Breathing - Chest drain (24-32 Fr)
This procedure is performed using procedural sedation which is covered separately
Haemothorax visible on chest X-ray (traumatic)
Contraindications (absolute in bold)
Coagulopathy or thrombocytopenia (APTT >50 seconds, platelets <50, INR >1.5 or NOAC use in last 24 hours)
Loculated effusion or pleural adhesions
Prior pleural space surgical intervention
Overlying skin infection`
Needle thoracostomy or aspiration
Small intercostal catheter (Seldinger technique)
Consent is not required if the patient lacks capacity or is unable to consent
Brief verbal discussion is recommended if the situation allows
More complex non-emergency procedure with higher risk of complications
Neurovascular, visceral and pulmonary parenchymal damage
Re-expansion pulmonary oedema
Failure (blockage, incorrect position, dislodgement)
Surgical aseptic non-touch technique
PPE: sterile gloves x 2, gown, surgical mask, eye protection, sterile ultrasound probe cover
Procedural clinician and assistant
Syringe and needle for local anaesthetic
Chest drain kit (scalpel, Harrison Cripps curved forceps, 24-32Fr chest tube)
Clamp (Howard Kelly or equivalent)
Underwater sealed drain with tubing and 500ml sterile water
Suture (2.0) and suture set
On the bed with head elevated to 45 degrees
Arm on the side of the lesion behind the patient’s head (abducted and externally rotated)
Supine with arm out to the side on side of lesion (crucifix position)
Locate safe triangle: lateral to pectoralis major, medial to latissimus dorsi, fourth or fifth intercostal space, anterior to mid-axillary line
With the arm by the side, mark the anterior mid-arm point from shoulder tip to antecubital fossa (preferred), or
Place your open hand in the axilla and mark the edge of the hand between the anterior and mid-axillary line, or
Palpate the second intercostal space at the sternal angle, move down two spaces and palpate space around to the axilla
It is common for incisions to be too low in the chest, with risk of visceral injury
Place an intercostal space higher in pregnant patients due to increased elevated diaphragm
Supplemental oxygen throughout procedure
20ml lignocaine 1% with adrenaline (1:100,000)
Cephazolin IV 2g (traumatic drains only)
Procedural sedation covered separately, or consider:
Ketamine IV 10-20mg (pain relief pre-procedure adjusted to co-morbid status)
Morphine IV 5-10mg (opioid pain relief pre-procedure adjusted to co-morbid status)
Midazolam IV 1-2mg (anxiolytic pre-procedure adjusted to co-morbid status)
Sequence (large intercostal catheter)
Anaesthetise skin and proceed over the top of rib to anaesthetises soft tissue, muscle, periosteum
Discard trocar and insert curved forceps through distal side hole of chest tube to aid insertion
Incise 2.5cm just above and parallel with the upper border of rib at insertion site (avoiding neurovascular bundle)
Blunt dissection through soft tissue with curved clamp then close clamp and hold firmly 2-3cm from tip
Push clamp through muscle to enter the pleural space with ‘give’ or ‘gush’ of air or blood
Open the clamp 1cm and pull it out open to create a larger tract
Palpate through thoracotomy with little finger, opening tract and confirming position in thoracic cavity (optional)
Perform a finger sweep of pleura around thoracostomy excluding pleural adhesions (optional)
Insert catheter through incision and direct tip superiorly and posteriorly
Inserts until all eyelets within pleural cavity (approximately 6cm + subcutaneous tissue depth)
Clamp tube prior to underwater seal drain attachment if large volume of blood
Suture the skin closed either side of the tube with 2-0 non-absorbable interrupted sutures
Place a ‘stay’ suture close to the skin incision at the site of insertion
The ends of this suture are left long, then wrapped tightly around the chest tube and tied securely
A split gauze dressing is placed around the catheter
Dress with water-permeable transparent dressing so the insertion site is visible
A trauma drain should be connected to a drainage system that contains a valve mechanism to prevent fluid or air from entering the pleural cavity. This is generally an underwater sealed drain.
Sequence (underwater sealed drain)
Attach drain to underwater sealed drain without suction (air vent open)
Ensuring sealed drain rod 2cm underwater and not touching bottom of bottle
Unclamp catheter and identify ‘swinging’ of underwater sealed drain
Secure connections between intercostal catheter and drainage tubing with non-stretch tape
Taping should be applied to allow the connection points to be clearly visible
The use of a mesentery or omentum tag dressing allows the tube to lie off the chest wall reducing tension
Cephazolin IV 2g (traumatic drains only)
Check function of underwater seal (output, oscillation, bubbling)
Confirm position with chest X-ray
Drain observations (output, oscillation, leaks) 30 minutely until stable then hourly for four hours
Patient observations 30 minutely until stable then hourly for four hours (or as directed by other injuries)
Analgesia (oral, or IV considering PCA) to allow deep breathing and coughing
Document insertion with depth, complications, fixation and function
Palpate rib borders prior to incision, orienting yourself to the anatomy (ribs angle inferiorly as you move anterior)
Locating landmarks by mid-arm point is evidence-based and our recommended method
Skin markings made at the mid-arm point move slightly superior with abduction, still incise at the marking
Chest tubes >32Fr demonstrate diminished benefit with increased discomfort
Trocars are associated with organ injury and should not be used
Purse string suture leaves worse scars than simple interrupted sutures
Antibiotics reduce the incidence of pneumonia and empyema after chest drain in trauma
Antibiotics are not required for non-traumatic chest drains
Large catheters should not be clamped due to the risk of air leak causing tension pneumothorax
Intercostal catheters should not be clamped in massive haemothorax, tamponade is not possible
There is no evidence to recommend suction on initial placement of a chest drain in the emergency department
Without suction the underwater sealed drain air vent must be left open to avoid tension pneumothorax
The underwater sealed drain should remain below the level of the chest
Keep a clamp near to chest tube in case of disconnection
The triangle of safety is the key landmark. A significant proportion of chest drains and thoracostomies are placed outside of this area due to procedural error. Of the various methods for determining correct position of placement, rapid measurement of mid-arm point appears the most practical and accurate and is our preferred method.
Making an oblique track slightly upwards (<45 degrees) and through the intercostal space reduces the risk of chest tube placement in the lung fissure, which is associated with increased failure requiring replacement. We advocate entering the rib space low, to enable an oblique path to be formed.
The finger sweep is a useful part of chest tube placement, confirming position in the thoracic cavity, maintaining the track and excluding lung and pleural adhesions (which increase the risk of parenchymal injury and fissure placement). The finger sweep carries a risk of sharps injury to the proceduralist if broken ribs are present. We advocate a cautious finger sweep using double gloves for increased sharps protection. Easily disrupted adhesion should be lysed with the finger. Firm adhesions require an alternative site of tube placement. The finger sweep should be omitted in trauma patients suspected to be at high risk of blood-borne pathogens (hep B, C or HIV). The proceduralist is required to make this judgement at the bedside and is it acceptable for providers to choose to always omit a finger sweep in trauma due to risk of sharps injury.
This guideline has been reviewed and approved by the following expert groups:
Emergency Care Institute
Greater Sydney Area Helicopter Emergency Service
Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.
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