Site and position
Confirm the site for drain insertion
The marking of a site using thoracic ultrasound for subsequent remote aspiration or pleural drain insertion is not recommended.
Real time bedside ultrasound imaging, wherever available, should be used to select the appropriate site for pleural drain placement3,10.
A chest x-ray (CXR) must be available at the time of drain insertion unless the patient is in shock or has haemodynamic compromise from the tension pneumothorax. In this instance, an urgent CXR should be obtained after needle decompression.
A pleural drain should not be inserted without further image guidance if:
- the expected free air (in case pneumothorax) or fluid (in case of pleural effusion) cannot be aspirated with a needle at the time of inserting the local anaesthesia
- if the expected free air is not evident at the time of needle/cannula decompression of suspected tension pneumothorax.
Triangle of safety
Insertion of a pleural drain should be made within the triangle of safety (Figure 1) with the following potential exceptions:
- where breast tissue covers the triangle of safety and insertion would require the drain to pass through breast tissue
- when an ultrasound assessment has defined a better position for access to a pleural effusion
- the mid clavicular line is considered more appropriate for management of pneumothorax.
Figure 1: Triangle of Safety
Havelock T et al. Thorax 2010;65:i61-i76. Copyright © BMJ Publishing Group Ltd & British Thoracic Society
Position the patient
The preferred position for standard pleural drain insertion is on the bed, head and trunk elevated 30-45 degrees and slightly rotated, with the arm on the side of the lesion behind the patients head or on the hips to expose the lateral decubitus position. (Figure 2).
An alternative is for the patient to sit upright leaning over an adjacent table with a pillow under the arms or in the lateral posture.
Figure 2: Common patient positions for chest drain insertion
Havelock T et al. Thorax 2010;65:i61-i76. Copyright Â© BMJ Publishing Group Ltd & British Thoracic Society.