Chest drain malfunction
Trap bottle:
collects the pleural fluid.
color, volume
Water-seal bottle:
act as a "one-way valve"
fluctuation
no bubbling after 24 h
(bubbling > 24 h suggest air leak in the system)
Manometer bottle:
the distance below its fluid line to generate a negative pressure when suction is applied.
Bubbling
The original three-bottle system consisted of a trap bottle, a water-seal bottle, and a manometer bottle. Chest tube size
Flow rate
The first is Poiseuille's law, which states that flow through a tube depends on the internal diameter (D) and length (L) of the tube, the viscosity of the liquid (η), and the pressure difference between its ends (ΔP):
The Fanning equation determines the flow of moist gas with turbulent flow characteristics through a chest tube:
In the equation, v represents the flow, r denotes the radius, l indicates the length, P is the pressure, and f stands for the friction factor.
Management of chest tube
A malfunctioning chest tube can pose greater risks than having no chest tube at all, particularly when positive-pressure ventilation is being used. Once a thoracic drain is inserted, it is essential to obtain and review a chest radiograph immediately.
Subsequently, a chest radiograph should be performed daily for the duration that the tube remains in place. If there is a significant air leak, if the pneumothorax worsens, or if subcutaneous emphysema develops, the tube should be reconnected to suction, usually set at 20 cm H2O. In such cases, another chest radiograph should be obtained immediately.
If there is no air leak for 24 hours and the drainage is less than 2 mL/kg/day, it is safe to remove the tube. Additionally, if a tube is found to be nonfunctional, it should be removed.
Clamping the tube followed by a chest X-ray may help determine if the patient is likely to develop a pneumothorax after the tube is removed. If any respiratory difficulties arise, the tube can be unclamped immediately.
There is no evidence to support the use of prophylactic antibiotics for chest tube placement in ICU patients who are not trauma cases. In cases of traumatic hemothorax, multiple factors contribute to the risk of pleural space infection. These factors include whether the chest tube is inserted in an emergent or urgent situation, the mechanism of injury, the presence of retained hemothorax, and the type of ventilator care provided. The incidence of empyema ranges between 0% and 18% and is decreased with prophylactic antibiotics. Administration of antibiotics for longer than 24 hours does not reduce this risk further.
Chest X-rays are routinely performed after the chest tube is removed, typically within 6 to 24 hours. For mechanically ventilated patients, an X-ray should be taken after the drain is removed. Pizano and colleagues suggest obtaining it within 3 hours post-removal.
Post-placement chest radiographs may raise concerns about lung fissure placement, potentially compromising function. This situation may necessitate manipulation to change placement.
The data do not support routine milking and stripping unless there is a clot in the tubing. During the procedure, a significant negative pressure can be generated in the chest, which could be detrimental.
Positioning the tubing connecting the chest tube to the drainage system is important. It was found that the dependent loop, left alone, did not drain adequately.
Removal of the chest tube must be timed according to the patient's breathing pattern. Some authors advocate removal at end inspiration, whereas others recommend removal at end expiration. The reason some advocate end inspiration is that when the tube is removed the patient may gasp from the pain and may be more likely to suck in air through the site. In one study, a similar rate of postremoval pneumothorax was found.
Identifying the Source of Air Leak in a Chest Drainage System
Bubbling in the water-seal chamber observed.
Clamp the chest tube near the chest wall.
If the bubbling stops, the air leak is likely from the patient's lung (e.g., alveolar, pleural fistula or ongoing pneumothorax).
If the bubbling continues, the air leak is between that clamp and the water-seal bottle.
Clamp progressively along the tubing toward the drainage system.
Clamp sections sequentially to isolate the leak.
If bubbling stops at a certain point, the leak is between that clamp and the previous segment—likely from the tubing or connection.
If the bubbling continues, the air leak is between that clamp and the water-seal bottle.
References
Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine E-Book: Principles of Diagnosis and Management in the Adult (Kindle). Elsevier Health Sciences. Kindle Edition.