Breathing - Chest drain (8-20 Fr)

Indications

Pneumothorax

Pleural effusion

Empyema (20Fr)

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 decompression or aspiration

Large intercostal catheter (blunt dissection)

Open 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 and gown, surgical mask, eye protection, sterile ultrasound probe cover

Area

Monitored bed with adequate working space

Staff

Procedural clinician and assistant

Equipment

Ultrasound machine

Syringe and needle (local anaesthetic)

Intercostal catheter kit (including scalpel)

Underwater sealed drain with tubing with 500ml sterile water or Heimlich valve

Suture kit and non-absorbable 2-0 suture

Specimen jar and syringe (for samples)

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)

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 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

10ml lignocaine 1% with adrenaline (1:100,000)

Consider procedural sedation (covered separately), or

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 (small intercostal catheter)

Inject lignocaine in lower third of subcostal space to anaesthetise skin and soft tissue, muscle, periosteum

Place larger needle and syringe for guidewire along the same tract, aspirating until you withdraw pleural fluid

Remove syringe and thread over half of the guidewire through needle, removing needle after wire placement

Use scalpel to enlarge tract in skin next to the guidewire

Thread dilator over wire into the pleural space firmly holding guidewire (may require some force)

Insert dilator to ultrasound estimated chest wall distance, then remove dilator

Pass the catheter over the guidewire into the pleural cavity firmly holding guidewire

Ensure all drainage holes of the catheter are completely within the pleural cavity (10cm+ soft tissue depth)

Remove the guidewire, take samples and close the stopcock to ensure that no air enters the pleural cavity

Place a ‘stay’ suture to close the skin incision at the site of insertion (not required for small bore drains)

Leave the ends of this suture long, then wrap tightly around the chest tube and tie securely

Place a split gauze dressing around the catheter (to protect skin from pressure)

Dress with water-permeable transparent dressing so the insertion site is visible

A pleural 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 or Heimlich valve (pneumothorax).

Sequence (underwater sealed drain)

Attach drain to underwater sealed drain without suction (air vent open)

Ensuring sealed drain rod is 2cm underwater and not touching bottom of bottle

Open three-way tap to neutral position 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 point/s to be clearly visible

The use of a mesentery or omentum tag dressing allows the tube to lie off the chest wall, reducing tension

Sequence (Heimlich valve)

Connect the blue end of the valve to the ICC and the clear end away from the patient (arrow away from patient)

It may be necessary to cut the bevelled end of the ICC tube using sterile scissors to connect to the valve

The valve should function immediately, observe for movement of the rubber tubing inside the valve

A flutter noise may be heard, and airflow felt from the exposed end during expiration

Secure the chest drain valve to the patient’s body to prevent dislodgment

Post-procedure care

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)

Drain maximum of 1500ml at once to reduce incidence of re-expansion pulmonary oedema

Turn off drain for 30 minutes and if patient observations show no deterioration, continue to drain

Analgesia (oral, or IV considering PCA) to allow deep breathing and coughing

Document insertion with depth, complications, fixation and function

Tips

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 insert at the marking

Antibiotics are not required for non-traumatic chest drains

Intercostal catheters should not be clamped after initial drainage (risk of air leak causing tension pneumothorax)

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

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.

Re-expansion pulmonary oedema can occur with re-expansion of a collapsed lung after drainage. Risk is higher with lung collapse greater than three days. Re-expansion pulmonary oedema is related to the generation of high negative intrathoracic pressures after draining. The risk is reduced by pausing drainage of large effusions after 1500ml of drainage, or if pain is experienced during drainage (which may represent high negative intrathoracic pressures).

Peer review

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

Emergency Care Institute

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

References

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