Indications

Pneumothorax (see Chapter 64). Chest drain insertion is indicated as the first-line intervention for:

• Pneumothorax in any ventilated patient
• Tension pneumothorax (following on from initial needle decompression)
• Large symptomatic spontaneous secondary pneumothorax
• Large symptomatic recurrent or persistent pneumothorax (following thoracocentesis)

• Symptomatic spontaneous primary pneumothorax of any size
• Small symptomatic spontaneous secondary pneumothorax in patients under 50 years

• Pleural infection, that is, complicated parapneumonic effusion or empyema (following diagnostic thoracocentesis)
• Symptomatic malignant pleural effusion where the intention is to perform a subsequent pleurodesis
• Traumatic haemothorax

• Pleural effusion of unknown cause, for diagnostic purposes (small volume thoracocentesis, that is, usually between 20 and 50 mL pleural fluid)
• Large symptomatic pleural effusion for therapeutic purposes (large volume thoracocentesis, that is, usually up to 1.5L pleural fluid depending on patient's symptoms)

Uncertain diagnosis (e.g. emphysematous bulla misdiagnosed as pneumothorax; elevated hemidiaphragm, lung collapse or lung consolidation misdiagnosed as pleural effusion).

Evidence of lung adherent to the chest wall on imaging studies.

Coagulopathy including INR (international normalized ratio) >1.5, platelet count <50×10⁹/L, recent use of thrombolytic or anticoagulant therapy; any concerns should prompt discussion with a haematologist before going ahead with the procedure.

Potential complications

Failure of treatment

Pain

Malposition of the ICD

Damage to viscera

Bleeding, including from intercostal vessels, during or following ICD insertion

Infection (wound or intrapleural) following ICD insertion

Drain dislodgement or blockage following ICD insertion

Re-expansion pulmonary oedema following ICD insertion and re-expansion of the collapsed lung