Thoracic Drainage. Thomas Malfait M.D. Endoscopische eenheid UZ Gent 3K12 IE Longziekten UZ Gent 7K12IE

Thoracic Drainage

Thomas Malfait M.D.

[email protected] Endoscopische eenheid UZ Gent – 3K12 IE Longziekten UZ Gent – 7K12IE

© 2010 Universitair Ziekenhuis Gent

Pleural Procedures 1. 2.

Thoracocentesis Chest drain insertion

BTS Pleural Disease Guideline 2010 - Pleural procedures and thoracic ultrasound Thorax 2010;65(Suppl2):ii61eii76.doi:10.1136/thx.2010.137026


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Chest Drain Insertion


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Goal • •

• •

Understand basic princples of thoracic drainage and apply them in real life Recognition of most widespread systems and apply basic pricples on these systems Not every detail will be discussed Not all drainage systems will be discussed


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I work at

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Hospitalisation internal

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Hospitalisation surgical 23%

Policlinic 11%

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Thoracic drainage : A.

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Agenda 1. 2. 3.

Pleural anatomy and (pathofysiology) Thoraxdrainage Different systems up close


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Agenda 1. 2. 3.



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Pleural anatomy and pathofysiology

Knowledge of basic principles = fundamental © 2010 Universitair Ziekenhuis Gent

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Pleural anatomy and pathofysiology Pleural space = real space between parietal and visceral pleurae. 10 à 20 µm wide Around the entire lung Visceral = around lungs Parietal = against thoracic wall


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Pleural anatomy and pathofysiology Electronmicroscopy pleural space – – –


PP : parietal pleura VP : visceral pleura PS : pleural space

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Pleural anatomy and pathofysiology Continuous negative pressure in the pleural space. - 2cmH20 (=vacuum) Sum of lung recoil, thoracic wall strengths, oncotic en hydrostatic pressures.

Visceral pleura sucks to the parietal pleura When thoracic wall moves outside (inspiration) lung is opened and air is sucked into the lungs = active process. When thoracic wall relaxes (expiration) lung recoils and air is pushed outside = passive process


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Pleural anatomy and pathofysiology

http://people.eku.edu/ritchisong/301notes6.htm © 2010 Universitair Ziekenhuis Gent

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Pleural anatomy and pathofysiology 1. 2.

Air in the pleural space = pneumothorax Fluid in the pleural space = pleural fluid


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Pleural anatomy and pathofysiology Pneumothorax Every condition when air is in the pleural space Detachment between parietal and visceral pleurae. Less expansion of the lung

Tension pneumothorax : Valve principle Whole unilateral thoracic cavity filled with air and extra air is pushed in – high pressure on mediastinum and shift of mediastinum hemodynamic instability

Primary pneumothorax  Secondary pneumothorax. Underlying comorbidity © 2010 Universitair Ziekenhuis Gent

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Pleural anatomy and pathofysiology Pleural Fluid

Pleural fluid absorption Pleural fluid production


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Pleural anatomy and pathofysiology Systemic circulation


Pulmonal circulation

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Pleural anatomy and pathofysiology Transudative Pleural Effusions Congestive heart failure Pericardial disease Hepatic hydrothorax Nephrotic syndrome Peritoneal dialysis Urinothorax Myxedema Fontan procedure Central venous occlusion Subarachnoid-pleural fistula Veno-occlusive disease Bone marrow transplantation Iatrogenic

+/- 70

Exudative Pleural Effusions Neoplastic diseases Metastatic disease, Mesothelioma, Primary effusion lymphoma, Pyothorax-associated lymphoma Infectious diseases Pyogenic bacterial infections, Tuberculosis,Actinomycosis and nocardiosis, Fungal infections, Viral infections, Parasitic infections Pulmonary embolism Gastrointestinal disease Esophageal perforation, Pancreatic disease, Intra-abdominal abscesses, Diaphragmatic hernia, Post-abdominal surgery Collagen vascular diseases Rheumatoid pleuritis, Systemic lupus erythematosus ,Drug-induced lupus, Immunoblastic lymphadenopathy, Sjögren's syndrome, Churg-Strauss syndrome, Wegener's granulomatosis Post-cardiac injury syndrome Post-coronary artery bypass surgery Asbestos exposure Sarcoidosis Uremia Meigs' syndrome Ovarian hyperstimulation syndrome Yellow nail syndrome Drug-induced pleural disease Nitrofurantoin Dantrolene Methysergide Bromocriptine Procarbazine Amiodarone Trapped lung Radiation therapy Electrical burns Iatrogenic injury Hemothorax Chylothorax


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Agenda 1. 2. 3.



