9: Techniques for Pleural Drainage and Chest Tube Management

The concept of chest tube drainage was first advocated by Hippocrates when he described the treatment of empyema by means of incision, cautery, and insertion of metal tubes.¹ The technique was not widely used until the influenza epidemic of 1917 which saw an increased use of intercostal drainage for postpneumonic empyema.² The use of chest tubes was imperative in the management of World War II causalities requiring thoracotomy and was reported in 1922 for postoperative care.³ The concept of emergency thoracostomy for acute trauma gained wider popularity following the Korean War in 1945.⁴ Today the use of chest tubes is part of the day-to-day management of acute trauma and care of thoracic surgery patients.

Chest tubes are indicated for both emergent and elective situations.^4-6 The most common indication for tube thoracostomy is pneumothorax and/or hemothorax. Other indications are summarized in Table 9-1. There are no absolute contraindications to drainage by means of chest tube, especially in the case of life-threatening emergency.⁴ Relative contraindications to chest tube insertion include postoperative inflammatory and infective pleural space adhesions, presence of a diaphragmatic hernia, or hepatic hydrothorax with documented coagulopathy.⁷

The essential steps to inserting a pleural drainage tube are summarized in Table 9-2. The technique can also be viewed online.⁸ Good insertion technique and appropriate post-insertion care are associated with less morbidity and shorter hospital stays.⁹ The most common site of insertion is the “safe triangle,” which as the name implies, is the safest entry into the chest.^10,11 The boundaries of this triangle are identified by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, and a line superior to the horizontal level of the nipple and an apex below the axilla (Fig. 9-1). In this space, the likelihood of damaging vital structures during insertion is considerably low.¹² As the diaphragm can rise to the fifth rib at nipple level during expiration, chest tubes should be placed above this level to avoid inadvertent damage to abdominal structures.

An incision 1.5 to 2 cm in length is made parallel to the rib. A Kelly clamp or an artery forceps is used bluntly to dissect through the subcutaneous layers and intercostal muscles. The path of dissection should aim toward the upper superior intercostal space. A dissection plane is created through the subcutaneous tissue layers and the intercostal muscles on the superior surface of the rib. Adhering to the superior surface will avoid inadvertent injury to the neurovascular bundle located at the inferior surface. The blunt bevel of the dissecting instrument is used to gently puncture through the parietal pleura. Digital penetration (usually with the index finger) is followed to avoid puncturing any adjacent lung tissue. Once entry into the pleura is confirmed, the Kelly clamp is withdrawn and the tube is inserted along the established tract. When thoracostomy is needed to drain an apical pneumothorax, an anticlockwise wrist maneuver will permit the tube to slide away from the fissure and lie in the desired position in the apex of the lung. Mattress or interrupted sutures are used on both sides of the incision to close the ends (Fig. 9-2). The loose ends of the sutures are wrapped around the tube and tied to anchor the tube to the chest wall. The tube is then taped to the side of the patient and wrapped by a petroleum-based gauze dressing. Several pieces of regular sterile gauze and multiple pressure dressings are used to secure the chest tube in place. A chest x-ray is obtained to confirm placement.¹³

The tube is then connected to a water seal drainage container. This allows the air and fluid to be evacuated and avoids inadvertent suction into the chest cavity. The water seal container connected to the chest tube also permits one-way movement of air and liquid from the pleural cavity. Traditionally, the underwater seal drainage apparatus comprises a series of up to three reusable glass bottles connected to one another and attached to the chest tube (Fig. 9-3). The water seal drainage container normally is filled with approximately 250 to 350 mL of sterile water to a marked level. The first bottle provides the collection chamber. The second, the water seal valve. It has an afferent tube that is kept below water level. Fluid and air can egress from the tube. The vacuum produced by inhalation draws fluid into the tubing but does not allow air to be re-introduced into the pleural cavity. The intrapleural vacuum can be countered by the application of suction to the third bottle, the suction control. In addition to the afferent and efferent tubes, the suction control bottle has a third tube open to air. The depth at which the tube penetrates below the fluid level determines the degree of suction; hence the familiar measure of surgical suction in centimeters. Currently, commercially available clear plastic disposable containers are used instead. These consist of either a single chamber with an underwater seal (Fig. 9-4) or a three-chamber container with a collection chamber, suction chamber, and water seal chamber in the middle (Fig. 9-5).

Complications of chest tube insertion are summarized in Table 9-3. The most important complications include bleeding from intercostal artery perforation, perforation of visceral organs (lung, heart, diaphragm, or intra-abdominal organs), and perforation of major vascular structures.⁴

Although there is general agreement among surgeons on the indications and techniques for chest tube insertion, there is no consensus on the subsequent management of these tubes following placement. Management practices are often institution-based and physician-specific according to training and preferences developed from anecdotal experience. Subsequent management of the chest tube must be individualized to the patient, taking into consideration the indication for chest tube placement, whether or not the patient has had pulmonary resection or is dependent on mechanical ventilation, and if the patient has a bronchopulmonary fistula. Premature removal of the tube, as well as unnecessary delay, leads to increased hospital stays and unjustified costs.

The timing of chest tube removal in regard to drainage volume has been investigated by Younes et al.¹⁴ in a prospective randomized trial. There was no major difference in the rate of fluid accumulation and need for thoracentesis between groups with drainage amounts of ≤100, ≤150, or ≤200 mL/day, respectively. Using a daily threshold of 200 mL could lead to quicker removal of the chest tube, thereby reducing hospitalization time and overall cost. The ideal timing of chest tube removal in regard to the respiratory cycle also has been investigated. A prospective, randomized by Bell and colleagues evaluated whether recurrent pneumothorax was more likely when the chest tube was removed at end-inspiration or end-expiration. This study concluded that the risk of recurrent pneumothorax was similar between both groups and that either method of chest tube removal was safe.¹⁵

The ideal algorithm has yet to be determined for managing chest tubes. Specifically, wide variation in management practices exist in regard to timing and parameters under which chest tubes should be removed, the best method of removal, and the need for chest x-rays to monitor patients pre- and post-chest tube removal. An algorithm developed for chest tube management at Brigham and Women's is provided in Figures 9-6 to 9-8.

Few aspects of Thoracic Surgery are surrounded with more confusion than chest tube management. Yet, this topic is so important and commonplace we felt justified in adding this chapter to the new edition of the book. We are grateful for the authors for presenting a straightforward and short review to demystify these drains. Chest tubes are actually a surprisingly recent development. The authors explain their history and the physics behind the water seal mechanism. Most importantly, they present (with internet video support) a safe and simple way to place a chest tube. This chapter should be required reading for every resident rotating onto a Thoracic Surgery Service.