Author: John Corcoran
Indications, contraindications and potential complications of intercostal chest drain (ICD) insertion are summarized in Table 122.1. One assistant is required to monitor the patient and assist with the equipment (Table 122.2).
- You should only insert an intercostal chest drain (ICD) if you have received appropriate training or are being supervised by someone who has been appropriately trained. ICD insertion is potentially associated with significant morbidity and even mortality.
- Whenever possible, the decision to place an ICD, and the type of drain to be used, should be discussed with a chest physician or thoracic surgeon.
- Many patients with symptomatic pleural disease should be managed without an ICD. Often, simple pleural aspiration (thoracocentesis) will suffice and allow the patient to be managed as an outpatient or day case.
- Pleural interventions, including intercostal chest drain (ICD) insertion, should not be performed out of hours unless it is a clinical emergency (i.e. a patient with significant physiological compromise and/or symptoms). If an out-of-hours intervention is necessary, it is worth considering whether thoracocentesis will provide adequate treatment and be safer than insertion of an ICD.
- Pleural interventions should be performed using full aseptic technique in a dedicated clean room (e.g. procedural suite, operating theatre) to reduce the risk of iatrogenic infection. A procedure should only be performed at the bedside in a clinical emergency when it is unsafe to move the patient elsewhere.
- Informed written consent should be taken from all patients undergoing any pleural intervention, including ICD insertion, unless it is a clinical emergency and the planned treatment may be lifesaving.
- The use of thoracic ultrasonography is strongly recommended. The marking of a site remotely for subsequent thoracocentesis or chest drain insertion in a separate clinical area (e.g. ‘X marks the spot’ in radiology, prior to chest drain insertion on a medical ward) is not recommended, as it can provide false reassurance and is no more accurate than a ‘blind’ intervention.
- There is no evidence to support the routine use of thoracic ultrasonography prior to pleural intervention for a pneumothorax. The operator should utilize an anatomical landmark technique (i.e. ‘triangle of safety’ for ICD insertion, Figure 122.1).
Technique
Preparation
- Confirm the indications for the procedure. Review the relevant imaging (e.g. chest X-ray) and if appropriate perform thoracic ultrasonography to define the location and anatomy of the effusion.Explain the procedure to the patient and obtain written consent where possible (see above).
- Assemble the equipment, including an appropriately sized chest tube, and ensure that any connections fit, for example for the underwater seal (Figure 122.2).
- Connect the patient to appropriate monitoring, including ECG, blood pressure and pulse oximetry. Give supplemental oxygen via nasal cannulae or a mask if indicated. Ensure the patient has venous access (e.g. peripheral cannula).
- Consider pre-medication with either an opioid analgesic (e.g. morphine 2.5 mg IV) or an anxiolytic (e.g. midazolam 1–2 mg IV), taking care particularly in patients who are elderly and/or at particular risk of respiratory compromise (e.g. chronic obstructive pulmonary disease). Reversal agents (i.e. naloxone or flumazenil) should be immediately available if required.
- Ensure the patient is comfortable and in a position (Figure 122.3) that allows access to the site where the chest drain is to be inserted. This will usually be within the ‘triangle of safety’ (Figure 122.1).
- Put on a surgical hat, mask, gown and gloves. Prepare the skin with chlorhexidine or povidone-iodine and apply drapes.
- Draw up 20 mL of 1% lidocaine. Generous use of local anaesthetic (up to 3 mg/kg lidocaine), focusing on highly innervated areas such as the skin, periosteum and parietal pleura will reduce the risk of patient discomfort during the procedure. Infiltrate the skin with 3–4 mL using a 25G (orange) needle, then change to a 18G (green) needle in order to infiltrate the subcutaneous tissues.
- Advance the needle into the thorax (passing just superiorly to the lower rib of the intercostal space) until air or fluid is aspirated, then withdraw slightly in order to infiltrate 5 mL at the parietal pleural surface. Withdraw the needle completely, infiltrating a further 5–10 mL in and around the needle track as you withdraw. If you have been unable to freely aspirate air or fluid from the pleural space, do not proceed further at this site and seek advice from a senior colleague.
