Water seal drainage

A short description of chest thoracostomy

1. Presenter- Guided by- Dr. Twinkle Joshi Dr. Vaishali Kuchewar Water Seal Drainage

2. Introduction Chest drains/ chest tubes/under water sealed drainage (UWSD), thoracic catheter/tube thoracostomy / intercostal drain Creates one-way mechanism that allows air/fluid to escape from the pleural space with each exhalation and to prevent that return flow with each inhalation Distal end of the drainage tube is submerged in 2cm of H2O. Flexible plastic tubes are inserted through the chest wall into the pleural space between 5th and 6th intercostal space in the mid- axillary line, venting the space which allows air back out. 

3. Principle UWSD prevents air re-entry into pleural space. The distal end of the drain tube is submerged 2cm under the surface level of the water in the drainage chamber. This creates a hydrostatic resistance of +2cm H20 in the drainage chamber. Normal intrapleural pressure is negative. If air or fluid enters the pleural space, it becomes positive. Air is eliminated from the pleural space into the drainage chamber when intrapleural pressure is greater than +2cm H20. Thus, air moves from a higher to lower pressure along a pressure gradient. Fluids drain by gravity into the drainage chamber, and the bottle is always kept below the level of the patient's chest.

4. Components Unobstructed chest tube - inserted into pleural cavity/ mediastinal cavity to allow air/fluid to leave the chest Tubing - 6 ft long flexible tubing connects the chest tube to chest drain system Water Seal Chamber – oscillating ball No oscillation implies (a) kink in the system (Ex-patient is lying on any tubes) or (b) the pneumothorax has healed (verified via CXR) Unnamed Chamber  - Column C – records the amount of bubbling taking place. 1-2 bubbles is normal >5 indicates leak in the system due to (a) disconnection in the circuit or (b) a massive tear in the pleura which requires negative pressure in the form of a suction drain. One-way mechanism to prevent return of air/fluid (valve). Suction control device (optional)/Usually 3-5kPa

5. Systems Glass Bottle System: 1 bottle simplest form of USD system. can drain both fluid and air. Has an outlet to the atmosphere to allow air to escape. suitable for use with a simple pneumothorax 2 bottle for air and fluid drainage. first chamber collects fluid and second is for air. As the two are separate, fluid drainage does not affect the pressure gradient for evacuation of air from the pleural space and enables monitoring of volume expelled. 3 bottle Suction is required when air or fluid needs greater pressure gradient to move from the pleural space to the drainage system. Suction is applied via third bottle or suction chamber.

6. Indications  Pneumothorax Pleural Effusion Haemothorax Chylothroax Empyema Post Cardiac or thoracic surgery

7. Assessment Of Proper Functioning Observing oscillating movements of the fluid in the water-sealed tube Observing intermittent bubbling in the water seal bottle Observing the collection of drainage in drainage bottles Observing bubbling in the suction control bottle when a mechanical suction is attached to the under-water seal drainage system CXR Auscultation

8. Precautions To Be Taken While Replacing Chest Drainage Bottles Assemble the bottle with tight stopper and tubes Double clamp chest catheters close to the patient’s chest at the end of a full inspiration to prevent entry of air into the pleural cavity Use new sets while replacing, to prevent contamination of the chest catheters Proper positioning to prevent falling of bottles. Watch the patient’s vital signs for few minutes to see any changes

9. Chest Catheter Removal The chest catheter is removed only on written order of physician. Usually , chest catheters are removed in two or three days, when chest X-ray shows remaining lung tissue expands well, air leaks are absent fluid drainage is < 75 ml per day. breath sounds present over whole thorax on auscultation After chest catheter removal, the wound is covered with sterile petrolatum gauze and a firm dressing is applied secured by wide adhesive tapes. Patient is observed closely for any complication

10. Complications of Chest Drains Pain – chest wall/ neck / shoulder Failure to enter the pleural space Intra-pleural infection at insertion site Penetration / lacerations to lungs Penetration into peritoneal space - laceration of the diaphragm Haemorrhage Blocked drains Pleural sepsis Subcutaneous emphysema

11. Thank you

12. Thought of the day