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Thoracic Drainage 1. 2. 3.

4. 5. 6. 7.

8.

Pre – Procedure Preparation Indications Complications Equipment Patient position and site of insertion Analgesia, sedation and local anaesthesia Insertion technique Chest drain management


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Pre – Procedure Preparation Pleural procedures should not take place out of hours except in an emergency


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Pre – Procedure Preparation Pleural procedures should not take place out of hours except in an emergency Pleural procedures should be performed in a clean area using full aseptic technique Written consent should be obtained for chest drain insertions, except in emergency situations Non-urgent pleural procedures should be avoided in anticoagulated patients until INR < 1.5


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Pre – Procedure Preparation Healthy subjects : no need for lab testing Patients at risk : lab testing Hematologic, oncologic Thrombocytes - clotting

INR < 1.5 or antico stop > 5 days LMWH : stop > 12hrs NOAC’s : stop > 24 hrs


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Pre – Procedure Preparation Pre-drainage risk assessment Cave emphysema – cave adjacent lung Imaging available Marking side Equipment available and checked

Time – out procedure !!!! SOP !!!


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Indications 1.

Pneumothorax* • • •

•

In any ventilated patient Tension pneumothorax after needle relief Persistent or recurrent pneumothorax after simple aspiration Large secondary spontaneous pneumothorax in patients > 50 years

2.

Malignant pleural effusions + pleurodesis*

3.

Empyema and complicated parapneumonic pleural effusion*

4.

Traumatic heamopneumothorax

5.

Post-surgical •

Thoracotomy, oesophagectomy, cardial surgery)


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Complications Pain Intrapleural infection

Wound infection Drain dislodgement Drain blockage

Drain related visceral injury


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Equipment Sterile gloves and gown

Needleholder

Mask and hat

Instrument for blunt dissection

Skin antiseptic solution iodine chloorhexidine in alcohol

Large bore drain insertion

Guidewire and dilatators Small bore – Seldinger technique

Sterile drapes

Chest tube

Gauze swabs

Fitting connecting pieces

Syringes + needles (21-25 G)

Connecting tubing + clamp

Local anaesthetic

Closed drainage system

eg lidocaïne 1% of 2%

Scalpel + blade Suture

Underwater seal – sterile water Electronic seal - drainage

Dressing

Non - resolving : Silk 0 - 1 © 2010 Universitair Ziekenhuis Gent

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Equipment : small bore drain - seldinger


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Equipment : large bore drains


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Site of insertion

I

Angulus Ludovici Sternum II III IV V


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Site of insertion (1) : triangle of safety

Axilla Base Lateral edge pectoralis major Latissimus dorsi

5th intercostal space


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Site of insertion (2) : 2nd IC - midclavicular

Can J Rural Med 2009; 14 (4) © 2010 Universitair Ziekenhuis Gent

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Site of insertion


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Site of insertion


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Analgesia, sedation, local anaesthesia Inserting chest drain = painful !!! 50% pts : 9-10 VAS

Analgesia + sedation : No established evidence – cave operators unfamiliarity Cfr local SOP Local aneasthesia

Lidocaïne 1% - particular attention to the skin, periostium and pleura Up to 3mg/kg Epinephrine aids hemostasis + localise anaesthesia Not been studied in this context © 2010 Universitair Ziekenhuis Gent

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Inserting technique Confirming site of insertion Control site

‘Drawing’ Prior to insertion expected pleural contents (air or fluid) should be aspirated Usually while administering local anaesthesia If this not possible → stop procedure Further imaging (eg US) might be helpful


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Inserting technique : Small bore Needle into pleural space with aspiration (air / fluid) Guidewire is passed through the needle Needle is removed – small incision next to te wire Dilator over the wire – twisting action – gentle, no substantial force – no more then 1 cm into pleural cavity

Series of enlarging dilators up to the size of the drain Drain over the wire - aiming : Apical : pneumothorax Posterobasal : pleural fluid © 2010 Universitair Ziekenhuis Gent

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1

2

3

4

http://elearning.scot.nhs.uk:8080/intralibrary/open_virtual_file_path/i287n2751048t/chestdrains_18.htm © 2010 Universitair Ziekenhuis Gent

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Inserting technique : Large Bore Needle into pleural space with aspiration (air / fluid) Local aneaesthesia Incision (Ø drain) – alignement with intercostal space Blunt dissection using Spencer – Wells clamp or similar Gently spreading No substantial force

(No) trocars !!! Air : aiming apical Fluid : aiming posterobasal

Clamp drain © 2010 Universitair Ziekenhuis Gent

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Inserting technique : Large Bore


