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Three Part Question

In [a patient presenting with a pleural effusion that requires draining] should [the chest drain be inserted apically or basally] to [drain most efficiently] ?

Clinical Scenario

A patient presents to the Emergency department with significant dyspnoea. A chest x-ray reveals a pleural effusion. Should the chest drain be aimed apically or basally to drain efficiently?

Search Strategy

Medline OVID 1950–June week 3 2010.

The Cochrane Database of Systematic Reviews (CDSR) June 2010.

Chest drain, ti, ab, kw–8 review 0 relevancies

{(exp chest tubes/ or exp thoracostomy/ or chest drain$.mp.) and (exp pneumothorax/ or pneumothora$.mp. or exp pleural effusion/ or haemothorax.mp. or hemothorax.mp.) and (exp apical/ or basal.mp. or place$.mp. or direction.mp.) [mp=title, abstract, name of substance, mesh subject heading]} limit to (human and english language)

Search Outcome

252 papers found of which 2 were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Alex et al, 2003, UK	120 patients undergoing lobectomy. Single mid position chest drain versus apical and basal drain.	Clinical trial	Duration of drainage	Same in both groups (4 days)	Not blind Not randomised Relatively small numbers
			Length of stay	Same in both groups
			Pain	Higher with 2 drains
Ishikawa et al, 1998, Japan	20 Patients with malignant pleural effusion Posterobasal chest drain versus other	Observational	90% drainage	87% with posterobasal and 25% with other positions	Very small numbers Not blind Open to bias Subjective result reporting Variable time period to assess drainage

Comment(s)

The British Thoracic Society guidelines for inserting a chest drain suggest positioning the tip apically for air and basally for fluid but admit that it does not matter, and it goes on to say that no chest drain should be repositioned solely because of its position. The Japanese study, which concluded that basal drains are better for draining effusions, is too flawed to consider seriously. The UK study was significantly better and did conclude that one drain inserted midway was as effective as the usual apical and basal drains for draining air and fluid. The authors also comment that with lung expansion, any space would be obliterated and the fluid or air pushed out through any drain.

Clinical Bottom Line

Although no large RCT has been undertaken to answer this question it seems that it doesn't matter where you place the tip of the chest drain (as long as its in the pleural cavity!) when draining air or fluid.

References

1. Alex J, Ansari J, Bahalkar P et al. Comparison of the immediate postoperative outcome of using the conventional two drains versus a single drain after lobectomy. Annals of Thoracic Surgery 2003;76:1046–9.
2. Ishikawa H, Satoh H, Yamashita T et al. Curved chest tube for drainage of malignant pleural effusion. Respiratory Medicine 1998;92:633–7.