Chest Drains

Chest drain is a conduit to remove air or fluid from the pleural cavity
The fluid can be blood, pus or a pleural effusion
Allows re-expansion of the underlying lung
Must prevent entry of air or drained fluid back into the chest
A chest drain must therefore have three components

o An unobstructed chest drain
o A collecting container below chest level
o A one-way mechanism such as water seal or Heimlich valve

Mechanism of action

Drainage occurs during expiration when pleural pressure is positive
Fluid within pleural cavity drains into water seal
Air bubbles through water seal to outside world
The length of drain below fluid level is important
If greater than 2-3 cms increases resistance to air drainage

Insertion

Unless emergency situation then pre-procedure chest x-ray should be performed
Drain usually inserted under local anaesthesia using aseptic technique
Inserted in 5th intercostal space in mid-axillary line
Inserted over upper border of rib to avoid intercostal vessels and nerves
Blunt dissection and insertion of finger should ensure that pleural cavity is entered
Used to be taught that:

o To drain fluid it should be inserted to base of pleural cavity
o To drain air it should be inserted towards apex of lung

Probably does not matter provided there is no loculation of fluid within pleural cavity
A large drain (28 Fr or above) should be used to drain blood or pus
Drain should be anchored and purse-string or Z-stitch inserted in anticipation of removal

Does and don'ts of chest drains

Avoid clamping of drain as it can result in a tension pneumothorax
Drain should only be clamped when changing the bottle
Always keep drain below the level of the patient
If lifted above chest level contents of drain can siphon back into chest
If disconnection occurs reconnect and ask patient to cough
If persistent air leak consider low pressure suction
Observe for post-expansion pulmonary oedema

Removal
Remove drain as soon as it has served it purpose
For a simple pneumothorax it can often be removed within 24 hours
To remove drain ask patient to perform a Valsalva manoeuvre
Remove drain at the height of expiration
Tie to pre-inserted purse-string or Z-stitch
Perform a post-procedure chest x-ray to exclude a pneumothorax

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