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1

2

3

4

http://elearning.scot.nhs.uk:8080/intralibrary/open_virtual_file_path/i287n2751048t/chestdrains_18.htm


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Insertion technique : sutures and securing Prevention of kinking at skin surface Dressing under drain Anchoring suture not to firm Mattress suture Prevention of traction Omental taping Commercially available dressings Patient comfort Anterior


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Main concern – dressing :

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Only white gauzes Connection to aspiration Pain Relief Kinking of the drain

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79%


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Chest drain management Connection to a drainage system that contains a valve mechanism to prevent air or fluid from entering the pleural cavity. 1.

Underwater seal

2.

Heimlich Flutter valve

3.

Other recognised mechanism: Electronic system (Thopaz) Indwelling tunneled pleural catheters (PleurX - Aspira)


52

Chest drain management Connection to a drainage system that contains a valve mechanism to prevent air or fluid from entering the pleural cavity. 1.

Underwater seal

2.

Heimlich Flutter valve

3.

Other recognised mechanism: Electronic system Indwelling tunneled pleural catheters


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Under water seal – thoracic drainage Basic Principles 1- bottle system

2- bottle system 3- bottle system 4- bottle system


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1 – bottle system Fluid drains spontaneously due to gravity Air drains spontaneously when there is postive pressure in the pleural cavity (e.g. tension pneumothorax)

Thomas Malfait – schematische voorstelling thoraxdrain

1 – bottle system Fluid drains spontaneously due to gravity Air drains spontaneously when there is postive pressure in the pleural cavity (e.g. tension pneumothorax) !!! When there is negative pressure in the pleural space (normal condition / inspiration) air can flow inwards


1 – bottle system Fluid drains spontaneously due to gravity Air drains spontaneously when there is postive pressure in the pleural cavity (e.g. tension pneumothorax) !!! When there is negative pressure in the pleural space (normal condition / inspiration) air can flow inwards To overcome this the drain is sealed by water • 2cm H20

2cm

• Easy to overcome by slight + intrathoracic pressure

• - pressure of inspiration cannot overcome the seal


1 – bottle system

Inspiration : Intrapleural negative pressure – water is pulled up Expiration : Normalisation of intrapleural pressure and lowering of waterlevel. Water is going up and down with every breathing cycle ► ‘Pendelen’ ►‘Tidaling’ ►‘Oscillation’

2cm

Expiration

Inspiration

Excessive air intrapleural wil escape by drain - exhaling ► ‘Air Leak’


2-bottle system Blood en fluid drains from pleural cavity into drainage recipient.

Waterseal > 2cm

Air cannot be removed anymore


2-bottle system Blood en fluid drains from pleural cavity into drainage recipient.

Waterseal > 2cm

Air cannot be removed anymore An collector in between ► 2-bottle system


3- bottle - system 2 bottle system = passive system Extra negative pressure (= aspiration/suctie) more rapidly expansion of the lung – better adherens lung to thoracic wall Extra bottle attached after waterseal – this is connected to an aspiration manometer : - ‘suctioncontrol’ - the amount of water in this bottle regulates the suctionforce - mostly15 to 20 cm water ►3- bottle - system


3-flessen - systeem

15cm

2cm

Suctioncontrol

Waterseal


Collector

3-flessen - systeem

!

Chest. 2005;127(6):2211-2221.

3- bottle - system 2 bottle system = passive system Extra negative pressure (= aspiration/suctie) more rapidly expansion of the lung – better adherens lung to thoracic wall Extra bottle attached after waterseal – this is connected to an aspiration manometer : - ‘suctioncontrol’ - the amount of water in this bottle regulates the suctionforce - mostly15 to 20 cm water ►3- bottle – system Sommige systemen hebben dry-suctioncontrol – geen water meer invoeren maar draaien aan knop die de suctie regelt – principe blijft hetzelfde Thomas Malfait – schematische voorstelling thoraxdrain

3-flessen - systeem

Wat gebeurt als in dit systeem aspiratie / suctie stopt?

15cm

2cm

Suctioncontrol

Waterseal


Collector

Wat gebeurt als in 3 flessen systeem suctie stopt ? 69%

Vocht en lucht blijven verder draineren B. Borrelen van waterslot wordt heviger C. Luchtlek neemt toe D. Kans op spanningspneumothorax A.

