Chest drain insertion

Indications include drainage of air (pneumothorax), fluid (effusion), blood (haemothorax), or pus (empyema) from the pleural space.

Insertion technique

1 Use 28Fr drain (or larger) for haemothorax or empyema; 20Fr will suffice for a pure pneumothorax. Seldinger-type drains with an integral guidewire are now available. The drain is usually inserted through the 5^th intercostal space in the mid-axillary line, first anaesthetising skin and pleura with 1% lidocaine. Ensure that air/fluid is aspirated.

2 Make a 1–1.5cm skin crease incision, create a track with gloved finger (or forceps) to separate muscle fi bres and open pleura.

3 Insert drain through open pleura without trochar.

4 Angle and insert drain to correct position (toward lung apex for pneumothorax and lung base for haemothorax/effusion). CT scan or ultrasound is useful for directing placement for small collections.

5 Connect to the underwater seal and keep bottle below level of heart.

6 Secure drain to chest wall by properly placed sutures.

7 Perform chest X-ray to ensure correct siting and lung reinflation.

8 Place on 5–10cmH2O (0.5–1.3kPa) negative pressure (low pressure wall suction) if lung has not fully expanded.

Subsequent management

• Do not clamp drains prior to removal or during transport of patient.

• Drains may be removed when lung has re-expanded and no air leak is present (no respiratory swing in fluid level nor air leak on coughing).

• Unless long-term ventilation is necessary, a drain inserted for a pneumothorax should usually be left in situ during IPPV.

• Remove drain at end-expiration. Cover hole with thick gauze and ElastoplastR; a purse-string suture is not usually necessary. Repeat chest X-ray if indicated by deteriorating clinical signs or blood gas analysis.

Complications

• Morbidity associated with chest drainage may be up to 10%.

• Puncture of an intercostal vessel may cause significant bleeding. Consider: (i) correcting any coagulopathy, (ii) placing deep tension sutures around drain, or (iii) removing drain, inserting a Foley catheter, inflating the balloon, and applying traction to tamponade bleeding vessel. If these measures fail, contact (thoracic) surgeon.

• Puncture of lung tissue may cause a bronchopleural fistula. Consider suction (up to 15–20cmH2O), pleurodesis, high frequency ventilation, a double-lumen endobronchial tube or surgery. Extubate if feasible.

• Perforation of major vessel (often fatal); clamp but do not remove drain, resuscitate, contact surgeon, consider double-lumen ET tube.

• Infection: take cultures; antibiotics (staphylococcal 9 anaerobic cover); consider removing/resiting drain.

• Local discomfort/pain from pleural irritation may impair cough. Consider simple analgesia, subcutaneous lidocaine, instilling local

anaesthetic, local or regional anaesthesia, etc.

• Drain dislodgement; if needed, replace/resite new drain, depending on cleanliness of site. Don’t advance old drain (infection risk).

• Lung entrapment/infarction: avoid milking drain in pneumothorax.