaswellasinassociationwithspontaneouspneumothorax.4748Thishasbeenreportedtobefatalinsomecases(upto20%ofsubjectsinoneseriesof53cases).Inthecaseofspontaneouspneumothoraxthisisararecomplicationwithnocasesofre-expansionpulmonaryoedemareportedintwolargestudiesof400and375patients,respectively.5051Itisusuallyassociatedwithdelayeddiagnosisandthereforeawarenessofitspotentialoccurrenceissuf®cient.Mildersymptomssuggestiveofre-expansionoedemaarecommonafterlargevolumethoracentesisinpleuraleffusion,withpatientsexperiencingdiscomfortandcough.Ithasbeensuggestedthatthetubebeclampedfor1hourafterdraining1litre.Whilethereisnoevidenceforactualamounts,goodpracticesuggeststhatnomorethanabout1.5litresshouldbedrainedatonetime,ordrainageshouldbeslowedtoabout500mlperhour.14.2ClosedsystemdrainageAllchesttubesshouldbeconnectedtoasingle¯owdrainagesysteme.g.underwatersealbottleor¯uttervalve.[C]Useofa¯uttervalvesystemallowsearliermobilisa-tionandthepotentialforearlierdischargeofpatientswithchestdrains.Thechesttubeisthenattachedtoadrainagesystemwhichonlyallowsonedirectionof¯ow.Thisisusuallytheclosedunderwatersealbottleinwhichatubeisplacedunderwateratadepthofapproximately3cmwithasideventwhichallowsescapeofair,oritmaybeconnectedtoasuctionpump.2±47Thisenablestheoperatortoseeairbubbleoutasthelungre-expandsinthecaseofpneumothoraxor¯uidevacua-tionrateinempyemas,pleuraleffusions,orhaemothorax.Thecontinuationofbubblingsuggestsacontinuedvisceralpleuralairleak,althoughitmayalsooccurinpatientsonsuctionwhenthedrainispartlyoutofthethoraxandoneofthetubeholesisopentotheair.Therespiratoryswinginthe¯uidinthechesttubeisusefulforassessingtubepatencyandcon®rmsthepositionofthetubeinthepleuralcavity.Thedis-advantagesoftheunderwatersealsystemincludeobligatoryinpatientmanagement,dif®cultyofpatientmobilisation,andtheriskofknockingoverthebottle.Figure4Exampleofstayandclosingsutures. Figure5Omentaltagtosupportthetubewhileallowingittoliealittleawayfromthechestwall. BTSguidelinesfortheinsertionofachestdrain TheuseofintegralHeimlich¯uttervalveshasbeenadvocatedinpatientswithpneumothoraces,especiallyastheypermitambulatoryorevenoutpatientmanagementwhichhasbeenassociatedwitha85±95%successrate.5354In176casesofpneumothoraxtreatedwithsmallchesttubesandaHeimlich¯uttervalvetherewereonlyeightfailures(hospitaladmis-sionsforproblemswithtubefunctionorplacement).Themeanlengthofinpatientstayhasbeenquotedat5hourswithathoracicventand144hourswithanunderwaterseal,withacostsavingUS$5660.Casereportsofincorrectuse(wrongdirectionof¯ow)ofsuchvalveshavebeendescribed,however,withtensionpneumothoraxasaresult.Fluttervalvescannotbeusedwith¯uiddrainageastheytendtobecomeblocked.However,intheUKasimilarshorthospitalstayisachievedbyinitialaspirationofpneumothoraces(seeguidelinesonpneu-mothorax,pageii39).Theuseofadrainagebagwithanincorporated¯uttervalveandventedoutlethasbeensuccessfullyusedpostoperatively.5657Arandomisedtrialof119casesfollowingelectivethoracotomycomparedtheuseofanunderwatersealwiththe¯utterbagandfoundnodifferenceindrainagevol-umes,requirementforsuction,orcomplicationswiththeaddedadvantageofearliermobilisationwithdrainagebags.IncasesofmalignantpleuraleffusiondrainageaclosedsystemusingadrainagebagoraspirationviaathreewaytaphasbeendescribedtoaidpalliationandoutpatientOnereportofamodi®edurinarycollectingbagforprolongedunderwaterchestdrainagehasbeendescribedforusewithempyemas,bronchopulmonary®stula,andpneumothoraxassociatedwithemphysemawithnocom-plicationsinthe12patientsstudied.14.3SuctionWhenchestdrainsuctionisrequired,ahighvolume/lowpressuresystemshouldbeused.[C]Whensuctionisrequired,thepatientmustbenursedbyappropriatelytrainedstaff.[C]Theuseofhighvolume/lowpressuresuctionpumpshasbeenadvocatedincasesofnon-resolvingpneumothoraxorfollow-ingchemicalpleurodesis,butthereisnoevidencetosupportitsroutineuseintheinitialtreatmentofspontaneous5960Ifsuctionisrequired,thismaybeperformedviatheunderwatersealatalevelof10±20cmHAhighvolumepump(e.g.Vernon-Thompson)isrequiredtocopewithalargeleak.Alowvolumepump(e.g.Robertspump)isinappropriateasitisunabletocopewiththerapid¯ow,therebyeffectingasituationsimilartoclampingandriskingformationofatensionpneumothorax.Awallsuctionadaptormayalsobeeffective,althoughchestdrainsmustnotbeconnecteddirectlytothehighnegativepressureavailablefromwallsuction.Inthemanagementofpleuralinfection,theuseofsuctionislessclear.Moststudiesareobservationalandhaveusedsuc-tionappliedviathechesttubeafter¯ushingtopreventblock-ingandhavereportedsuccess,butthishasnotbeencomparedwithcaseswithoutsuction.Thisisdiscussedfurtherintheguidelineonpleuralinfection(pageii18).Thereisnoevidencethatbrie¯ydisconnectingadrainfromsuctionusedforspontaneouspneumothoraxorpleuraleffusionisdisadvantageous.Therefore,aslongasadequateinstructionisgiventopatient,porteringandnursingstaffwithregardtokeepingtheunderwatersealbottlebelowthelevelofthechest,itisacceptabletostopsuctionforshortperi-odssuchasforradiography.14.4WardinstructionsPatientswithchesttubesshouldbemanagedonspecialistwardsbystaffwhoaretrainedinchestdrainmanagement.[C]Achestradiographshouldbeperformedafterinser-tionofachestdrain.[C]Patientsshouldbemanagedonawardfamiliarwithchesttubes.Instructiontoandappropriatetrainingofthenursingstaffisimperative.Ifanunderwatersealisused,instructionsmustbegiventokeepthebottlebelowtheinsertionsiteatalltimes,tokeepitupright,andtoensurethatadequatewaterisinthesystemtocovertheendofthetube.Dailyreassessmentoftheamountofdrainage/bubblingandthepresenceofrespi-ratoryswingshouldbedocumented,preferablyonadedicatedchestdrainchart.Instructionwithregardtochestdrainclampingmustbegivenandrecorded.Patientsshouldbeencouragedtotakeresponsibilityfortheirchesttubeanddrainagesystem.Theyshouldbetaughttokeeptheunderwatersealbottlebelowtheleveloftheirchestandtoreportanyproblemssuchaspullingonthedraininsertionsite.Educationalmaterial(e.g.lea¯ets)shouldbeavailableonthewardforpatientsandnursingstaff.Achestradiographshouldbeperformedtoassesstubeposition,excludecomplicationssuchaspneumothoraxorsur-gicalemphysema,andassessthesuccessoftheprocedureinthevolumeof¯uiddrainageorpneumothoraxresolution.Concernhaspreviouslybeenexpressedincaseswherethetubeentersthelung®ssure.Inastudyof66patientswithchesttubesinsertedforacutechesttrauma,58%ofwhichwerelocatedwithinapulmonary®ssure,nodifferenceinoutcomewasseenbetweenthesecasesandthoseinwhomthetubewaslocatedoutsidethe®ssures.14.5RemovalofthechesttubeIncasesofpneumothorax,thechesttubeshouldnotbeclampedatthetimeofitsremoval.[B]Incasesofpneumothorax,thereisnoevidencethatclampingachestdrainatthetimeofitsremovalisbene®cial.ThechesttubeshouldberemovedeitherwhilethepatientperformsValsalva'smanoeuvreorduringexpirationwithabrisk®rmmovementwhileanassistanttiesthepreviouslyplacedclosuresuture.2±478Thetimingofremovalisdependentontheoriginalreasonforinsertionandclinicalprogress(seeguidelinesformanagementofpneumothorax(pageii39),malignantpleuraleffusions(pageii29),andpleuralinfections(pageii18)).Inthecaseofpneumothorax,thedrainshouldnotusuallyberemoveduntilbubblinghasceasedandchestradiographydemonstrateslungrein¯ation.Clampingofthedrainbeforeremovalisgenerallyunnecessary.Inonestudytheremovalofchesttubesaftercontinuoussuctionwascomparedwiththeremovalafteraperiodofdisconnectionfromsuctiontoanunderwaterseal.Nosigni®cantdifferencewasseenbetweenthesetwomethodswithonlytwoof80cases(2.5%)requiringreinsertionofachesttube.15PATIENTSREQUIRINGASSISTEDVENTILATIONDuringtheinsertionofachesttubeinapatientonahighpressureventilator(especiallywithpositiveendexpiratorypressure(PEEP),itisessentialtodisconnectfromtheventila-toratthetimeofinsertiontoavoidthepotentiallyserious Auditpoints ·Thepresenceanduseofanappropriatenursingchestdrainobservationchartshouldbenoted.·Thefrequencyofchestdraincomplicationsshouldbe·Theuseofpremedicationandanalgesicsandpatientpainscoresrelatingtochestdraininsertionshouldberecorded.·Thedurationofchesttubedrainageshouldberecorded.Laws,Neville,Duffy complicationoflungpenetration,althoughaslongasbluntdissectioniscarriedoutandnosharpinstrumentsareused,thisriskisreduced.TheauthorsaregratefultoDrRichardHolmesfor®gs3,4,and5.Authors'affiliationsDLaws,DepartmentofThoracicMedicine,RoyalBournemouthHospital,BournemouthBH77DW,UKENeville,RespiratoryCentre,StMary'sHospital,PortsmouthPO36AD,JDuffy,CardiothoracicSurgeryDepartment,CityHospital,NottinghamNG51PB,UKAmericanCollegeofSurgeonsCommitteeonTrauma.In:AdvancedTraumaLifeSupportprogramforphysicians:instructorChicago:AmericanCollegeofSurgeons,1993.[MillerKS,SahnSA.Review.Chesttubes.Indications,technique,managementandcomplications.:258±64.[ParmarJM.Howtoinsertachestdrain.BrJHospMed:231±3.[TreasureT,MurphyJP.Pneumothorax.:1780±6.[WestabyS,BrayleyN.Thoracictrauma±I.I.IV]6HarrissDR,GrahamTR.Managementofintercostaldrains.BrJHosp:383±6.