Porcel José M
Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, Lleida, Spain.
Tuberc Respir Dis (Seoul). 2018 Apr;81(2):106-115. doi: 10.4046/trd.2017.0107. Epub 2018 Jan 24.
Chest tube insertion is a common procedure usually done for the purpose of draining accumulated air or fluid in the pleural cavity. Small-bore chest tubes (≤14F) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients and pleural effusions in general, with the possible exception of hemothoraces and malignant effusions (for which an immediate pleurodesis is planned). Large-bore chest drains may be useful for very large air leaks, as well as post-ineffective trial with small-bore drains. Chest tube insertion should be guided by imaging, either bedside ultrasonography or, less commonly, computed tomography. The so-called trocar technique must be avoided. Instead, blunt dissection (for tubes >24F) or the Seldinger technique should be used. All chest tubes are connected to a drainage system device: flutter valve, underwater seal, electronic systems or, for indwelling pleural catheters (IPC), vacuum bottles. The classic, three-bottle drainage system requires either (external) wall suction or gravity ("water seal") drainage (the former not being routinely recommended unless the latter is not effective). The optimal timing for tube removal is still a matter of controversy; however, the use of digital drainage systems facilitates informed and prudent decision-making in that area. A drain-clamping test before tube withdrawal is generally not advocated. Pain, drain blockage and accidental dislodgment are common complications of small-bore drains; the most dreaded complications include organ injury, hemothorax, infections, and re-expansion pulmonary edema. IPC represent a first-line palliative therapy of malignant pleural effusions in many centers. The optimal frequency of drainage, for IPC, has not been formally agreed upon or otherwise officially established.
胸腔置管引流是一种常见的操作,通常用于排出胸腔内积聚的气体或液体。对于未通气患者的自发性气胸以及一般的胸腔积液,通常推荐使用小口径胸腔引流管(≤14F)作为一线治疗方法,但血胸和恶性胸腔积液可能除外(对于后者计划立即进行胸膜固定术)。大口径胸腔引流管可能对非常大的漏气情况有用,以及在小口径引流管治疗无效后使用。胸腔置管应在影像学引导下进行,可采用床旁超声检查,较少情况下使用计算机断层扫描。必须避免所谓的套管针技术。相反,应使用钝性分离法(用于管径>24F的引流管)或塞丁格技术。所有胸腔引流管都连接到一个引流系统装置:单向活瓣、水封瓶、电子系统,或者对于留置胸膜导管(IPC),连接到真空瓶。经典的三瓶引流系统需要(外部)壁式吸引或重力(“水封”)引流(除非后者无效,否则不常规推荐前者)。拔管的最佳时机仍存在争议;然而,数字引流系统的使用有助于在该领域做出明智和谨慎的决策。一般不主张在拔管前进行夹管试验。疼痛、引流管堵塞和意外脱落是小口径引流管常见的并发症;最可怕的并发症包括器官损伤、血胸、感染和复张性肺水肿。在许多中心,IPC是恶性胸腔积液的一线姑息治疗方法。对于IPC,最佳引流频率尚未正式达成一致或正式确定。