CHEST DRAIN

(Water Sealed Drainage)

Divisi Bedah Toraks Kardiovaskular

FKUI/RSCM
Chest Drain

“A chest drain is a tube inserted into the pleural space to drain

its contents of air or fluid. The tube remains in place until
drainage is complete.”

(Havelock et al, 2010)

Anatomy

 Pleura fluid separates

parietal and visceral
pleural surfaces.
 Amount of pleural fluid
in 24 hours: 0,3 ml/kg
or 25 ml.
 Fluid reduces friction,
allowing the pleura to
slide easily during
breathing.
Physiology
Mechanics of Breathing
 Pleural Physiology

 Area between the pleurae

  the pleural space (potential space)

 Inspiration: -7 cmH2O
 Exhalation : -4 cmH2O

Guyton AC.Textbook of Medical Physiology 11th ed

 Pressure

 Intrapulmonary pressure (the pressure in the lung)

rises and falls with breathing
 Atmospheric pressure
 Intrapleural pressure also fluctuates with breathing
~ 4 cmH2O less than the intrapulmonary pressure
 The pressure difference of 4 cmH2O across the alveolar wall
creates the force that keeps the stretched lungs adherent to the
chest wall
Indications

 Diagnose

 Therapeutik

 Preventive
 Indications

Emergency Non Emergency

 Tension Pneumothorax  Malignant Pleural Effusion
 Unstable Hemodynamic  Recurrent Pleural Effusion
Traumatic  Parapneumonic effusion or
hemopneumothorax empyema
 Chylothorax
 Post care (after cardiac,
pulmonary, mediastinal or
pleural)
 Post pneumonectomy
bronchopleural fistula
Conditions
requiring Chest Drainage

 Air between the pleurae

(Pneumothorax)
Conditions
requiring Chest Drainage

 Blood in the pleural space

(Hemothorax)
Conditions
requiring Chest Drainage

 Transudate or exudate in
the pleural space (Pleural
Effusion)
 Chest Tube Size

Diameter depends on: Choosing Size:

 Size of Patient  Newborn/Infant (12-14 Fr)
 Type of Drainage
 Children (16-24 Fr)
(Air/Fluid)
 Adult (28-36 Fr)
 Duration of Drainage

Dev SP, et al. Chest Tube Insertion. N. Engl J Med. 2007;357

Pre-drainage Risk Assessment

 Careful clinical evaluation Contraindication:

 Differentiate between:  Absolute:
Pneumothorax and bullous Lung completely adherent to
disease chest wall
Collapse and pleural effusion
 Risk of Hemmorrhage:  Relative:
Correct any platelet or Bleeding Diathesis
coagulopathy defect Patient on Anticoagulant
WATER SEAL DRAINAGE
One Bottle System
 This system works if only air is
leaving the chest

 If fluid is draining, it will add to

the fluid in the water seal, and
increase the depth

 As the depth increases, it

becomes harder for the air to
push through a higher level of
water, and could result in air
staying in the chest
Two Bottle System
 For drainage, a second bottle was
added

 The first bottle collects the

drainage

 The second bottle is the water

seal

 With an extra bottle for

drainage, the water seal will then
remain at 2cm
Three Bottle System
Three Bottle System

 If suction is required, a third bottle is added

 The straw submerged in the suction control bottle (typically to
20cmH2O) limits the amount of negative pressure that can be applied to
the pleural space – in this case -20mmH2O
 As the vacuum source is increased, once bubbling begins in this bottle, it
means atmospheric pressure is being drawn in to limit the suction level
Insertion Site

Triangle of safety (Mid Axillary Line) 4th or 5th ICS

Insertion Site

Midclavicular line 2nd ICS ~ For emergencies needle

Thoracosynthesis (Tension Pneumothorax)
 Technique

Choose site
Suture tube to chest

Explore with finger

Place tube with clamp

Photos courtesy trauma.org
 How do We know whether the Chest
Drain properly functional or not?

 Positive Undulation (Prove of connection between the tube and

intrathoracic cavity)
 Less Painful (Appropriate place and Tube Size)
 Correct Pressure (Enough Negative Pressure)
 Bubble Production (Pneumothorax)
 Drainage Production (Amount, and Type of Fluid)
 WSD Removal

WSD is removed when the intrapleural condition is

physiologic:
 Patient is clinically stable
 Good CXR result (adequate lung expansion, with/or little to no
Effusion)
 Drain Production (No more Bubble, Fluid drainage <100cc/24 hr
in adult; 25-50 cc/24 hr in children, there’s no expectation for
recurrent pleural effusion)
Chest Drain Insertion Complication

 Infection
 Laceration of lung tissue
 Intraabdominal organ laceration
 Bleeding
 Subcutis Emphysema
 Malposition
Chest drain for Open Chest
(Special Condition)
TERIMAKASIH
 Kriteria yang digunakan untuk menentukan eksudat adalah kriteria
Light, mencakup : (1) ratio protein cairan pleura dan serum adalah
> 0,5; (2) ratio LDH cairan pleura dan serum adalah >0,6; dan
(3) kadar LDH cairan pleura lebih dari 2/3 batas atas kadar di
serum. Adanya salah satu dari kriteria di atas dinamakan eksudat.
Kriteria minor lainnya yang mengindikasikan eksudat adalah
peningkatan kolesterol cairan pleura (>45 mg/dL, 1,16 mmol/L)
dan kadar protein cairan pleura >3 g/dL. Pada transudat, kadar
serum albumin lebih besar dari cairan pleura sekurang-kurangnya
1,2 mg/dL (12 g/L).