[IbertiTJ,SternPM.Chesttubethoracostomy.CritCareClin:879±95.[QuigleyR.L.Thoracentesisandchesttubedrainage.CritCareCli:111±26.[TomlinsonMA.TreasureT.Insertionofachestdrain:howtodoit.BrJHospMed:248±52.[CollopNA,KimS,SahnSA.Analysisoftubethoracostomyperformedbypulmonologistsatateachinghospital.:709±13.[LuketichJD,KissMD,HersheyJ,etal.Chesttubeinsertion:aprospectiveevaluationofpainmanagement.ClinJPain:152±4.[ReinholdC,IllescasFF,AtriM,etal.Thetreatmentofpleuraleffusionsandpneumothoraxwithcathetersplacedpercutaneouslyunderimage:1189±91.[WardEW,HughesTE.Suddendeathfollowingchesttubeinsertion:anunusualcaseofvagusnerveirritation.JTrauma:258±9.[BolandGW,LeeMJ,SilvermanS,etal.Review.Interventionalradiologyofthepleuralspace.ClinRadiol:205±14.[KleinJS,SchultzS,HeffnerJE.Interventialradiologyofthechest:image-guidedpercutaneousdrainageofpleuraleffusions,lungabscess,andpneumothorax.:581±8.[RosenbergER.Ultrasoundintheassessmentofpleuraldensities.:283±5.[HarnsbergerHR,LeeTG,MukunoDH.Rapid,inexpensiverealtimedirectedthoracocentesis.:545±6.[HoldenMP.Managementofintercostaldrainagetubes.In:Practiceofcardiothoracicsurgery.Bristol:JohnWright,1982:3.[AslamPA,HughesFA.Insertionofanapicaltube.SurgGynecolObstet:1097.[GalvinIF,GibbonsJRP,MagoutM,etal.Placementofanapicalchesttubebyaposteriorapproach.BrJHospMed:330±1.[HydeJ,SykesT,GrahamT.Reducingmorbidityfromchestdrains.:914±5.[ClementsenP,EvaldT,GrodeG,al.Treatmentofmalignantpleuraleffusion:pleurodesisusingasmallborecatheter.Aprospectiverandomizedstudy.RespirMed:593±6.[PatzEF,GoodmanPC,ErasmusJJ.PercutaneousdrainageofpleuralJThoracImaging:83±92.[HendersonAF,BanhamSW,MoranF.Re-expansionpulmonaryoedema:apotentiallyseriouscomplicationofdelayeddiagnosisof:593±4.[ThomasRJ,SagarSM.WhatsizepleuraltubeforpleuraleffusionsBrJHospMed:184.[TaylorPM.Catheterssmallerthen24Frenchgaugecanbeusedforchestdrains(letter).:186.[ConcesDJ,TarverRD,GrayWC,etal.Treatmentofpneumothoracesutilizingsmallcaliberchesttubes.:55±7.[ParkerLA,CharnockGC,DelanyDJ.Smallborecatheterdrainageandsclerotherapyformalignantpleuraleffusions.21.[MorrisonMC,MuellerPR,LeeMJ,etal.Sclerotherapyofmalignantpleuraleffusionthroughsonographicallyplacedsmall-borecatheters.:41±3.[GoffBA,MuellerPR,MuntzHG,etal.Smallchesttubedrainagefollowedbybleomycinsclerosisformalignantpleuraleffusions.:993±6.[SeatonKG,PatzEF,GoodmanPC.Palliativetreatmentofmalignantpleuraleffusions:valueofsmall-borecatheterthoracostomyanddoxycyclinesclerotherapy.:589±91.[ThompsonRL,YauJC,DonnellyRF,etal.Pleurodesiswithiodizedtalcformalignanteffusionsusingpigtailcatheters.AnnPharmacother:739±42.[VanLeL,ParkerLA,DeMarsLR,etal.Pleuraleffusions:outpatientmanagementofpigtailcatheterchesttubes.GynecolOncol:215±7.[MatsumotoAH.Image-guideddrainageofcomplicatedpleuraleffusionsandadjunctiveuseofintrapleuralurokinase.:1190±1.1190±1.IV]35MoultonJS,BenkertRE,WeisigerKH,etal.Treatmentofcomplicatedpleuralfluidcollectionswithimageguideddrainageandintracavitary:1252±9.