Thoraxdrainage SGP Jahresversammlung 2016, Lausanne
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1 Thoraxdrainage SGP Jahresversammlung 2016, Lausanne Dr. med. Lukas Kern
2 a bit of history (incomplete.) a bit of physiology (basic ) indication data guidelines
3 a bit of history (incomplete.) a bit of physiology (basic ) indication data guidelines
4 Firs mentioned by Hippocrates ( BC) drainage of pus through tubes made out of - wood - gold - silver
5 First description of pleural empyema by Aulus Cornelius Celsus (25 BC 50 AD) - roman encyclopedist
6 then it took a while until Girolamo Fabrizi d`acquapendente ( ) - described pleural drainage using a thread and by the way - developed modern embryology
7 First use of a rubber tube by Charles Marie Edouard Chassaignac ( )
8 The «father» of modern thoracic drainage, Gotthard Bülau ( ) - lateral entry site, ICS large bore drains, up to 35F Source: Springer 2008 C= π d
9 Also widely used, is the technique after Vincenzo Monaldi ( ) - intermediate bore drains - insertion ICS 2-3, anterior Source: Springer 2008
10 Commonly used in many (swiss?) hospitals, the drainage after Heinrich Matthys - «easy» - Small bore drain 9Ch. But ultra-sharp needle!!
11 a bit of history (incomplete.) a bit of physiology (basic ) indication data guidelines
12 Principle of fluid/air evacuation (the aim of a drainage ) - key point is to know the (very basic) principles of ventilation
13 - difference in pressure leads to movement of air from highly pressurised areas to regions with low pressure - causing wind in the athmosphere
14 - since p x V= constant Lowering of the diaphragm leads to decreased pressure and thus to influx of air into the lungs Dr. Lukas Kern SGP Lausanne 2016
15 - the opposite happens when contraction of the diaphragm ends. Dr. Lukas Kern SGP Lausanne 2016
16 - virtual space between visceral and parietal pleura - subathmospheric pressure «intrapleural pressure» - opposing elastic forces of chest wall and lung
17 - pleural fluid formation due to pressure difference ( ml per kg) - reduces friction - exits pleural cavity via lymphatic stomata of parietal pleura Dr. Lukas Kern SGP Lausanne 2016
18 - Excess liquid lowers the pressure gradient, leading to collapse of the lung - mechanisms of eccess liquid production: - increased permeability - increase in microvascular pressure - decrease in pleural pressure - decrease in oncotic pressure
19 So once your tube is in place. how can you restore normal pleural physiology?
20 - using a undirectional valve invented by Henry Heimlich (*1920) X
21 or alternatively: wasserschloss
22 - air exits pleural cavity passing the water seal Tube open to atmosphere vents air Tube from patient - air cannot enter the pleural cavity
23 - not applicable for the evacuation of fluid Tube open to atmosphere vents air - Rising liquid level leads to very high pressure needed to overcome the water seal Tube from patient
24 - problem is solved by adding a second chamber/bottle Tube open to atmosphere vents air Tube from patient - constant pressure warranted 2cm fluid Fluid drainage
25 These measures maintain passive drainage: - pneumothorax - persistent air leaks - drainage of large volume effusions - pleural effusion with trapped lung
26 Tube to vacuum source Tube open to atmosphere vents air Tube from patient Straw under 20 cmh 2 O Fluid drainage
27 from patient Suction control bottle Water seal bottle Collection bottle
28
29
30 a bit of history (incomplete.) a bit of physiology (basic ) indication guidelines data
31 when to place a chest tube - pneumothorax - large pleural effusion - empyema - hematothorax - chest trauma - thoracic surgery - talc pleurodesis
32 a bit of history (incomplete.) a bit of physiology (basic ) indication guidelines data
33 there are quite a few different tubes..which tube would you use in which situation?
34
35 In other words: does size matter?
36 what would you do? Dr. Lukas Kern SGP Lausanne 2016
37 Clinical context: - female, 56 years, non smoker - Unremarkable history - Presents with fever and cough for 10 days. Short of breath since 2 days - Treated with azithromycin by her family doctor with no improvement - BP 100/55, HR 120, BF 26, temp CRP >500, Leuc 15.9
38 SGP Lausanne 2016
39
40 large pleural effusion with septae - pleural enhancement in CT scan - clinical context of pneumonia complicated parapneumonic effusion/empyema
41 what you should do Kern et al. Respiration 2011
42 what we did 14F pigtail catheter with Seldinger wire
43 and now? Dr. Lukas Kern SGP Lausanne 2016
44 what about fibrinolytics? many studies no benefit MIST1-Trial Maskell, NEJM 2005 Meta-Analysis Tokuda, Chest 2006
45 not anymore! N Engl J Med 2011;365: Dr. Lukas Kern SGP Lausanne 2016
46 N Engl J Med 2011;365: Dr. Lukas Kern SGP Lausanne 2016
47 N Engl J Med 2011;365: Dr. Lukas Kern SGP Lausanne 2016
48 our own experience, retrospectively:
49 Respiration 2013;86: Dr. Lukas Kern SGP Lausanne 2016
50
51 BTS guidelines provide an accurate diagnostic and therapeutic path Dr. Lukas Kern SGP Lausanne 2016
52
53 what is the problem? Male, 75y COPD 4D ptco2 8.5kPa
54
55 your next step? Dr. Lukas Kern SGP Lausanne 2016
56 A little help from the BTS guidelines (Thorax 2010) Dr. Lukas Kern SGP Lausanne 2016
57 what we did 14F pigtail catheter
58 Full expansion 1h after insertion ptco2 down to 6.8kPa in 5min
59 thank you for your attention! Dr. Lukas Kern SGP Lausanne 2016
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