Why is chest drain repositioning done?

Why Chest Drain Repositioning is Done

Chest drain repositioning is performed when a drain becomes malpositioned, kinked, or blocked and fails to adequately drain fluid or air, leading to persistent pneumothorax, retained hemothorax, or pleural effusion—but only when the drain is not functioning effectively, as radiographic appearance alone is not an indication for repositioning if drainage is adequate. 1

Primary Indications for Repositioning

Drain Malfunction Despite Adequate Initial Placement

• When there is sudden cessation of fluid draining, the drain must be checked for obstruction (blockage or kinking) by flushing, and if it cannot be unblocked, it should be removed and replaced if significant pleural fluid remains. 1
• Repositioning becomes necessary when the drain tip is not in contact with blood or fluid collections, leading to incomplete drainage and retained hemothorax. 2
• A drain that is partly out of the thorax with holes open to atmosphere will show continuous bubbling on suction and requires repositioning. 1

Persistent Air Leak or Failure of Lung Re-expansion

• Failure of pneumothorax to re-expand or persistent air leak exceeding 48 hours duration should prompt evaluation for drain repositioning as part of complex drain management. 1
• Patients requiring sustained chest drainage with complex drain management (including repositioning) should be referred to respiratory physicians with specific training and experience. 1

Development of Surgical Emphysema

• Malpositioned, kinked, blocked, or clamped tubes can cause surgical emphysema by bringing an air-filled pleural space into communication with subcutaneous tissues. 1
• This complication indicates the need for drain assessment and potential repositioning to restore proper function. 1

Critical Caveat: When NOT to Reposition

An effectively functioning drain should not be repositioned solely because of its radiographic appearance. 1 This is a crucial principle emphasized by the British Thoracic Society guidelines—if the drain is producing adequate output and clinical parameters are improving, radiographic position alone does not warrant manipulation. 1

Clinical Assessment Before Repositioning

Verify True Malfunction

• Check for external causes first: kinking of tubing, dependent loops below chest level, or disconnection from drainage system. 1
• Confirm the underwater seal system shows appropriate respiratory swing in fluid level, which indicates tube patency and proper pleural cavity position. 1
• Assess whether continuous bubbling represents true visceral pleural air leak versus malpositioned drain with holes exposed to atmosphere. 1

Imaging Confirmation

• A chest radiograph must be performed after any drain manipulation to verify new position and exclude complications such as pneumothorax. 1, 3
• Ultrasound guidance should be used when repositioning or replacing drains to optimize placement at the site of fluid or air collection. 1

Management Approach

Initial Conservative Measures

• Attempt flushing the drain to clear blockage before considering repositioning or replacement. 1
• Ensure the drainage system is functioning properly with unidirectional flow and kept below the level of the patient's chest at all times. 1

When Repositioning Fails or is Unsafe

• A drain that cannot be unblocked should be removed and replaced if significant pleural fluid remains. 1
• Consider using steerable chest tube technology in trauma settings where optimal initial positioning is critical to prevent retained hemothorax. 2
• Referral to specialists with experience in complex drain management is recommended when standard measures fail. 1

Prevention of Need for Repositioning

• Use ultrasound guidance at initial insertion to place drains at the optimum site for fluid or air collection. 1
• Small bore percutaneous drains should be inserted at the optimum site suggested by chest ultrasound. 1
• Secure the drain adequately after insertion with stay sutures or fixation devices to prevent accidental dislodgment or migration. 1
• Avoid substantial force or trocar use during insertion, which increases risk of malposition and organ injury. 1