PLEURAL DRAINAGE: TYPES, PROCEDURE AND CARE - MEDICINE - 2024

The pleural drainage is a surgical procedure whose function is to insert a chest tube to dislodge any abnormal contents inside. The pleural space - a virtual cavity that normally has nothing in it - can fill with air, blood or other fluid after illness or trauma, causing respiratory disorders.

Any content in the pleural cavity that causes dyspnea or other severe symptoms must be drained. Depending on the type, amount or viscosity of the content, the ideal drainage technique will be decided. In this text, the pleural drainage through the chest tube will begin, different from the thoracentesis that has been explained in previous publications.

Thoracentesis is a non-massive procedure, mainly performed for diagnostic purposes. Instead, chest tube pleural drainage is performed for therapeutic purposes, generally emergency, to re-expand one or both lungs, thus restoring the normal ventilatory pattern.

Types

It should not be assumed that chest tube placement equals pleural drainage. In fact, the placement of a chest tube has two basic purposes: one is the one we discuss in this article, which is to drain an abnormal content inside; and the other is to administer drugs and substances into the chest or perform a pleurodesis.

Regarding pleural drainage, it can be said that there are two fundamental types: passive and active:

Passive pleural drainage

Described in some literature as a non-aspiration drainage system, it was the first to be used. Even Hippocrates had already proposed it as a treatment for lung infections complicated by effusion or empyemas. There are different types of passive drainage, among which we have the following:

Water seal drains

One or two bottles can be used. The physiology of the system, while complex in theory, is not technically difficult.

The essential thing is that one of the tubes inside the bottle is submerged in at least 2 centimeters of water to prevent the air extracted from the pleura from being returned through the tube and perpetuating the problem.

The other tubes, whether in the one-bottle or two-bottle system, should never be within the water level, because their function is that the excessive air coming from the thorax is not filtered and that the bottle acts as a reservoir. There is a lot of literature on this that can be reviewed to better understand how it works.

Heimlich valve

It is a very basic one-way flow system; it only works to drain air. It has a latex valve that is inside a plastic chamber with tube connectors that are attached to the chest tube and facilitates the exit of air without allowing it to re-enter. It is usually done by hand, with a thick needle and a latex glove finger.

Active pleural drainage

Also known as an aspiration drainage system, it allows the aspiration of the content manually or with suction. Currently there are different types of suction drainage: from the oldest and artisanal to the most modern and technological.

Three bottle system

It is very similar to draining one or two bottles, but a third is added that is connected to permanent suction.

It was described in 1952 by Howe and that technique continues to be used today with virtually no change. The physics of this system has been used by some medical companies to produce commercial suction kits.

The advantage of permanent suction is that the risk of air rebreathing is largely avoided. Lung expansion is optimal when using this method.

The commercial presentations include some extra security systems, and even ports to take samples of the pleural contents.

Digital drainage system

Not available worldwide, it is an important technological advance that offers security and exact measurements. It is very similar to any active drainage system, but includes a digital device with specialized software that measures airflow and pleural pressure, which helps better management of drainage.

Balanced drainage

Another exclusive commercial drainage system for pneumonectomy patients. It should not be used in other clinical conditions and its handling is reserved for physicians and specialists in thorax surgery.

Pleuro-peritoneal diversion

It is used in the postoperative period of thoracic surgeries complicated with chylothorax or in malignant pleural effusions. They are placed by chest surgeons and activated by the patient himself.

It uses a valve system that works when pressed, draining the pleural fluid into the peritoneal cavity, where it is absorbed or eliminated.

Process

The placement of a chest tube requires a common equipment and trained personnel. If possible, the patient and family members should be informed of the reason for the procedure and possible complications. Among the materials to use we have the following:

- Chest tube, the size of which will depend on the conditions of the patient and the pathology.

- Scalpel # 11.

- Kelly forceps or arterial forceps. A practical substitute can be used.

- Various injectors of medium capacity, and short and long needles for local and deep anesthesia.

- Lidocaine or any other local anesthetic.

- Pleural drainage system.

- Sutures and scissors.

Technique

The patient should be lying on a table, slightly reclined, with the arm resting behind the head. The fourth or fifth intercostal space is located and marked on the anterior axillary line, at the same height or slightly below the nipple. Once the insertion area has been decided, the aseptic and local antisepsis measures are carried out.

The tissues that will be traversed by the tube, both superficial and deep, are then anesthetized.

You should be generous with anesthesia, as it is a painful procedure, always trying to breathe in on the way to make sure you are not inside a blood vessel. Once this step is completed, the tube is inserted.

A 2-centimeter incision is made parallel to the rib and the subcutaneous tissue and intercostal muscles are pierced with the forceps.

Once the canal is made, the upper edge of the lower rib is searched with the finger and the tube supported on it is inserted to avoid the neurovascular bundle. The pleura is traversed with pressure and the tube is fixed.

Drain care

Once the procedure is completed, the air or liquid outlet has been verified and the tube is fixed with the appropriate sutures, certain care measures must be followed.

They are usually carried out by the nursing staff and by the doctor who performed the technique. The main points to consider are the following:

- Grooming the patient and the dressing that covers the tube.

- Checking the proper functioning of the drainage system.

- Measurements of the amount of liquid aspirated.

- Verification of compliance with the diet.

- Frequent mobility of the patient to avoid the formation of trabeculae or pillars.

References

1. Zisis, Charalambos and collaborators (2015). Chest drainage systems in use. Annals of Translational medicine, 3 (3), 43.
2. Oxford Medical Education (2017). Intercostal drain (chest drain / pleural drain) insertion. Recovered from: oxfordmedicaleducation.com
3. Dev, Shelley; Birth, Bartolomeu; Simone, Carmine and Chien, Vincent (2007). How is it done? Insertion of a chest tube. Recovered from: intramed.net
4. Andicoberry Martinez, María José and collaborators (nd). Nursing care for patients with chest drainage. Recovered from: chospab.es
5. Velásquez, Mauricio (2015). Management of pleural drainage systems. Colombian Journal of Surgery, 30: 131-138.
6. Wikipedia (last edition 2018). Chest Tube. Recovered from: en.wikipedia.org