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Fig. 12.—This
photograph illustrates water-seal drainage, the method of fixing the tube to
the chest wall and the "gate-strapping" used for keeping the dressings in position.
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by the negative pressure induced by water-seal drainage, provided that
the lung is not bound down by rigid scar tissue. As a practical guide, it is
probable that water-seal drainage is serving a useful purpose so long as the
column of water in the glass tube shows a large respiratory " swing "
and a mean negative pressure exceeding 10 centimetres. With an empyema of less
than 500 millilitres capacity at the time of drainage, it is usually
unnecessary to persist with water-seal drainage for more than a week, but with
large cavities it may be advisable to continue for 2-3 weeks. When the
water-seal is deemed to have completed its purpose, the tube is cut off close
to the safety-pin with which it is anchored to the chest wall, and any discharge
subsequently drains into the dressings. This has the great advantage of
allowing the patient to move more freely.
It is very
important that the patient should perform breathing and postural exercises
under the direction of a physiotherapist who is specially versed in this form
of treatment. The exercises are started on the day following operation, they
are continued until the empyema has completely healed and further, until
respiratory movements have been restored to normal. The patient should practice
these exercises as much as possible throughout the day, and not only in the
presence of the physiotherapist.
Re-expansion
of the lung will also occur more quickly if the patient is physically active.
He should therefore leave his bed early and undertake as much exertion as the
general condition permits. Most patients are able to get up within 24-48 hours
of operation.
Irrigation
of the empyema cavity, which was popular at one time and is still
 (a) |
Fig. 13.—Serial "sino-grams " to show pro-gress in obliteration of an acute empyema cavity, (a) The tube
is correctly placed at the bottom of the cavity ; (b) the cavity is slightly smaller. In (c) a
tube of excessive length has been inserted and a bronchial fistula has
de-veloped (probably due to ulceration secondary to pressure from the end of
the tube), (d) The fistula has healed although some residual oil can be
seen in the alveoli. The tube is again too long and requires short-ening. The
tube is not removed until the sinogram shows complete obliteration of the
intra-thoracic cavity.
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(b)
(c) (d)
frequently employed,
should not be done, for it serves no useful purpose and may be harmful, because
there is always a risk that secondary infection will be introduced. It is obviously strongly contra-indicated
if a bronchial fistula is present.
