Jump to comment:

• Chest drain insertion in ventilated patients
  Murad Ghrew
  Published on: 29 April 2016
• Length of tube in the underwater seal drain as fluid fills in
  Sridevi Valluri
  Published on: 29 April 2016
• Ventilation and drainage of pleural effusions
  Jeremy S Bewley
  Published on: 29 April 2016
• Insertion of chest drain guidelines:other experiences
  Calvin S.H. Ng
  Published on: 29 April 2016

• Published on: 29 April 2016

  Chest drain insertion in ventilated patients

  • Murad Ghrew, Consultant in respiratory and critical care medicine

  Dear Editor

  I have read with interest the BTS guidelines for the insertion of a chest drain. In the last paragraph (15) you have recommended that during the insertion of a chest tube in a patient on a high pressure ventilation (especially with positive end expiratory pressure-PEEP), it is essential to disconnect from the ventilator at time of insertion. I have some concerns about this recommendation. I think i...

  Show More

  Dear Editor

  I have read with interest the BTS guidelines for the insertion of a chest drain. In the last paragraph (15) you have recommended that during the insertion of a chest tube in a patient on a high pressure ventilation (especially with positive end expiratory pressure-PEEP), it is essential to disconnect from the ventilator at time of insertion. I have some concerns about this recommendation. I think it was based on the hypothetical risk that the lung may come closer to the wound site or even forced out through the wound as the pleura is breached given the high airways pressure. I think this risk is over exaggerated and its significance is at best disputable. When high mean airway pressure is required to expand a lung with poor compliance, this pressure may not significantly affect the intrapeural or intrathoracic pressure and therefore sudden decompression when the pleura is breached is unlikely. The risk of disconnection from the ventilator is well known. Especially in patients requiring high inflation pressures and high PEEP, sudden disconnection from the ventilator can be associated with severe alveolar de-recruitment and consequently profound hypoxia which my not simply and quickly respond to re-connection. Blunt discetion is reasonably safe for pneumothorax and large effusions. For small effusions, ultrasound guided grains are probably safer keeping in mind that small effusions are very common in critically ill patients due to various reasons and their drainage is not normally indicated unless proven to be infected.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 29 April 2016

  Length of tube in the underwater seal drain as fluid fills in

  • Sridevi Valluri, Registrar Anaesthetics

  Dear Editor,

  Re: BTS guidelines for the insertion of a chest drain.

  This is a wonderful article on chest drain and everything related to it. I do understand that 1-2cm of tube should normally be left underwater when doing an underwater seal drain. My actual site of interest is regarding the length of the tube in the underwater seal when draining a pleural effusion. So when it starts filling in... should we...

  Show More

  Dear Editor,

  Re: BTS guidelines for the insertion of a chest drain.

  This is a wonderful article on chest drain and everything related to it. I do understand that 1-2cm of tube should normally be left underwater when doing an underwater seal drain. My actual site of interest is regarding the length of the tube in the underwater seal when draining a pleural effusion. So when it starts filling in... should we still stick on to 1-2 cm of the tube under the fluid or just leave the tube as it was 1-2 cm underwater not the fluid?!!

  Many Thanks

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 29 April 2016

  Ventilation and drainage of pleural effusions

  • Jeremy S Bewley, Consultant in Intensive Care

  Dear Editor

  The BTS guideline on chest drain management unfortunately fails to recognise the severity of illness of patients who generally require chest drain insertion on an intensive care unit. In our practice chest drainage for pleural effusions only occurs in ventilated patients who require more than 5cm H₂0 PEEP and still have significantly impaired oxygenation limiting their ability to be weaned fr...

  Show More

  Dear Editor

  The BTS guideline on chest drain management unfortunately fails to recognise the severity of illness of patients who generally require chest drain insertion on an intensive care unit. In our practice chest drainage for pleural effusions only occurs in ventilated patients who require more than 5cm H₂0 PEEP and still have significantly impaired oxygenation limiting their ability to be weaned from ventilation. In this population of patients portable ultrasound guidance is used routinely to reduce the risk of damaging underlying lung but the ventilator is not disconnected as lung recruitment will be lost and hypoxia will rapidly develop.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 29 April 2016

  Insertion of chest drain guidelines:other experiences

  • Calvin S.H. Ng, Cardiothoracic Surgeon
  • Other Contributors:
    • Professor Anthony P.C. Yim

  Dear Editor

  I read with interest the latest comprehensive BTS guidelines on chest drain insertion. We would like to share with you some tips and words of caution accumulated by experience from our institute.

  During chest drain insertion, we routinely monitor oxygen saturation continuously with or without prior sedation. Patient with secondary pneumothorax i.e. from COAD can deteriorate during chest drai...

  Show More

  Dear Editor

  I read with interest the latest comprehensive BTS guidelines on chest drain insertion. We would like to share with you some tips and words of caution accumulated by experience from our institute.

  During chest drain insertion, we routinely monitor oxygen saturation continuously with or without prior sedation. Patient with secondary pneumothorax i.e. from COAD can deteriorate during chest drain insertion. Furthermore, at the start of the procedure, the nasal oxygen cannula is sited ( but not necessarily turned on) to allow quick delivery of oxygen in an emergency situation. This is particularly true when patients are put in the lateral decubitus position because placing nasal cannula may be more difficult than if the patient is sitting.

  In the section on drain removal, as a reminder to junior doctors, it is generally recommended that the suction should be turned off prior to removing the drain because of the theoretical risk of tearing the lung.

  Interestingly, there is currently no strong evidence to support removal of chest drains during the Valsalva manoeuvre or expiration; even though the majority of doctors follow this guideline. Physiological understanding suggest that creating a positive intrapleural pressure during chest drain removal may reduce the risk of air entering the pleural cavity. However, study by Bell et al. found no difference in pneumothorax rate whether removal was performed at end inspiration or end expiration.[1] Our experience suggest that important factors influencing post-removal pneumothorax rate are:
  (a) speed of chest drain removal to prevent air entering the pleural cavity through the side holes at removal, and
  (b) preventing para-drain leakage by digital compression of wound site during removal.

  Finally, we have experience of the drain kinking at the point where the tube penetrates the chest wall. The "omental tag of tape" referred by the guidelines can help reduce this occurence. In addition, we found it useful to roll up 2-3 pieces of gauze and place it under (rather than over) the drain right at the point where the tube penetrates the chest wall to bolster the tube and prevent the acute angle it can form with the chest wall, especially with over zealous or tight dressings at that area.

  Reference

  (1) Bell RL, Ovadia P, Abdullah F, Spector S, Rabinovici R. Chest tube removal: end-inspiration or end-expiration? J Trauma 2001;50:674-7.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top