Essentials of pleural

Essentials of pleural

cavity drainage

cavity drainage

Department of General, Oncological and Thorax Surgery
Medical University of Lodz
Head: prof. dr hab. med. Marian Brocki

Authors: Robert Gruda MD, Robert Stolarek MD

•

Drainage or puncture of pleural
cavity is relatively common surgery
procedure at the thoracic surgery
wards or general, ICU, internal or
oncology departments

•

It is a simple procedure but usually
multiple minor problems are
encountered

History

History

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VI century BC. – Hippocrates – described open pleural

drainage and the use of metal drain in pleural empyema

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XV century AC. – Celsius – described rib removal, tocar use

and metal pipe for pleural drainage

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1860 – Hunter – applied hypodermal needle for pleural

drainage

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1875 – Playfair – introduced drainage with underwater valve

for pleural empyema therapy

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1876 – Hewett – described closed system for continuous

drainage in the therapy of pleural empyema

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1910 – Robinson – introduced vacuum into chest drainage

with the use of sucking pump

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1922 – Lilienthal – introduced closed vacuum pleural

drainage in patient after the chest surgery

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1945 – introduction of three bottle sets

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1986 – introduction of single use sets

Anatomy and physiology of

Anatomy and physiology of

pleura cavity

pleura cavity

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Pleural cavity is a bilateral serum space inside the chest limited by

parietal pleura, lining chest walls and visceral pleura which is

lining lungs

•

Under physiological conditions parietal and visceral pleura form

capillary space

7 – 24 m wide, containing small amount

•

Under normal conditions visceral fluid is produced at the

approximate rate 0,01 ml/kg m.c. /h

•

The elastic recoil of chest wall maintains negative pressure inside

the thorax cavity and the constant expansion of the lungs.

•

Chest intrusion, accumulation of fluid or air inside pleural cavity

abolish the negative pressure inside leading to the decrease of

lung volume and the increase of pleural volume.

•

Pleural drainage is necessary for the restoration of physiological

conditions

Pleural cavity drainage

Pleural cavity drainage

•

open – when pleural cavity directly
connects with the atmosphere (used
rarely, mainly in case of chronic
pleural empyema)

•

Closed – when pleura is separated
from the atmosphere with drainage set

– passive – without vacuum
– active – with vacuum

Indications for

Indications for

pleural

pleural

drainage

drainage

•

pneumothorax

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Pleural fluid (exudation, empyema,
hematoma, lymph)

•

Postoperative pleural drainage

•

Pleurobronchial fistula

Contradiction for pleural

Contradiction for pleural

drainage

drainage

There are no unconditional

contradictions for pleural drainage

pneumothorax

pneumothorax

The presence of gas in

pleural cavity

•

Internal (via bronchial wall)

•

External (via chest wall)

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Spontaneous

–

Primary (no lung pathology)

–

Secondary (the presence of lung pathology)

•

Traumatic

–

Non-iatrogenic (open/closed trauma)

–

Iatrogenic (after BAC of the lungs, Mediastinum, subcalvucular

venosection, etc.)

•

entire

•

partial

Pleural drainage systems

Pleural drainage systems

System of pleural drainage includes:

•

Drainage systems

– Pleural drain
– connectors
– Connecting drainage

•

Bottle system

– Drainage bottle
– Underwater valve
– Reduction bottle

Drainage systems

Drainage systems

•

No toxicity

•

No allergy reaction

•

No agitation

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Should be flexible and at the same time

stiff enough to avoid collapse

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Should be transparent

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X ray marker incorporated into the wall

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The terminal lumen should be the same as

drainage diameter

Small drainage

Small drainage

These are plastic small drainages up

to 10F in size, with a needle inside for

penetration or outside for drainage

insertion . Thin drainage are used in

diagnostics and the therapeutical

pleurocentesis, surgical anesthesia

and pericardiocentesis. They are

fragile, can be stuck easily, may

break and therefore are not suitable

for routine pleural drainage.

Medium drainage

Medium drainage

They are vinyl drainages of 10-20F
size with a lancet inside. The
presence of stiff lancet inside allows
for the insertion from a tiny hole in
skin surface. These drainage is
especially useful in the drainage of
encapsulated containers and lung
apex drainage from supraclavicular
access.

