Does it matter whether a chest drain is aimed upwards or downwards for the optimum drainage of fluid or air from the pleural cavity ?
Date First Published:
May 28, 2004
Last Updated:
October 21, 2010
Report by:
John Trenfield, SpR Emergency Medicine (St Mary's Hospital, Paddington, London.)
Search checked by:
Ian Maconochie, St Mary's Hospital, Paddington, London.
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
The Cochrane Database of Systematic Reviews (CDSR) June 2010.
Chest drain, ti, ab, kw–8 review 0 relevancies
Search Details:
{(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)
Outcome:
252 papers found of which 2 were relevant
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Comparison of the immediate postoperative outcome of using the conventional two drains versus a single drain after lobectomy. Alex J, Ansari J, Bahalkar P 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 | ||||
| Curved chest tube for drainage of malignant pleural effusion. Ishikawa H, Satoh H, Yamashita T 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 |
Author Commentary:
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.
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:
- 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.
- Ishikawa H, Satoh H, Yamashita T et al.. Curved chest tube for drainage of malignant pleural effusion.