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Sir,I read with interest the excellent audit on the use of chest drains by different hospital specialties published in the August edition of the Postgrad Med J.1 As a chest physician, I wanted to make a further few points.
Firstly, there have been guidelines published by the British Thoracic Society on the management of spontaneous pneumothorax, containing within them a specific flowchart for the management of intercostal drains.2 These guidelines were published after consultation with over 150 British respiratory physicians and thoracic surgeons.
Secondly, there now appears to be emphasis on the use of simple aspiration of spontaneous pneumothoraces before the use of intercostal tube drainage, even for complete collapse, thus potentially avoiding all the possible inherent complications of drain use.3 It would be of interest to audit the use of aspiration before drain insertion amongst the respondents in the article.
Thirdly, I am surprised at the number of chest physicians who advocated direct pleural puncture with the trocar (68%) where the above-mentioned guidelines recommend blunt dissection and then gentle introduction of drain/trocar assembly together. I am equally surprised at the practice of drain removal. Again the published guidelines recommend a Valsalva manoeuvre, where in fact, in the audit, only 36% of chest physician respondents actively employed this.
The audit conclusions suggest the adoption of standardised protocols for the management of intercostal tubes, particularly to help guide those specialties less familiar with their use. Even with some guidelines having been published (though solely for the use of chest drains in pneumothoraces), it would appear from the audit that great variation still exists. This might suggest that, even if extensive guidelines were introduced, they still might not be followed by the chest specialties. What hope then for the non-specialist?
This letter was shown to the authors who responded as follows:
Sir,We share Dr Murray's concerns over the apparent non-adherence to published guidelines on the management of chest drains as revealed in our survey. Just over half of all consultant chest physicians who responded had adopted some kind of policy on the use of chest drains and in this respect they are ahead of the other three specialties included in the survey. It is difficult to understand exactly why the others failed in this task but a combination of ignorance, indifference, problems with implementation or concern over medicolegal implications may be involved. The large variations in virtually every aspect of usage of chest drains under survey must at least in part stem from this observation. We firmly believe that adoption of safe standardised practice goes a long way to reduce unnecessary complications following chest drainage. It is up to the individual consultants and units concerned to implement appropriate local measures to this end.