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Consensus Guideline

Pleural Drains in Adults

Pleural drain complications

  • Tension pneumonthorax.
  • Trauma to intrathoracic structures, intra-abdominal structures and intercostal muscles.
  • Re-expansion pulmonary oedema.
  • Haemorrhage.
  • Incorrect tube position.
  • Blocked tube.
  • Pleural drain falls out.
  • Subcutaneous emphysema.
  • Infection.

Preventing a pleural drain from falling/pulling out

  • Insert chest drain so the proximal holes are well inside the chest wall.
  • Secure drain with a deep suture to skin, wrapped tightly around the tube to prevent slippage.
  • Secure the drain at a second site by taping to the skin.
  • Ensure adequate length of tubing to the under water drain to minimise traction on the chest tube.
  • Care when transferring patient from bed to bed/bed to chair.
  • Patient education.

Drain malposition

  • If malposition of a pleural drain is suspected, a CT scan is the best method to determine position. If access to urgent CT scan is not available, arrange an urgent repeat CXR and urgent review.
  • A chest drain may be withdrawn to correct a malposition but should never be pushed further in.

Re-expansion pulmonary oedema

  • Typical clinical signs of re expansion pulmonary oedema include shoulder tip pain, coughing, a sudden drop of blood pressure and/or oxygen saturations and increased respiratory rate and distress.
  • A maximum fluid drainage of 1.0-1.5 litres per hour is recommended to reduce the risk of re-expansion pulmonary oedema.
  • In patients of small stature or those with complex comorbidities, provision should be made for setting the maximum aspiration volume at less than one litre, or specify an initial volume, clamp and wait time before proceeding to drain.
  • Define and document maximum anticipated hourly fluid drainage based on the individual clinical need for a pleural drain. The MO should be notified if maximum output is exceeded over two consecutive hours.

Recommended actions if haemodynamic instability or severe hypoxemia suspected to be related to re-expansion pulmonary oedema are present.

  • Prevent further air or fluid drainage.
  • Administer high-flow oxygen.
  • Place a rapid response call.