Figure 5.1
Water seal (From: G. Heberer, F.W. Schildberg, L. Sunder-Plassmann, I. Vogt-Maykopf Die Praxis der Chirurgie – Lunge und Mediastinum. Second edition. ISBN 3-540-19114-3, Page 191 ff)
Using a Heber-drain (see below), water seal is absolutely necessary, as the system uses an active, analogue suction source that the water seal represents. In the event of failure, an additional safety feature to prevent the patient from harm, such as a pneumothorax, is in place. In an electronic system, the check valve acts in the sense of a water seal, and is integrated into the system.
5.1.2 Heber-Drain
The Heber-drain is the classic gravity drain that works according to the so called Heber-principle using hydrostatic pressure (Fig. 5.2). When this is applied to a chest drainage system, the tubing is filled with fluid with the vertical height between chest cavity and collection canister determining the resultant subatmospheric pressure in the pleural space. In clinical practice, this means that having a patient in a bed and the canister on the floor causes a vertical height of about 60 cm. This results in a pressure in the pleural space of minus 60 cm of water.
Figure 5.2
Heber-principle
When using a Heber-drain, it is mandatory that the collection canister is placed below the level of the chest!
A Heber-drain is always combined with a water seal component.
A Heber-drain or a water seal collection canister is without an active suction source. This system always generates a subatmospheric pressure in the pleural space dependent on the vertical height between the chest and the collection canister. This is usually a distance of 60 cm with the patient in bed with the canister on the floor causing minus 60 cm of water. It is assumed that the tubing is partially filled with fluid.
5.1.3 Bülau-Drain
The Bülau-Principle was developed by the pulmonologist Gotthard Bülau (1835–1900) in Hamburg. He used this principle for the first time in 1875 to treat a pleural empyema. The Bülau-principle is based on the application of a permanent passive suction generated by an Heber-system within a closed system (Fig. 5.3).
Figure 5.3
(a) and (b) Bülau-Drain-System
A Bülau-principle is a therapeutic drain using permanent passive suction generated by a Heber-drain rather than a particular catheter or drainage system.
5.1.4 Monaldi-Drain
Vincenzo Monaldi (1899–1969) first described chest tube insertion in the second intercostal space in the midclavicular line. According to the author, this localization should be avoided as the intercostal spaces in that area are very narrow leading to pain when chest a tube is placed there. The skin incision is also in a very visible region where scars can develop keloids and are unsightly. There was a drain used for the therapy treatment of pulmonary abscesses named the “Monaldi-drain”.
5.1.5 Heimlich-Valve
A Heimlich-valve (Fig. 5.4) is a check or one way valve that was named after the American physician Henry Heimlich who was born in 1920. Due to the integrated rubber lip in device, fluid and air are allowed to escape from the chest into the collection bag. Fluid and air are unable to reflux in the opposite direction as the rubber lip will collapse making such transit impossible.
Figure 5.4
Heimlich-valve
Heimlich-valves can be used if there is a relatively small but persistent air leak in a mobile patient with minimal fluid production. In emergency situations such as a tension pneumothorax), the Heimlich-valve is a safe and simple but effective tool. In Germany it is part of the standard equipment in rescue vans.
In German speaking regions, the Heimlich-valve is used less often than in the American world as the length of stay due to many non-medical reasons is much shorter compared to Europe or Germany.
5.2 Drainage Systems
Before discussing different drainage systems, one must consider some basic requirements that a clinicians will ask for today in such a system. The following criteria must be fulfilled:
- 1.
The system is simple and safe
- 2.
The different components are simple, easy, and fast to assemble
- 3.
The system can be used for all chest drain indications
- 4.
Mobility of the patient is guaranteed
- 5.
The system is reliable
- 6.
The system is quiet
- 7.
The system is light weight
- 8.
The system is cost effective
This list includes safety issues [1–5], aspects of patient’s comfort [6, 7] as well as economic points that have become more and more important.
In regards to #3, the possibility of ubiquitous use is also a safety issue as the use of a single system in a hospital will increase patient’s safety due to familiarity and availability.
5.2.1 One-Chamber-System
A one chamber system consists of the collection canister (Fig. 5.5) that in convention includes a water seal component with the possibility to evacuate air (actively or passively) towards the atmosphere. In the new electronic devices, the collection chamber is directly connected to the suction source where a check-valve is integrated.
Figure 5.5
One-chamber-system (From: G. Heberer, F.W. Schildberg, L. Sunder-Plassmann, I. Vogt-Maykopf Die Praxis der Chirurgie – Lunge und Mediastinum. Second edition. ISBN 3-540-19114-3, Page 191 ff)
In theory, the majority of indications for chest drainage can be fulfilled with a one chamber system. Such a system can be used as a Heber-drain or in combination with an active suction source. There is a limitation with conventional systems that include a collection canister and suction source from different suppliers when there is a huge air leak.
When using a one chamber system such as a Heber-drain (no active suction), the fluid must be manually milked down to the canister because there is a potential for air to not be able to escape depending on the pressure gradient. Remember the difference in height between the canister and patient determines this pressure. This could mean that the patient would not be able to evacuate air just by breathing and/or coughing which could cause a pneumothorax and possibly subcutaneous emphysema.
The occurrence of a so called “siphon-effect” (see below) must also be prevented.
Modern electronic systems in which the canister is integrated into the system do not have these same limitations as they are in effect a two chamber system. This is achieved with the geometry of the tubing and the connections that are in place. When entering the system, fluid and air are separated with fluid into the collection chamber and air evacuated through the system into the atmosphere.
5.2.2 Two-Chamber-System
Two chamber systems were developed to prevent foam formation which is due to protein rich surfactant seen in patients with a large air leak. There can be a lot of foam in a one chamber system with water seal which can make the observation and quantity of an air leak more difficult or even impossible to see. The two chamber system also prevents that from rising up in the tubing towards the patient.
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