What are the contraindications to using negative suction on an intercostal drainage (ICD) tube?

Contraindications to Negative Suction on Intercostal Drainage Tubes

Negative suction should not be applied to intercostal drainage tubes in patients with bronchopleural fistulas, as it can worsen air leaks and potentially convert a simple pneumothorax into a life-threatening tension pneumothorax. 1

Primary Contraindications

• Bronchopleural fistula: Negative suction can exacerbate air leaks through the pleural space 1, 2
• Persistent air leaks: May worsen with negative pressure application 1
• Patients on mechanical ventilation: Increased risk of tension pneumothorax development 1
• Small pneumothoraces with small-bore catheters: Initial management should be with water seal drainage without suction 1

Relative Contraindications

• Patients with bullous lung disease: Higher risk of expanding existing air leaks 1
• Subcutaneous emphysema: May worsen with negative pressure, though paradoxically, controlled suction may be needed in severe cases 3
• Post-surgical thoracic patients at high risk: Particularly those with poor functional respiratory reserve 2

Evidence-Based Management Approach

1. Initial management: Connect chest tubes to an underwater seal drainage system without initial suction, as recommended by the American College of Chest Physicians 1

2. When to consider suction:

   • Only apply suction if the lung fails to re-expand with water seal alone 1
   • Use appropriate tube size (24F-28F for large pneumothoraces or bronchopleural fistulas; 16F-22F for most cases) 1

3. Monitoring during suction:

   • Watch for worsening air leaks (increased bubbling)
   • Monitor for development of subcutaneous emphysema 1, 3
   • Obtain chest radiographs to assess lung re-expansion 1

Important Precautions

• Never clamp a bubbling chest tube as this can convert a simple pneumothorax into a life-threatening tension pneumothorax 1
• Avoid mechanical positive pressure ventilation when possible in patients with bronchopleural fistulas 2
• Be cautious with BiPAP and CPAP in patients with chest tubes, as they can affect blood pressure, respiratory mechanics, and potentially worsen air leaks 1

Complications of Inappropriate Suction

• Conversion to tension pneumothorax 1
• Worsening of subcutaneous emphysema 3
• Increased risk of pneumonia (13.3% vs 4.9% in patients without persistent air leaks) 1
• Prolonged hospital stay (14.2 vs 7.1 days) 1
• Increased chest tube duration (11.5 vs 3.4 days) 1

Special Considerations

In cases of debilitating subcutaneous emphysema secondary to chest tube placement, high negative pressure subcutaneous suction drains may be required as a separate intervention, rather than increasing suction on the existing chest tube 3.

When intercostal approaches are used for drainage procedures, there is a higher risk of pleural complications (26.2% vs 8.1% with subcostal approaches), including pneumothorax and pleural effusions 4. This should be considered when determining whether to apply suction.