[ParryGW,MorganWE,SalamaFD.Managementofhaemothorax.RCollSurgEngl:325±6.[MillikanJS,MooreEE,SteinerE,etal.Complicationsoftubethoracostomyforacutetrauma.AmJSurg:738±41.[DavisJW,MacKersieRC,HoytDB,etal.Randomisedstudyofalgorithmsfordiscontinuingtubethoracostomydrainage.JAmCollSurg:553±7.[FallonWF,WearsRL.Prophylacticantibioticsforthepreventionofinfectiouscomplicationsincludingempyemafollowingtubethoracoscopyfortrauma:resultsofameta-analysis.JTrauma:110±7.[LeBlancKA,TuckerWY.ProphylacticantibioticsandclosedtubeSurgGynecolObstet:259±63.[WootenSA,BarbarashRA,StrangeC,etal.Systemicabsorptionoftetracyclinefollowingintrapleuralinstillation.instillation.IIa]42MellorDJ.Anewmethodofchestdraininsertion.Anaesthesia:713±4.[HaggieJA.Managementofpneumothorax:chestdraintrocarisunsafeandunnecessary.:443.[RashidMA,WikstromT,OrtenwallP.Asimpletechniqueforanchoringchesttubes.EurRespirJ:958±9.[BaumannMH,StrangeC,HeffnerJE,etal.Managementofspontaneouspneumothorax.AnAmericanCollegeofChestPhysiciansDelphiConsensusStatement.TrapnellDH,ThurstonJGB.Unilateralpulmonaryoedemaafterpleural1970;i:1367±9.[RozenmanJ,YellinA,SimanskyDA,etal.Re-expansionpulmonaryoedemafollowingpneumothorax.RespirMed:235±8.[HendersonAK.Furtheradviceoninsertingachestdrain(letterandBrJHospMed:82.[MafhoodS,HixWR,AaronBI,etal.Re-expansionpulmonaryoedema.AnnThoracSurg:340±5.[MillsM,BalschB.Spontaneouspneumothorax:aseriesof400cases.AnnThoracSurg:286.[BrooksJ.OpenthoracotomyinthemanagementofspontaneousAnnSurg:798.[HallM,JonesA.Clampingmaybeappropriatetopreventdiscomfortandreduceriskofoedema(letter).:313.[RoegelaM,RoegglaG,MuellnerM,etal.Thecostoftreatmentofspontaneouspneumothoraxwiththethoracicventcomparedwithconventionalthoracicdrainage(letter).:303.[PonnRB,SivermanHJ,FedericoJA.Outpatientchesttubemanagement.AnnThoracSurg:1437±40.[MaininiSE,JohnsonFE.Tensionpneumothoraxcomplicatingsmall-caliberchesttubeinsertion.:759±60.[MatthewsHR,McguiganJA.Closedchestdrainagewithoutanunderwaterseal.:804P.[GrahamANJ,CosgroveAP,GibbonsJRP,etal.Randomisedclinicaltrialofchestdrainagesystems.:461±2.[Bar-ElY,LeibermanY,YellinA.Modifiedurinarycollectingbagforprolongedunderwaterchestdrainage.AnnThoracSurg:995±6.[SharmaTN,AgrihotriSP,JainNK,etal.Intercostaltubethoracostomyinpneumothorax:factorsinfluencingre-expansionoflung.IndJChestDisAlliedSci:32±5.[SoSY,YuDY.Catheterdrainageofspontaneouspneumothorax:suctionornosuction,earlyorlateremoval:46±8.[WilliamsT.Toclampornottoclamp.NursingTimes:33.[CurtinJJ,GoodmanLR,QuebbermanEJ,etal.Thoracostomytubesafteracutechestinjury:relationshipbetweenlocationinapleuralfissureand.AJR:1339±42.[PeekGJ,FirminRK,ArsiwalaS.Chesttubeinsertionintheventilated.Injury:425±6.[MainA.Asfewsharpobjectsaspossibleshouldbeusedonenteringpleuralspace(letter).:68.[BTSguidelinesfortheinsertionofachestdrain