What is the management protocol for a patient with a chest wound treated with vacuum-assisted closure (VAC) and chest tubes?

Management of Chest Wound VAC with Chest Tubes

The management of chest wounds with vacuum-assisted closure (VAC) and chest tubes requires specialized care with a focus on maintaining proper drainage, preventing infection, and ensuring optimal wound healing while avoiding complications.

Initial Setup and Placement

• Small bore percutaneous chest drains should be inserted at the optimum site suggested by chest ultrasound to ensure proper placement and minimize patient discomfort 1
• VAC dressing should be applied after thorough debridement and adequate hemostasis, with a fenestrated tube embedded in the foam and the wound sealed with adhesive tape to create an airtight environment 2
• The chest drain should be connected to a unidirectional flow drainage system (underwater seal bottle) that must be kept below the level of the patient's chest at all times to prevent backflow 1, 3
• VAC therapy should be set to deliver negative pressure ranging from 50 to 125 mmHg, with -125 mmHg being commonly used for chest wounds 2, 4

Ongoing Management

• All chest tubes should be monitored for proper functioning, with attention to bubbling patterns which indicate air in the pleural space 3
• A bubbling chest drain should never be clamped as this can convert a simple pneumothorax into a life-threatening tension pneumothorax 1, 3
• VAC dressings should be changed every 2-3 days to assess wound progress and ensure proper function 5
• When there is a sudden cessation of fluid draining from the chest tube, check for obstruction (blockage or kinking) by flushing with saline 1
• Patients with chest drains and VAC therapy should be managed on specialized wards by staff trained in chest drain and VAC management 1

Antibiotic Management

• All patients with pleural infection should receive intravenous antibiotics with coverage for common pathogens including Streptococcus pneumoniae 1
• Broader spectrum antibiotic coverage is required for hospital-acquired infections and those secondary to trauma 1
• Antibiotic choice should be guided by microbiological results whenever possible 1
• For contaminated chest wounds, antibiotic prophylaxis has shown to be protective against empyema and pneumonia, particularly in penetrating injuries 1

Special Considerations

• If chest tube drainage becomes inadequate with persistent pleural collection despite antibiotics, consider intrapleural fibrinolytics (urokinase) which can improve drainage and shorten hospital stay 1
• Limit initial drainage to 10 ml/kg body weight, then clamp the drain for 1 hour if not bubbling to prevent re-expansion pulmonary edema 1, 3
• For persistent air leaks, suction may be applied via the underwater seal at a pressure of 5-10 cm H₂O, which should be supervised by appropriately trained nursing staff 1
• VAC therapy has been shown to be effective for complex chest wounds without the need for rotational muscle flaps, allowing for delayed primary closure, split-thickness skin grafting, or healing by secondary intention 5

Monitoring for Complications

• Monitor for signs of surgical site infection, which can be significantly reduced with VAC therapy compared to conventional wound management 1
• Watch for subcutaneous emphysema, which may require additional management including subcutaneous infraclavicular incision and VAC therapy if conservative measures fail 4
• Assess for persistent sepsis despite drainage and antibiotics, which should prompt early discussion with a thoracic surgeon 1
• Check for proper chest tube position with chest radiography after insertion and periodically during treatment 1

Criteria for Removal

• The chest drain should be removed once there is clinical resolution of the pleural infection or pneumothorax 1
• A drain that cannot be unblocked should be removed and replaced if significant pleural fluid remains 1
• VAC therapy can typically be discontinued when the wound shows adequate granulation tissue formation, reduced depth and volume, and decreased bacterial load 2, 5

Advantages of VAC Therapy for Chest Wounds

• VAC therapy stabilizes the wound environment, reduces wound edema and bacterial load, improves tissue perfusion, and stimulates granulation tissue and angiogenesis 2
• The use of VAC therapy for chest wounds has been shown to reduce the need for complex reconstructive procedures such as muscle flaps 5, 6
• VAC therapy appears to be more effective than conventional dressings for managing complex chest wounds in terms of reducing wound volume, depth, treatment duration, and cost 2, 5