Breathing - Chest drain (24-32 Fr)

This procedure is performed using procedural sedation which is covered separately

Indications

Pneumothorax (traumatic)

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

Bullous disease

Prior pleural space surgical intervention

Overlying skin infection`

Alternatives

Needle thoracostomy or aspiration

Small intercostal catheter (Seldinger technique)

Thoracostomy

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Written consent

More complex non-emergency procedure with higher risk of complications

Potential complications

Pain

Haemorrhage

Neurovascular, visceral and pulmonary parenchymal damage

Tension pneumothorax

Re-expansion pulmonary oedema

Surgical emphysema

Failure (blockage, incorrect position, dislodgement)

Infection

Procedural hygiene

Standard precautions

Surgical aseptic non-touch technique

PPE: sterile gloves x 2, gown, surgical mask, eye protection, sterile ultrasound probe cover

Area

Resuscitation bay

Staff

Procedural clinician and assistant

Equipment

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

Gauze

Transparent dressing

Positioning

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)

or

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

Medication

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

Post-procedure care

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

Tips

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

Discussion

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.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Greater Sydney Area Helicopter Emergency Service

CareFlight

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

NSW Agency for Clinical Innovation. Consensus guideline: pleural drains in adults. Sydney: ACI; 2016. 55pp. Available from: https://www.aci.health.nsw.gov.au/resources/respiratory/pleural-drains/pleural-drains-in-adults.

Havelock T, Teoh R, Laws D, Gleeson F on behalf of the BTS Pleural Disease Guideline Group.

Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline. Thorax. 2010;65:i61-i76. Available from: https://thorax.bmj.com/content/65/Suppl_2/i61.

Sydney South Western Area Health Service. Intercostal Catheters (ICC) and Underwater Seal Drains (UWSD) Clinical Manual. Liverpool Hospital: SSWAHS; n.d.. MC_PD2011_422.

St George and Sutherland Hospitals and Health Services. Respiratory - Underwater Seal Drain (UWSD). Sydney: South Eastern Sydney Local Health District. 2011. Clinical Business Rule SGSHHS Clin145.

Butson B, Kwa P. Intercostal catheter insertion. Emerg Med Australas 2015 Feb;27(1):66-8. doi: 10.1111/1742-6723.12347. Epub 2015 Jan 8.

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges' clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

American College of Surgeons. Advanced trauma life support Student Course Manual. 9. American College of Surgeons; Chicago: 2012.

MacDuff A, Arnold A, Harvey J on behalf of the BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65:ii18:1131. Available from: https://thorax.bmj.com/content/65/Suppl_2/ii18.

Royal Perth Bentley Group. Occult pneumothorax (OPTX) patients presenting for surgery management: clinical guideline (RPH). Perth: Government of Western Australia Eastern Metropolitan Health Service; 2014. 4pp. Available from https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0008/426293/Trauma_Occult-Pneumothorax-OPTX-Patients-Presenting-for-Surgery-Management.pdf.

Huggins JT, Carr S, Woodward GA. Placement and management of thoracostomy tubes and catheters in adults and children. In: UpToDate [Internet]. Waltham (MA): UpToDate. 7 May 2020. Available from: https://www.uptodate.com/contents/placement-and-management-of-thoracostomy-tubes-and-catheters-in-adults-and-children.

Laan DV, Vu TD, Thiels CA, Pandian TK, Schiller HJ, Murad MH, Aho JM. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2016;47(4):797-804. doi:10.1016/j.injury.2015.11.045.

Fitzgerald M, Mackenzie CF, Marasco S, Hoyle R, Kossmann T. Pleural decompression and drainage during trauma reception and resuscitation. Injury. 2008;39(1):9-20. doi:10.1016/j.injury.2007.07.021.

Carter P, Conroy S, Blakeney J, Sood B. Identifying the site for intercostal catheter insertion in the emergency department: is clinical examination reliable?. Emerg Med Australas. 2014;26(5):450-454. doi:10.1111/1742-6723.12276.

Bing F, Fitzgerald M, Olaussen A, Finnegan P, O’Reilly G, Gocentas R, Stergiou H, Korin A, Marasco S, McGiffin D. Identifying a safe site for intercostal catheter insertion using the mid-arm point (MAP): Journal of Emergency Medicine, Trauma and Acute Care: 2017:1 http://dx.doi.org/10.5339/jemtac.2017.3.

Hernandez MC, El Khatib M, Prokop L, Zielinski MD, Aho JM. Complications in tube thoracostomy: Systematic review and meta-analysis. J Trauma Acute Care Surg. 2018;85(2):410-416. doi:10.1097/TA.0000000000001840.

Hernandez MC, Laan DV, Zimmerman SL, Naik ND, Schiller HJ, Aho JM. Tube thoracostomy: Increased angle of insertion is associated with complications. J Trauma Acute Care Surg. 2016;81(2):366-370. doi:10.1097/TA.0000000000001098.

Kim YW, Byun CS, Cha YS, Kim OH, Lee KH, Park IH. Differential outcome of fissure-positioned tube in closed thoracostomy for primary spontaneous pneumothorax. Am Surg. 2015;81(5):463-466.

Sanabria A, Valdivieso E, Gomez G, Echeverry G. Prophylactic antibiotics in chest trauma: a meta-analysis of high-quality studies. World J Surg. 2006;30(10):1843-1847. doi:10.1007/s00268-005-0672-y.

Luchette FA, Barrie PS, Oswanski MF, et al. Practice Management Guidelines for Prophylactic Antibiotic Use in Tube Thoracostomy for Traumatic Hemopneumothorax: the EAST Practice Management Guidelines Work Group. Eastern Association for Trauma. J Trauma. 2000;48(4):753-757. doi:10.1097/00005373-200004000-00027.

Wraight WM, Tweedie DJ, Parkin IG. Neurovascular anatomy and variation in the fourth, fifth, and sixth intercostal spaces in the mid-axillary line: a cadaveric study in respect of chest drain insertion. Clin Anat. 2005;18(5):346-349. doi:10.1002/ca.20133.

© Agency for Clinical Innovation 2021

Feedback