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3- bottle - system

15cm

2cm

Suctioncontrol

Waterslot


Collector

4-flessen - systeem 3-flessen systeem is een volledig afgesloten systeem

De lucht kan enkel via het afzuigsysteem ontsnappen

Indien probleem met afzuigsysteem gevaar voor pneumothorax

Hiertoe nog een 4de fles aankoppelen (vlak naast de opvangfles waar overtollige druk toch nog een uitweg vindt

Een extra veiligheidswaterslot

Reeds vaak vervangen door balletje – vlotter langswaar lucht kan ontsnappen


4-flessen - systeem

Suctioncontrol

Waterslot

Collector


Veiligheidsslot / manometer

Chest drain management Drain should be checked daily for Drainage volumes – Swinging - Bubbling

Underwater seal Beneath insertion site - Keep upright

A bubbling drain should never be clamped A maximum of 1.5 L should be drained in the first hour After an hour of waiting the rest can be drained off slowly

Suction : No evidence to recommend or discourage the use of suction in a medical scenario © 2010 Universitair Ziekenhuis Gent

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Eens drain geplaatst


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Patiënt moet zo stil als mogelijk in bed liggen Patiënt mag opzitten maar niet stappen Patient mag rondstappen maar drainage kit lager als insteekplaats Patient mag rondlopen en zwieren en zwaaien met drainagebak

m

A.

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Chest drain management Removal Non functioning drain < 200ml / 24 fluid production

Brisk movement with assistent closing the mattress suture of holding skin firmly together Valsalva? No evidence for difference in pneumothoraces

In case of chest drain for pneumothoraces Clamping can be done – cave tension pneumothorax


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Verschillende systemen van dichtbij bekeken Atrium / Océan Pleurevac Flutter Valve / Heimlich Electronisch drainagesysteem Getunnelde permanente systemen


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Welk systeem meest gebruikt Atrium / Océan B. Pleurevac C. Flutter Valve / Heimlich D. Electronisch drainagesysteem E. Getunnelde permanente systemen F. Andere

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Veiligheidswaterslot

Suctioncontrol Waterslot

Collector

Dry suction control

Verschillende systemen van dichtbij bekeken Heimlich Valve Unidirectionele klep Mebraan die open en dicht kan klappen


80

Verschillende systemen van dichtbij bekeken Electronische drainage systemen

Thopaz (©Medela)– drainage


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©Medela


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Filosofie

©Medela


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Productbeschrijving

©Medela


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Product

©Medela Het hart van het thoraxdrainagesysteem • • • • •

Geïntegreerde vacuümbron Oplaadbare lithium-ionen accu Compact design Lichtgewicht Geluidsarm

Technische gegevens • • • • •


Laag vacuüm: -100 cm H2O Lage flow: 5 L/min Gewicht: 1 kg Veiligheidsklasse: IP33 Looptijd accu: min. 4 uur

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Product

Display


©Medela

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86

Product

©Medela Overloopbeveiliging /bacteriefilter

Overdrukventiel

Veiligheidskamer

Afdichtkapjes Opvangkamer

Gradatie Opvangpot 0.8L


87

Product

©Medela

Slangenset Materiaal: PVC (van medische kwaliteit) Lengte: 1.5 m / ø 5 mm Klem Afvoerslang Meetslang Connectie naar pomp

Slangenset enkel

Connectie naar opvangpot Enkele patiëntverbinding

Overloopbeveiliging


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Functies

Iedere 5 minuten wordt er een kleine hoeveelheid lucht door beide slangen geblazen

©Medela

closed open


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Functies

De druk wordt dicht bij de patiënt gemeten en wordt constant gehouden.


©Medela

90

Functie

Een terugslagklep zorgt voor de waterslotfunctie

©Medela

open dicht


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Thopaz thoraxdrainagesysteem = in essentie een 3-flessen systeem

Waterslot

Collector

Suction control

Verschillende systemen van dichtbij bekeken Getunnelde ‘permanente’ drainagesystemen

PleurX® catheter (Cardinal Health, McGaw Park, IL)

Aspira® catheter (Bard Access Systems, Salt Lake City, UT)


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PleurX® catheter


Aspira® catheter

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? © 2010 Universitair Ziekenhuis Gent

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FAQ Welke diameter van thoraxdrain te gebruiken? Kunnen alle thoraxdrains worden afgeklemd? Wanneer worden thoraxdrains afgeklemd? Mag een patiënt met een thoraxdrain bewegen? Welke suctie wordt nagestreefd? Hoe lang moet een drain ter plaatse blijven? Bestaan er alternatieven voor thoraxdrain?


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Thoracic Drainage. Thomas Malfait M.D. Endoscopische eenheid UZ Gent 3K12 IE Longziekten UZ Gent 7K12IE

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