Seldinger technique
- Advance the introducer needle mounted on a 10 mL syringe into the pleural space (again, passing just superiorly to the lower rib of the intercostal space) and confirm free aspiration of air or effusion. Pass the guidewire, J end first, through the needle into the pleural space; ideally, this should be directed apically for a pneumothorax or posterobasally for an effusion.
- Remove the needle and then pass the dilator(s) over the guidewire to dilate a track for the chest tube. A small incision (5 mm) may be needed initially to help with passing the dilator through the skin and subcutaneous tissue. Always keep hold of the distal end of the guidewire, and do not insert the dilator any further into the chest than is necessary to breach the parietal pleural surface.
- Pass the chest tube over the guidewire into the pleural space. In an adult of normal size, around 15cm of drain will usually lie within the chest. The depth to which a chest tube is inserted is determined by the need to ensure the side holes on the tube are well within the chest, otherwise subcutaneous emphysema will result. Remove the guidewire and any stiffening device/dilator used to help introduce the chest tube, leaving the tube itself in place.
- Attach the underwater seal bottle to the chest tube.
- Secure the chest tube in position using a non-absorbable 1/0 suture passed through the adjacent skin and subcutaneous tissues and then wrapped and tied several times around the tube (Figure 122.4). Place a pad of gauze between the patient's skin and the tube, then further anchor the tube to the chest wall using tape or other adhesive dressing.
Blunt dissection technique
The use of small-bore drains (8–14 French) inserted with a Seldinger technique is now the most common mode of chest drain insertion, and is sufficient for most effusions and pneumothoraces. Large-bore drains (>14 French) inserted with a blunt dissection technique are used less frequently than before, but are still seen in emergency trauma or thoracic surgical cases.
- Make a 1cm incision with a scalpel in line with and just above the edge of the lower rib of the intercostal space. Place two interrupted 3/0 non-absorbable sutures across the incision. These should be left loose so the tube can pass, and will be tied when the tube is removed. Place a separate 1/0 non-absorbable suture through the skin and subcutaneous tissues above the incision, which will be used to anchor the chest tube later (Figure 122.4).
- Using a Spencer Wells or similar straight forceps, enlarge the track down to and through the pleura so that the tube will pass with a snug fit. Note that the forceps should always be removed in an open position during the process of blunt dissection to prevent accidental avulsion of any structures, for example blood vessels. Once a track has been created, this should be explored with a finger to ensure there are no underlying organs that might be damaged during subsequent chest tube insertion.
- Remove the chest tube from any trocar (a trocar should never be used to guide a chest tube due to the high risk of damaging underlying structures) and, holding the tip of the tube with the forceps, gently pass the tube into the pleural space. The tube should ideally be directed apically for a pneumothorax and posterobasally for an effusion. In an adult of normal size, around 15 cm of the chest tube will usually lie within the chest. The tube must be inserted far enough so that the side holes are well within the chest, otherwise subcutaneous emphysema will result. Excessive force should never be required during drain insertion – if the tube does not pass easily then withdraw and seek advice from a senior colleague.
- Attach the underwater seal bottle to the chest tube.
- Secure the chest tube in position with the 1/0 suture wrapped and tied several times around it. Place a pad of gauze between the patient's skin and the tube, then further anchor the tube to the chest wall using tape or other adhesive dressing.
Final points
- Remove the drapes and ensure the patient is able to sit up comfortably. Check that the chest tube is well anchored, all connections are secure and the dressings are satisfactory. Clear up and dispose of all sharps safely. Arrange a chest X-ray to check the position of the chest tube. The procedure should be fully documented in the patient's record, including as a minimum: indications; approach; chest tube size; technique used; pre-medication and local anaesthetic used; any complications; post-procedure chest X-ray findings; further management plan.
- Ensure that the patient has regular analgesia prescribed whilst the chest drain remains in situ; assuming no contraindications this should include regular paracetamol (1g four times daily) and non-steroidal anti-inflammatory drugs as a minimum. Opioid analgesia may also be necessary on a regular or as required basis; this should be reviewed daily to ensure the patient is pain free.