Large drainage

Large drainage

Vinyl drainage of 20-36F size may
include a lancet. They are inserted
usually during toracotomy and their
narrowed ending makes the insertion
through the incision canal easier.
Insertion of drainage into the closed
chest required more force and the
expansion of the tissues with a tool or
a finger.

Connecting drainage

Connecting drainage

This is a drainage between pleural
drainage and the drainage bottle. It
has to be transparent, light, flexible,
resistant to collapse and breakings.
Optimal size of connecting drainage
determines its optimal resistance to
the flow: length 1.8 m., internal
diameter 9.5 – 12 mm

Drainage connections

Drainage connections

There are various types of
connectors for different size diameter
drainage. Their fixation should
maintain tight sealed connection,
good visibility inside the connector
and the drainage as well as the
safety of the connection

Drainage bottles

Drainage bottles

Features of drainage bottles

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Sealed thight

•

Quality of connection

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Resistance to incidental breakage

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Light, stiff material resistant to
collapse

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Construction preventing reverse
assembly

Passive drainage

Passive drainage

Passive drainage a gravity propelled
drainage including one bottle. It is the
most crude type of pleural drainage. Its
function involves containing and
underwater valve. The valve allows for
the removal of the air from the plural
cavity and prevent form the sucking of
the air. Intrusion of the air into the pleural
cavity is blocked by underwater valve.

Passive drainage

Passive drainage

The drainage pipe should be submerged

2 cm under water. Lower submersion

may lead to the loss of tight assembly,

increased air flow resistance. Lack of

alternated fluid levels indicates stucked

flow, flexed connection, fluid

accumulation in connecting drainage or

the complete expansion of the lung. The

set should be placed below the chest

level to maintain pressure gradient.

Two bottle passive drainage

Two bottle passive drainage

This set includes main bottle and the
bottle with submerged valve. Blood
or exudative fluid accumulates in the
main bottle whereas the air gets into
the other. The drainage allows for
freely air removal. The pressure in
the main bottle is always equal to the
pressure inside the pleural cavity.

Two bottle active drainage

Two bottle active drainage

This is the most common active
sucking system. It included
submerges valve and the bottle
regulating the suction power.

Three bottle active drainage

Three bottle active drainage

This set includes main bottle,
submerged valve and the bottle for
the regulation of suction power. The
reduction bottle decreases the sub
pressure generated by suction tools.

Four bottle active drainage

Four bottle active drainage

Fuor bottle system includes
additional bottle with submerges
valve connected to three bottle set.
Air pressure valve of the additional
bottle protects from pressure
increase in case of the failure of
suction providing the information on
the current pressure in the pleural
cavity.

Features of vacuum devices

Features of vacuum devices

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The maintenance of the lowered

pressure in the range between 0 and 60

cm H2O

•

The availability of high flow (20 l/min) at

the pressure – 10 cm H2O

•

The maintenance of the negative

pressure in the system

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The removal of drained air into the

atmosphere due to air removal drain

even if sucking does not operate

Other drainage systems

Other drainage systems

Pleural-peritoneal valve of Denver
type– unidirectional valve for fluid
trafficking from pleural to peritoneal
cavity in patients with recurrent
accumulation of pleural fluid without
the option of complete lung
expansion

Other drainage systems

Other drainage systems

Heimlich valve – invented in 1968 as
single or double płatowa valve,
especially useful in patient
transportation

Other drainage systems

Other drainage systems

The set for ambulatory pleural
drainage– it includes plastic sack
with płatkową valve and excess air
valve. It may be carried by the
patients similarly to the urine
containers. It is used in the therapy
of chronic pleurobronchial fistulae
and recurrent exudative pleuritis

Access to pleural cavity

Access to pleural cavity

Anterior access– commonly II or III
intercostal space in middle anterior
clavicle or axillar line. Most routine in
pneumothorax.

Access to pleural cavity

Access to pleural cavity

Lateral access – the drainage is place
in from IV to VI intercostal space in
anterior or middle axillar line. The
drainage ending at the time of air
evacuation is directed rostrally
(towards apex) whereas at the fluid
evacuation caudally and downwards
(towards above diaphragm).

Access to pleural cavity

Access to pleural cavity

Suprascapular access– second
intercostal space below the scapula
in posterior scapular line. For apex
limited pathology only.

Access to pleural cavity

Access to pleural cavity

Posterior access – used for the
drainage of encapsulated purulent
container in the dorsal region below
the scapula. It is guided by CT or
USG.