Essentials of pleural
Essentials of pleural
cavity drainage
cavity drainage
Department of General, Oncological and Thorax Surgery
Medical University of Lodz
Head: prof. dr hab. med. Marian Brocki
Authors: Robert Gruda MD, Robert Stolarek MD
Essentials of pleural
Essentials of pleural
cavity drainage
cavity drainage
Department of General, Oncological and Thorax Surgery
Medical University of Lodz
Head: prof. dr hab. med. Marian Brocki
Authors: Robert Gruda MD, Robert Stolarek MD
•
Drainage or puncture of pleural
cavity is relatively common surgery
procedure at the thoracic surgery
wards or general, ICU, internal or
oncology departments
•
It is a simple procedure but usually
multiple minor problems are
encountered
History
History
•
VI century BC. – Hippocrates – described open pleural
drainage and the use of metal drain in pleural empyema
•
XV century AC. – Celsius – described rib removal, tocar use
and metal pipe for pleural drainage
•
1860 – Hunter – applied hypodermal needle for pleural
drainage
•
1875 – Playfair – introduced drainage with underwater valve
for pleural empyema therapy
•
1876 – Hewett – described closed system for continuous
drainage in the therapy of pleural empyema
•
1910 – Robinson – introduced vacuum into chest drainage
with the use of sucking pump
•
1922 – Lilienthal – introduced closed vacuum pleural
drainage in patient after the chest surgery
•
1945 – introduction of three bottle sets
•
1986 – introduction of single use sets
Anatomy and physiology of
Anatomy and physiology of
pleura cavity
pleura cavity
•
Pleural cavity is a bilateral serum space inside the chest limited by
parietal pleura, lining chest walls and visceral pleura which is
lining lungs
•
Under physiological conditions parietal and visceral pleura form
capillary space
7 – 24 m wide, containing small amount
•
Under normal conditions visceral fluid is produced at the
approximate rate 0,01 ml/kg m.c. /h
•
The elastic recoil of chest wall maintains negative pressure inside
the thorax cavity and the constant expansion of the lungs.
•
Chest intrusion, accumulation of fluid or air inside pleural cavity
abolish the negative pressure inside leading to the decrease of
lung volume and the increase of pleural volume.
•
Pleural drainage is necessary for the restoration of physiological
conditions
Pleural cavity drainage
Pleural cavity drainage
•
open – when pleural cavity directly
connects with the atmosphere (used
rarely, mainly in case of chronic
pleural empyema)
•
Closed – when pleura is separated
from the atmosphere with drainage set
– passive – without vacuum
– active – with vacuum
Indications for
Indications for
pleural
pleural
drainage
drainage
•
pneumothorax
•
Pleural fluid (exudation, empyema,
hematoma, lymph)
•
Postoperative pleural drainage
•
Pleurobronchial fistula
Contradiction for pleural
Contradiction for pleural
drainage
drainage
There are no unconditional
contradictions for pleural drainage
pneumothorax
pneumothorax
The presence of gas in
pleural cavity
•
Internal (via bronchial wall)
•
External (via chest wall)
•
Spontaneous
–
Primary (no lung pathology)
–
Secondary (the presence of lung pathology)
•
Traumatic
–
Non-iatrogenic (open/closed trauma)
–
Iatrogenic (after BAC of the lungs, Mediastinum, subcalvucular
venosection, etc.)
•
entire
•
partial
Pleural drainage systems
Pleural drainage systems
System of pleural drainage includes:
•
Drainage systems
– Pleural drain
– connectors
– Connecting drainage
•
Bottle system
– Drainage bottle
– Underwater valve
– Reduction bottle
Drainage systems
Drainage systems
•
No toxicity
•
No allergy reaction
•
No agitation
•
Should be flexible and at the same time
stiff enough to avoid collapse
•
Should be transparent
•
X ray marker incorporated into the wall
•
The terminal lumen should be the same as
drainage diameter
Small drainage
Small drainage
These are plastic small drainages up
to 10F in size, with a needle inside for
penetration or outside for drainage
insertion . Thin drainage are used in
diagnostics and the therapeutical
pleurocentesis, surgical anesthesia
and pericardiocentesis. They are
fragile, can be stuck easily, may
break and therefore are not suitable
for routine pleural drainage.
Medium drainage
Medium drainage
They are vinyl drainages of 10-20F
size with a lancet inside. The
presence of stiff lancet inside allows
for the insertion from a tiny hole in
skin surface. These drainage is
especially useful in the drainage of
encapsulated containers and lung
apex drainage from supraclavicular
access.
