key: cord-0992725-d77hrsa6 authors: Dhanasopon, Andrew P.; Zurich, Holly; Preda, Angela title: Chest Tube Drainage in the Age of COVID-19 date: 2020-11-26 journal: Physician Assist Clin DOI: 10.1016/j.cpha.2020.11.011 sha: 5c3f679d385083349dfff137d4588be46a9434c9 doc_id: 992725 cord_uid: d77hrsa6 Patients with COVID-19 are at risk of developing acute respiratory distress syndrome (ARDS) requiring invasive mechanical ventilation. Barotrauma in these patients often leads to clinically significant pneumothorax, which necessitates chest tube thoracostomy. However, given the mode of transmission of the SARS-CoV-2 virus and the aerosolizing nature of the procedure, special considerations and care must be taken to mitigate the exposure risks to healthcare personnel. This article discusses the risk mitigation strategies proposed and under review at our institution. • Chest tubes are commonly placed at the bedside for the treatment of pneumothorax, and/or pleural effusion for the COVID-19 patient • Barotrauma due to mechanical ventilation can manifest as a pneumothorax which is commonly treated with tube thoracostomy • Pleural air released by tube thoracostomy is a potential source of airborne infection due to aerosolization of the SARS-CoV-2 virus • Various strategies are emerging to reduce the risk of infection associated with exposure to pleural air SYNOPSIS Patients with COVID-19 are at risk of developing acute respiratory distress syndrome (ARDS) requiring invasive mechanical ventilation. Barotrauma in these patients often leads to clinically significant pneumothorax, which necessitates chest tube thoracostomy. However, given the mode of transmission of the SARS-CoV-2 virus and the aerosolizing nature of the procedure, special considerations and care must be taken to mitigate the exposure risks to healthcare personnel. This article discusses the risk mitigation strategies proposed and under review at our institution. Chest tube thoracostomy in patients with airborne precautions requires special consideration as air leaks are a potential source of airborne infection. Although no definitive guidance exists regarding the potential aerosolization of the severe acute respiratory syndrome (SARS) CoV-2 virus 1 , chest tube insertion, management and removal are all potentially aerosol-generating procedures and may create a risk of exposure for healthcare personnel. COVID-19 is a respiratory syndrome whose clinical manifestations range from asymptomatic to severe interstitial pneumonia and acute respiratory distress syndrome (ARDS). 2 A meta-analysis of 19 observational studies showed that about one-third of hospitalized COVID-19 patients develop ARDS [32.8% (95%CI 13.7-51.8)]. 3 Pneumothorax appears to be a frequent complication of ARDS in general, with one study demonstrating the incidence to be 48.8% 5 . The proportion of mechanically ventilated COVID-19 patients with ARDS who suffer pneumothorax due to barotrauma is anticipated to be similar, but is not yet known. 4, 5 The development of pneumothorax in ARDS has been associated with as much as 20% higher mortality compared to those without pneumothorax 6 . Thus, prompt recognition and treatment of pneumothorax in any mechanically ventilated patient, and particularly in patients with ARDS and COVID-19 related ARDS, can prevent further respiratory and hemodynamic deterioration. The following risk mitigation strategies have been proposed and are under review at our institution to minimize exposure to pleural air during chest tube placement in the COVID-19 patient. These modifications of the standard insertion technique were developed in parallel and in correspondence with members of the AAST (American Association for the Surgery of Trauma) Acute Care Surgery and Critical Care Committee. Please refer to their guidelines for further details. 7 • Elective insertion should be postponed until COVID-19 testing can be performed if possible. • In patients with unknown COVID-19 status when chest tube placement is required on an urgent or emergent basis or in a patient with confirmed COVID-19 positive status, perform procedure in a negative pressure airborne precaution isolation room. J o u r n a l P r e -p r o o f • Use appropriate personal protective equipment for aerosol-generating procedures. • Bring only essential equipment into the room. • Leave backup equipment outside of the room with an assistant positioned outside. • Set up equipment outside of the room as much as possible, including the chest tube drainage system • The procedure should be performed by an experienced practitioner, with minimal nonessential personnel present. The AAST guidelines recommend establishment of a dedicated thoracic procedure team. 7 • If the patient is mechanically ventilated, consider the use of neuromuscular blockade to prevent coughing and to facilitate holding respirations while entering the pleural space and until placement of tube. Both coughing and respirations could expel potentially infectious pleural air. • Fully drape the entire patient instead of the half drape commonly used for this procedure. • When possible, use a small diameter pigtail catheter (e.g. 14Fr) with percutaneous Seldinger technique. If a large bore tube is required, use a smaller incision and a tunneled approach to reduce the amount of potentially infectious air leak. • Clamp the tube prior to insertion to prevent pleural air escaping via the newly inserted chest tube. • Attach the tube to the previously prepared chest tube management system tubing for egress of air from the thoracic cavity. • Close the skin incision around the tube to prevent air leakage around the tube. • Prone positioning is used to improve lung mechanics and gas exchange by enhancing lung recruitment 8 . This technique is used as an adjunct in the management of ARDS patients including mechanically ventilated COVID-19 patients. • When prone-positioned patients require chest tube thoracostomy, place a rolled blanket to elevate the lateral chest and insert the chest tube as close to the mid-axillary line as possible within the "safe triangle" (Fig 1) to avoid kinking of the tube. When possible, the drainage system should be placed on suction. In this setup, the suction canister and medical gas vacuum lines exhaust in a manner similar to a negative pressure room. When the system is placed on water seal and disconnected from wall suction, air leaking from the lung can flow into the drainage system and into the room. Thus, the use of water seal should be avoided. Patients, however, might need to be transported for various reasons and maintaining wall suction might not be feasible. While neither three-chamber nor digital chest drainage systems are equipped with viral filters, J o u r n a l P r e -p r o o f the three-chamber system can be easily modified using the following options to offer potential viral protection to make water seal safe. Repurposed ventilator or smoke evacuation viral in-line filters may be attached in between the three-chamber device and the wall canister. Filters that have been proposed by other groups include the in-line BILF-150/200 filter (Buffalo Filter LLC.) originally used in surgical smoke evacuation 7 or a ventilator filter such as the AirLife 303EU bacterial/viral filter (Carefusion) 9 or Filta-Guard TM (Intersurgical Ltd©). 1 (Fig 2, Figure 3) • Consider adding dilute bleach in the water seal chamber with or without the filter in the three-chamber chest drainage system. • Minimize staff in the room and use PPE appropriate for aerosol-generating procedure. • Place an occlusive dressing over the tube site, reinforced by pressure dressing. • Carefully dispose of the chest tube and the drainage device doubling the biohazard bag. Chest tube thoracostomy for patients with COVID-19 warrant special consideration given the mode of transmission of the SARS-CoV-2 virus and the aerosolizing nature of the procedure itself. Proper preparation, personal protective equipment, modified techniques, and drainage maintenance are critical to minimizing exposure to healthcare personnel. COVID-19: Chest Drains With Air Leak -The Silent 'Super Spreader Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China Clinical, laboratory and imaging features of COVID-19: A systematic review and metaanalysis Konstantinos Zarogoulidis, Paul Zarogoulidis. Barotrauma and pneumothorax COVID-19 PATIENTS. The Annals of thoracic surgery Lung structure and function in different stages of severe adult respiratory distress syndrome Tube thoracostomy during the COVID-19 pandemic: guidance and recommendations from the AAST Acute Care Surgery and Critical Care Committees. Trauma surgery & acute care open An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome Creating a COVID-19 safe chest tube drainage system