Pleural suction drainage

Synonyms

Chest suction drainage; Bülau drainage; Monaldi drainage; Redon drainage;

First descriptor

The basic concept of a thoracic drainage system was developed by Gotthard Bülau (1835-1900). The Bülau drainage system was named after him.

The first negative pressure continuous suction was developed by Heaton in 1898.

H. K. van Aken et. al also names Hewett in the book "Intensivmedizin" Thieme-Verlag (2007) as the first to describe chest drainage in 1876.

The pleural suction drainage is a plastic catheter of various sizes which is inserted between the parietal and visceral pleura into the so-called pleural gap in order to drain pathological fluids (such as blood, pus, secretion, lymphatic fluid, etc.) or air which has entered the pleural gap (e.g. in the case of pneumothorax) by means of negative pressure.

The catheter is connected to a vacuum or connected to an air-operated thoracic suction system (e.g. Medela pump).

This creates negative pressure for the previously collapsed lung so that the lung can again develop passively.

We distinguish between siphon drains, which work without suction, and so-called suction drains, which work with negative pressure.

• Siphon drains drain the fluid out of body cavities using the hydrostatic pressure gradient (e.g. Bülau siphon drain and the Robinson drain, which is mainly used in urology).
• Suction drains drain secretions from body cavities by means of negative pressure through suction. These include the Bülaudrainage, Monaldi suction drainage, Redon suction drainage and others.

There are different drainage systems:

The one-bottle and also the two-bottle system work by gravity. Only from the three-bottle system onwards is suction active. There are also electronic suction systems.

Indication

absolute:

• tension pneumothorax (for pressure relief)
• postoperatively after thoracic or cardiac surgery

relative

• Pneumothorax
• Hematopneumothorax
• Pleural Empyema
• Skin emphysema
• Pleural effusion
• Serial rib fracture

Contraindications (do not apply to tension pneumothorax, as this is a vital threatening situation)

• Taking anticoagulants
• Diseases associated with a bleeding abnormality
• Platelet count < 50.000 per µl
• Quick < 60% or INR > 1.5

Bülau drainage

In Bülau drainage (named after Gotthard Bülau, 1835-1900, see above), the puncture is performed in the 3rd - 5th ICR in the anterior to middle axillary line (in the so-called triangle of savety) at the upper rib margin. It is usually used for serothorax and pyothorax, less frequently for pneumothorax. For this purpose, bulky drains of 28 - 32 charr are used.

Through these, pathological fluids or air are sucked out with the help of a permanent suction of 5 to 20 cm H2O. If the suction is too strong, however, there is a risk of re-expansion edema (leading symptom: increasing dyspnoea).

The Monaldi drainage (named after Vincenzo Monaldi, 1899-1969) is a small-lumen (18 - 22 Charr) drainage and is mostly used for pneumothorax, since a smaller volume is sufficient.

In this case, access to the pleural gap is made in the medioklavicular line in the 2nd - 3rd ICR at the upper rib edge with a small incision.

The above-mentioned Redon - suction drainage is used exclusively to drain secretion and/or blood from wound cavities. A drain is inserted through the skin from the inside to the outside, which is then connected to a vacuum bottle. It is not normally used as a pleural suction drainage.

Creating a drainage system:

The patient should be positioned on his back with a raised upper body.

First of all, the insertion site is determined.

According to Bülau this is in the 3rd - 5th intercostal space in the anterior or middle axillary line, the so-called "triangle of safety". This triangle is limited ventrally by the lateral edge of the M. pectoralis major and dorsally by the edge of the M. latissimus dorsi. The 5th ICR at nipple height forms the caudal border. The arm should be placed in a slightly angled position. Excessive bending of the arm should be avoided, as the nipple will then shift cranially.

According to Monaldi, the insertion site is located in the 2nd - 3rd ICR medioklavicular (the 2nd rib is located at the transition from the manubrium sterni to the corpus sterni; the 2nd ICR is located below this).

This is followed by extensive disinfection and the surgical site is covered.

If the patient is still responsive, local anesthesia is applied and a 4 - 5 cm incision is made with a scalpel at the predetermined location (see above) (according to Bülau, ideally in the submammary fold).

Then the 5th ICR or the 2nd -3rd ICR is performed as atraumatically as possible using digital control and blunt preparation - if necessary with the aid of a clamp (e.g. overholt).

Ideally, a renewed local anaesthesia of the intercostal musculature should be carried out here, as the perforation of the intercostal muscles and also of the parietal pleura is felt to be very painful. It is absolutely necessary to make sure that perforations are made at the upper edge of the rib in order to reduce the risk of injury to the vessels and nerves running along the lower edge of the rib.