Aftercare
- Small-bore drains (8–14 French) require regular flushing (e.g. 20 mL normal saline three times daily) to prevent them becoming blocked.
- If draining a pleural effusion, no more than 1.5L should be drained in the first hour. After one hour, the rest of the fluid may be drained slowly (e.g. a further 1.0L every 2–3h) as clinically indicated. Controlling the rate and volume of fluid drainage in this way is necessary to reduce the risk of causing re-expansion pulmonary oedema. Drainage of fluid should also be stopped immediately if the patient develops worsening cough, chest pain or breathlessness. These symptoms may indicate the presence of unexpandable lung, or predict an increased risk of developing re-expansion pulmonary oedema. Further medical assessment should occur before drainage of fluid is started again.
- If draining a pneumothorax, the chest tube should never be clamped as long as it continues to bubble, due to the risk of potentially causing a tension pneumothorax. A chest X-ray should be repeated 24h after chest tube insertion to assess for re-expansion of the lung.
- If the lung has re-expanded fully and the chest tube/underwater seal is no longer bubbling when the patient breathes and coughs forcefully, then this implies resolution of the pneumothorax with no ongoing air leak. It may therefore be appropriate to remove the chest tube in discussion with a chest physician or thoracic surgeon.
- If the lung has not re-expanded fully and/or the chest tube/underwater seal continues to bubble when the patient breathes and/or coughs forcefully, then this implies a continued air leak. In these circumstances it may be appropriate to apply low-pressure, high-volume suction (e.g. using a Vernon-Thompson pump) via the underwater seal at a level of 10–20cm H2O. This decision should be made by an experienced specialist clinician, that is, a chest physician or thoracic surgeon.
- When removing a chest drain, consider pre-medication with an opioid analgesic. Remove the dressings, then cut and remove the suture which has anchored the drain. The drain should be briskly withdrawn while the patient performs a Valsalva manoeuvre or during expiration. An assistant should apply a gauze swab to the drain site immediately after removal. Small-bore drains inserted using a Seldinger technique do not usually require a suture to close the incision at the insertion site and a simple sterile adhesive dressing will suffice. For large-bore drains inserted using blunt dissection, the two interrupted 3/0 sutures should be tied to close the incision before covering with a simple sterile adhesive dressing. These closing sutures should be removed after one week.
- The patient should have specialist follow-up with either a chest physician or thoracic surgeon, ideally within two weeks of discharge from hospital and with a repeat chest X-ray taken prior to the appointment.
Troubleshooting
Pain
- Pain around the site of chest drain insertion is common post-procedure and should be managed with regular analgesia (see above).
- If the pain is distant to the insertion site (e.g. referring to the ipsilateral shoulder) this may relate to the drain tip position. A chest X-ray should be reviewed and if appropriate (e.g. chest tube tip seen to lie against the mediastinum) the tube should be withdrawn slightly.
Fluid level in underwater seal does not move with breathing (not ‘swinging’)- Check for kinking of the tube, usually seen due to angulation of the ribs where the tube enters the chest, and if necessary release the dressings or withdraw the tube slightly.
- Small-bore chest tubes should be flushed regularly as part of routine aftercare (see above) to prevent blockage. Occasionally it may be appropriate to replace a small-bore chest tube that has become blocked with a larger tube, although this should be discussed with a specialist beforehand.
- The drain may be in the wrong position or dislodged – this can be confirmed on either chest X-ray or clinical assessment (e.g. drainage holes may be partially or wholly extrapleural), in which case the tube should be removed and replaced with another if clinically necessary.
Surgical emphysema- It is normal to have a small amount of localized subcutaneous air at the drain insertion site.
- Increasing surgical emphysema may indicate malposition of the tube with a drainage hole in a subcutaneous position; if so, a new tube must be inserted.
Non-resolving pneumothorax- This may present as failure of the lung to re-expand following chest tube insertion and/or continued bubbling from the chest tube/underwater seal. Assuming the chest tube is well positioned and patent, this indicates an ongoing air leak from the underlying lung parenchyma.
- Some cases may resolve with application of suction (see above), but all patients with a non-resolving pneumothorax should be discussed with an appropriate specialist (chest physician or thoracic surgeon).