Blake Drain vs Traditional Chest Tube: Clinical Decision-Making
Direct Recommendation
For cardiac surgery, Blake drains (19F silicone-rubber) are preferred over traditional large-bore chest tubes (28-36F PVC) based on superior drainage efficiency, reduced postoperative atrial fibrillation, and shorter hospital stays, while maintaining equivalent safety profiles. 1 However, for thoracic surgery with significant air leaks, traditional larger-bore drains (24-32F) remain the standard due to Blake drain inadequacy in evacuating air. 1
Clinical Context: When to Choose Each Drain Type
Blake Drains (19F Silicone-Rubber) - Preferred For:
Cardiac Surgery Applications:
- Post-coronary artery bypass grafting (CABG): Blake drains demonstrated 71% more drainage volume with 49% reduction in pericardial effusion (P<0.001) and reduced postoperative atrial fibrillation from 23.8% to 11.3% (P=0.016) compared to semirigid drains. 1
- Mediastinal drainage: Multiple retrospective studies show noninferiority for drainage volume, reoperation rates for bleeding/tamponade, and pleural effusions when compared to 28-36F PVC tubes. 1
- Patient mobility: Shorter median hospital length of stay (4 vs 5 days, P=0.01) attributed to greater freedom to ambulate with flexible silicone drains. 1
- General cardiac procedures: Blake drains are as effective and safe as conventional chest tubes with no significant difference in mediastinal explorations (2.08% vs 3.47%, p=0.27) or pleural effusions (9.87% vs 9.54%). 2
General Thoracic Surgery (Selected Cases):
- Blake drains functioned efficiently in 420 general thoracic cases including lung resections, with successful management of postoperative bleeding, persistent air leaks, and chylothorax without complications. 3
- Equivalent fluid drainage: No difference between 19F Blake and 28F conventional drains for pleural fluid volume after lobectomy for cancer. 1
Traditional Chest Tubes (24-32F) - Required For:
Thoracic Surgery with Air Leak Management:
- Critical limitation of Blake drains: Evacuation of air leaks is insufficient with 19F Blake drains compared to 32F conventional drains in pulmonary surgery. 1
- Standard practice: 24-32F conventional drains are predominantly used in lobectomy studies where air leak management is the primary concern. 1
Specific Pleural Conditions:
- Pleural infection/empyema: Frank pus or pleural fluid pH <7.2 requires immediate chest tube drainage, with traditional tubes preferred for thick, purulent material. 1, 4
- Large hemothorax: Large-bore tubes may be necessary for adequate drainage of blood products. 5
- Loculated collections: Earlier chest tube drainage indicated, with traditional tubes often preferred for complex loculations. 1, 4
Evidence Quality and Limitations
Strongest Evidence (RCT):
The 2004 Ege trial remains the highest quality single study comparing Blake drains to semirigid drains in cardiac surgery, demonstrating clear superiority in drainage efficiency and clinical outcomes. 1
Retrospective Evidence:
Multiple retrospective studies (2003-2007) consistently show noninferiority or equivalence of Blake drains for cardiac surgery, though with less definitive conclusions due to varying outcome measures. 1, 6
Critical Evidence Gap:
No strong recommendations can be made regarding drain type selection based on current literature quality. 1 The 2021 pulmonary lobectomy guidelines explicitly state insufficient evidence exists to recommend specific drain types, with most studies using 24-32F conventional drains as standard. 1
Algorithmic Approach to Drain Selection
Step 1: Identify Surgical Context
- Cardiac surgery (CABG, valve, mediastinal) → Proceed to Step 2
- Thoracic surgery (lobectomy, pneumonectomy) → Proceed to Step 3
- Pleural infection/effusion management → Proceed to Step 4
Step 2: Cardiac Surgery Decision
- Use 19F Blake drain for routine mediastinal/pericardial drainage 1
- Consider single drain approach (reduces drainage time by 0.4-0.7 days and hospital stay by 0.2-0.5 days) 1
- Benefits: Enhanced mobility, reduced POAF, equivalent safety 1
Step 3: Thoracic Surgery Decision
- Anticipated significant air leak (extensive parenchymal resection, COPD, adhesions) → Use 24-32F conventional drain 1
- Minimal air leak expected (wedge resection, pleural procedures) → Consider 19F Blake drain 3
- Standard lobectomy → Use 24-32F conventional drain (current standard of care) 1
Step 4: Pleural Effusion/Infection Management
- Small-bore drains (≤14F) with ultrasound guidance are first-line for most pleural effusions (success rate 84-97%) 7, 5
- Empyema/thick purulent fluid → Use larger bore traditional tubes (24-32F) 1, 4
- pH <7.2 or frank pus → Immediate drainage required with traditional chest tube 1, 4
Common Pitfalls and Caveats
Critical Errors to Avoid:
- Never use Blake drains as sole drainage for thoracic surgery with expected air leaks - inadequate air evacuation documented. 1
- Never insert drains without imaging guidance (ultrasound preferred) - dramatically increases pneumothorax risk (8.9% vs 1.0%). 7
- Never use trocar technique - high risk of organ injury, hemothorax, and lung lacerations. 4
Clinical Nuances:
- Pain scores: Despite theoretical advantages of smaller Blake drains, pain at removal was similar across drain types in comparative studies. 6
- Drainage volume: Total blood loss and bleeding patterns do not differ significantly between Blake and conventional drains in cardiac surgery. 6
- Cost considerations: In absence of clear superiority, local cost and availability should guide selection. 6
Specialist Involvement:
- Respiratory physician or thoracic surgeon involvement is mandatory for all pleural infections requiring drainage - delay increases morbidity and mortality. 1, 4
Size Selection Within Drain Types
Small-bore approach (≤14F): First-line for spontaneous pneumothorax and most pleural effusions in non-ventilated patients. 5
Blake drains (19F): Optimal size for cardiac surgery mediastinal drainage. 1, 2
Medium-bore (24-32F): Standard for thoracic surgery and complex pleural collections. 1
Large-bore (>32F): Reserved for very large air leaks or failed trial of smaller drains. 5