Chest drainage is an ancient medical procedure that’s been used to treat infections, effusions, pneumothorax, and thoracic trauma. In the modern medical world, chest tubes are a ubiquitous tool for managing pneumothorax, pleural air leaks, traumatic hemothorax, infected pleural effusions, and draining empyemas.
Despite their historical usage, however, chest drainage and chest tube management remain an underestimated area of research and scientific study.
Let’s learn more about chest tube management and its latest techniques.
What Are Chest Tubes?
Chest tubes act as drains when they are placed into the pleural space or the area between the inner and outer linings of the chest cavity. They are made of plastic, hollow, and flexible. The negative pressure they create helps drain blood (hemothorax), air (pneumothorax), chyle (chylothorax), purulence (empyema), or fluid (pleural effusion or hydrothorax) from the intrathoracic space. Chest tubes can also facilitate the expansion of a collapsed lung.
Other terms that refer to their function are under water sealed drains (UWSDs), tube thoracostomies, chest drains, and thoracic catheters.
Chest tubes have been part of medical procedures since ancient times, going as far back as the fifth century BC. Hippocratic texts describe how a hollow tin tube was used to drain fluid from empyemas.
By 1922, chest tubes were being used in the postoperative care of patients who had undergone thoracic surgery. Nowadays, chest tubes are routinely used for managing traumatic, spontaneous, or iatrogenic pneumothorax, postoperative care for cardiac and thoracic surgeries, and complicated or infected parapneumonic effusions.
How Does Chest Tube Drainage Work
After the tube is inserted into the pleural cavity, one end is connected to a drainage line that is connected to a chest tube drainage system. The chest tube drainage system originally was a bottle and a leakage barrier water seal. The bottle is filled with sterile water with the drainage tube inserted 2 cm into it. The three bottle system contains a drainage compartment, a water seal compartment and a third bottle that can be connected to wall suction to increase the negative pressure in the pleural space. Modern chest tube drainage systems incorporate all three bottles in one unit for convenience.
The other end of the tube is placed into the pleural cavity to create negative pressure, or to decompress the pressure in the chest. It is stitched into place to prevent movement while a sterile bandage is applied to the insertion site to reduce the risk of bacterial infections.
The chest tube aids in removing the liquid or air from within the pleural area as the atmospheric pressure outside the body is higher than the pressure around the lungs due to the leakage barrier water seal. This one-way drainage ensures that fluid or air cannot flow back into the chest cavity.
Indications and Contradictions for the Use of Chest Tubes
Chest tubes facilitate the continuous drainage of large volumes of pus, bile, air, blood, and other fluids. Here are some indications for the placement of a chest drain:
- Pneumothorax preventing adequate lung expansion
- Lung collapse
- Difficulty breathing due to air or fluid buildup
- Lung infections such as bacterial empyema which causes pus to collect in the pleural space
- Postoperative care for cardiothoracic surgeries involving the organs within the thorax—the lungs, heart, and esophagus
- Bleeding around the lung due to trauma-induced thoracic injuries, a condition responsible for 25% of deaths
- When fluid or medication needs to be administered in the pleural space
While there are no absolute contradictions regarding chest tubes, bleeding diathesis, coagulopathy, and anticoagulation are some relative contraindications.
Other potential complications of chest tube placement include:
- Pain during placement: though anesthesia helps with chest tube pain management, the insertion procedure can still be very painful
- Excessive bleeding
- Injuries to the blood vessels, arteries, lungs, liver, spleen, or heart
- Punctured lung
- Perforation of the diaphragm
- Cardiac shock if the tube punctures an area of the heart
- Improper tube placement in chest wall
- Nerve damage
- Bleeding into the pleural cavity
- Stomach injury
- Lung collapse during chest tube removal
Patients should be advised of these potential complications before the placement of the chest tube.
A chest tube infection, or empyema, is another potential complication of a chest drain. The condition occurs when bacteria enter the body through the space surrounding the chest tube. This risk can be reduced by bandaging the skin around the point of insertion. Note that the longer the tube remains in the body, the higher the chances that an infection might develop.
Common symptoms of an infection are:
- Lack of energy
- Weight loss
- Pain in the chest
- Coughing mucus
- Night sweats
- Difficulty breathing
Hence, when a chest tube is inserted, it’s important to monitor the patient for signs of a lung infection.
Despite the risks associated with chest tube insertions, they are an effective, life-saving emergency procedure that may be essential for recovery.
It is also important to provide patients with aftercare tips to ensure the proper recovery from a chest tube insertion. Here are the recommended aftercare guidelines:
- Light exercise
- Deep breathing to re-expand the lungs
- Proper hydration
- Avoid smoking and alcohol
- Good hygiene
- Eat balanced meals
- Use an incentive spirometer
- Avoid being around sick individuals to prevent infections
Recovery from chest tube insertion typically takes 3 to 4 weeks. Patients must avoid driving until they can properly use their arms and shoulders.
Chest tubes aid in draining air, blood, pus, and other fluids from the thorax region with the help of negative pressure. Though it comes with certain risks, it is an essential life-saving medical procedure that healthcare professionals must learn.
Hospital Procedures Consultant offers a Chest Tube Course that can help you treat hemothorax, pneumothorax, complicated parapneumonic effusions, and empyema. This technique will also greatly help pleurodesis procedures.
For more information about chest tube management, refer to the second part of this article .
Lobdell, K. Engelman, D. Chest Tube Management: Past, Present, and Future Directions for Developing Evidence-Based Best Practices. Innovations. 2023 18(1):41-48.
Roebker, J. Kord, A. Chan, K. Rao, R. E Ray, C. Ristagno, R. Chest Tube Placement and Management: A Practical Review. Semin Intervent Radiol. 2023 Jun 16;40(2):231-239.
Haider, S. Taha Kamal, M. Shoaib, N. Zahid, M. Thoracostomy tube withdrawal during latter phases of expiration or inspiration: a systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2023 Jun 22. doi: 10.1007