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).