The actual perforation can be done with the finger. This often causes audible air to be evacuated.

The commercially available drains contain a trocar inside, which was previously used for perforation. This is no longer common nowadays, as it significantly increases the risk of injury to the lung parenchyma. The trocar should therefore be removed before the drainage is applied and the drain placed with the aid of a curved clamp. In case of a pneumothorax, the drain should be placed ventrocranially, in case of a hematothorax dorsocranially.

Then the insertion site is suturedby pouch sutureor single button sutures.

Finally, the suture shouldbe applied to the skin and the wound dressing applied.

Initially, suction is applied via the drainage and the Heimlich valve is connected (to avoid air aspiration via the drainage; air may escape).

A radiological check (X-ray or CT) after the drainage has been applied is mandatory.

If there is no radiological indication of complications and the drainage tube is placed correctly, the drain can be connected to an electric pump system.

The suction should be between - 20 and - 25 cm H2O in the presence of a pneumothorax[van Aken H K et al. (2007) Intensivmedizin Thieme-Verlag128]. Herold G et al. (2017) Internal Medicine, Verlag G. Herold 428 recommends a continuous suction with - 10 cm H2O and points out the danger of re-expansion edema.

In the further course of the disease, regular X-ray controls should be carried out. Here the a.p. radiation path is sufficient.

However, it is essential to ensure that the drainage is not disconnected during transport for X-ray. Otherwise there is a danger that air collects in the pleural cavity and a tension pneumothorax develops.

In order to prevent the fluid in the tube from flowing back into the thorax, the drainage and suction system should always be positioned below the thorax and the tube itself should always be placed at a slight incline to the suction bottle.

After successful application of the pleural drainage, the clinical symptoms that led to the application of the drainage must be re-evaluated. The circulatory situation should have improved, the initially cancelled breathing sound should be able to be auscultated again and any previously existing increased ventilation pressures should drop again or have normalized.

If obturating clots are visible in the tubing, the tubing must be wiped with the fingers every hour.

The losses via the drainage must be measured exactly. With haematothorax this should initially be done hourly, later only daily. With losses of > 1500 ml there is on the one hand the danger of hypotension and on the other hand the danger of re-expansion edema, which only becomes noticeable after a latency period of 2 - 3 hours (first sign is an increasing dyspnoea).

Breath-synchronous movements of the fluid column in the tube are normal. However, very strong fluctuations may indicate an incompletely expanded lung.

If air is evacuated synchronously with breathing, this may indicate a leak in the draining system or a parenchymal fistula.

If the fluid in the tube is no longer breath-synchronous, a malfunction of the drainage must be assumed or this must be interpreted as a complete air expansion.

In the event that a new chest tube has to be inserted, this is always done via a new access route.

Removal of the drainage:

The duration of the drainage treatment varies depending on the clinical picture. However, the drainage should only be removed again when

• the drainage losses are < 200 ml/d
• the lungs have fully developed
• no air leak is detectable anymore
• small amounts of secretion in the suction hose no longer play dependent on breathing

The drainage should first be disconnected for 12 - 24 h. After this time, another radiological check is performed to determine whether fluid has formed in the thorax after this time or to rule out the possibility of a (new) pneumothorax.

Pulling the drainage is associated with considerable pain. The patient should therefore be sufficiently analgesic.

To remove the drain, first loosen the holding thread(s). The patient is urged to perform a Valsalva compression test so that the respiratory muscles relax and the air pressure in the airways increases. At the same time, another person tightens the tobacco pouch suture to prevent air from entering the thorax again.

The tip of the drainage should be examined for germs in microbiology. However, if the wound looks irritation-free and there is no indication of an inflammatory event, the catheter tip should not be sent in.

Air-tightness should be supported with beta ointment and the entry point should be sterilely dressed.

It is not uncommon for serous, bloody fluid to leak into the dressing for 2 - 3 days after removal.

Some complications can besignificantly minimized by applyingthe suction drainage under sonographiccontrol .

Complications may occur:

• Pneumothorax
• Pleural Empyema
• Hematothorax
• Chest wall hematoma
• Injury to spleen or liver
• Intercostal neuralgia
• Vascular injuries (A. thoracica interna)
• with left-sided contact, additional cardiac injuries are possible.
• Injury of the lung parenchyma
• Risk of infection (<3 %)
• non-specific pleural pain after puncture (pleurodynia, functionally harmless, but most frequent complication)

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2. van Aken H K et al. (2007) Intensive Care Medicine. Thieme Publishing House 127 - 129

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