Essentials of pleural
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
• 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
pleura cavity
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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
• 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 pleural drainage
• pneumothorax
• Pleural fluid (exudation, empyema,
hematoma, lymph)
• Postoperative pleural drainage
• Pleurobronchial fistula
Contradiction for pleural drainage
There are no unconditional contradictions for
pleural drainage
pneumothorax
The presence of gas in pleural
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Internal (via bronchial wall)
External (via chest wall)
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Spontaneous
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Primary (no lung pathology)
Secondary (the presence of lung pathology)
Traumatic
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cavity
Non-iatrogenic (open/closed trauma)
Iatrogenic (after BAC of the lungs, Mediastinum, subcalvucular venosection,
etc.)
entire
partial
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
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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
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
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
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
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
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
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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 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
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
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
This is the most common active sucking
system. It included submerges valve and
the bottle regulating the suction power.
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
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
• 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
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
Heimlich valve – invented in 1968 as
single or double płatowa valve, especially
useful in patient transportation
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
Anterior access– commonly II or III
intercostal space in middle anterior
clavicle or axillar line. Most routine in
pneumothorax.
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
Suprascapular access– second
intercostal space below the scapula in
posterior scapular line. For apex limited
pathology only.
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.