Large drainage
Large drainage
Vinyl drainage of 20-36F size may
include a lancet. They are inserted
usually during toracotomy and their
narrowed ending makes the insertion
through the incision canal easier.
Insertion of drainage into the closed
chest required more force and the
expansion of the tissues with a tool or
a finger.
Connecting drainage
Connecting drainage
This is a drainage between pleural
drainage and the drainage bottle. It
has to be transparent, light, flexible,
resistant to collapse and breakings.
Optimal size of connecting drainage
determines its optimal resistance to
the flow: length 1.8 m., internal
diameter 9.5 – 12 mm
Drainage connections
Drainage connections
There are various types of
connectors for different size diameter
drainage. Their fixation should
maintain tight sealed connection,
good visibility inside the connector
and the drainage as well as the
safety of the connection
Drainage bottles
Drainage bottles
Features of drainage bottles
•
Sealed thight
•
Quality of connection
•
Resistance to incidental breakage
•
Light, stiff material resistant to
collapse
•
Construction preventing reverse
assembly
Passive drainage
Passive drainage
Passive drainage a gravity propelled
drainage including one bottle. It is the
most crude type of pleural drainage. Its
function involves containing and
underwater valve. The valve allows for
the removal of the air from the plural
cavity and prevent form the sucking of
the air. Intrusion of the air into the pleural
cavity is blocked by underwater valve.
Passive drainage
Passive drainage
The drainage pipe should be submerged
2 cm under water. Lower submersion
may lead to the loss of tight assembly,
increased air flow resistance. Lack of
alternated fluid levels indicates stucked
flow, flexed connection, fluid
accumulation in connecting drainage or
the complete expansion of the lung. The
set should be placed below the chest
level to maintain pressure gradient.
Two bottle passive drainage
Two bottle passive drainage
This set includes main bottle and the
bottle with submerged valve. Blood
or exudative fluid accumulates in the
main bottle whereas the air gets into
the other. The drainage allows for
freely air removal. The pressure in
the main bottle is always equal to the
pressure inside the pleural cavity.
Two bottle active drainage
Two bottle active drainage
This is the most common active
sucking system. It included
submerges valve and the bottle
regulating the suction power.
Three bottle active drainage
Three bottle active drainage
This set includes main bottle,
submerged valve and the bottle for
the regulation of suction power. The
reduction bottle decreases the sub
pressure generated by suction tools.
Four bottle active drainage
Four bottle active drainage
Fuor bottle system includes
additional bottle with submerges
valve connected to three bottle set.
Air pressure valve of the additional
bottle protects from pressure
increase in case of the failure of
suction providing the information on
the current pressure in the pleural
cavity.
Features of vacuum devices
Features of vacuum devices
•
The maintenance of the lowered
pressure in the range between 0 and 60
cm H2O
•
The availability of high flow (20 l/min) at
the pressure – 10 cm H2O
•
The maintenance of the negative
pressure in the system
•
The removal of drained air into the
atmosphere due to air removal drain
even if sucking does not operate
Other drainage systems
Other drainage systems
Pleural-peritoneal valve of Denver
type– unidirectional valve for fluid
trafficking from pleural to peritoneal
cavity in patients with recurrent
accumulation of pleural fluid without
the option of complete lung
expansion
Other drainage systems
Other drainage systems
Heimlich valve – invented in 1968 as
single or double płatowa valve,
especially useful in patient
transportation
Other drainage systems
Other drainage systems
The set for ambulatory pleural
drainage– it includes plastic sack
with płatkową valve and excess air
valve. It may be carried by the
patients similarly to the urine
containers. It is used in the therapy
of chronic pleurobronchial fistulae
and recurrent exudative pleuritis
Access to pleural cavity
Access to pleural cavity
Anterior access– commonly II or III
intercostal space in middle anterior
clavicle or axillar line. Most routine in
pneumothorax.
Access to pleural cavity
Access to pleural cavity
Lateral access – the drainage is place
in from IV to VI intercostal space in
anterior or middle axillar line. The
drainage ending at the time of air
evacuation is directed rostrally
(towards apex) whereas at the fluid
evacuation caudally and downwards
(towards above diaphragm).
Access to pleural cavity
Access to pleural cavity
Suprascapular access– second
intercostal space below the scapula
in posterior scapular line. For apex
limited pathology only.
Access to pleural cavity
Access to pleural cavity
Posterior access – used for the
drainage of encapsulated purulent
container in the dorsal region below
the scapula. It is guided by CT or
USG.