Comprehensive guide to chest drain insertion procedure and management
Indications
Tension pneumothorax
Open pneumothorax
Simple pneumothorax in some cases
Haemothorax
Severe surgical emphysema constricting respiration
Patients with penetrating thoracic trauma who are intubated or about to be intubated
Patients at risk of pneumothorax who are about to undergo air transport
Contraindications
Absolute
The need for resuscitative thoracotomy
Relative
Coagulopathy
Overlying skin infection
Clinical Anatomy
SAFE TRIANGLE DIAGRAM
Safe Triangle for chest drain insertion (Image by Brantigan, Otto C. [Public domain], via Wikimedia Commons)
Safe Triangle Boundaries
Anterior border: Lateral border of pectoralis major muscle
Posterior border: Anterior border of latissimus dorsi muscle
Inferior border: Horizontal line superior to nipple
Superior border: Apex below axilla
Procedure
Preparation
Gather supplies, sterile drapes, and antiseptic, tube thoracostomy kit (tray) and appropriately sized chest tube (28-32 Fr)
Prepare the underwater seal and collection device
Position the patient with the ipsilateral arm extended overhead and flexed at the elbow (unless precluded by other injuries)
Use an assistant to maintain the arm in this position
Widely prep and drape the lateral chest wall, include the nipple, in the operative field
Site Identification
Identify the site for insertion of the chest tube in the 5th intercostal space (ICS)
This site corresponds to the level of the nipple or inframammary fold
The insertion site should be between the anterior and midaxillary lines
Confirm that defined site is well within the safe triangle
Avoid placement directly over an area of infected soft tissue (e.g., cellulitis, skin abscess)
Consider 4th ICS in patients who are pregnant, have massive ascites or large haemoperitoneum where the increased intra-abdominal contents can elevate the diaphragm
Anesthesia and Measurement
Inject the site liberally with local anaesthesia to include the skin, subcutaneous tissue, rib periosteum, and pleura
While the local anaesthetic takes effect, use the thoracostomy tube to measure the depth of insertion
Premeasure the estimated depth of chest tube by placing the tip near the clavicle with a gentle curve of chest tube toward incision
Evaluate the marking on the chest tube that correlates to incision, ensuring the sentinel hole is in the pleural space
Often the chest tube markings will be at 10–14 at the skin, depending on the amount of subcutaneous tissue (e.g., obese patients)
Insertion Technique
Make a 2- to 3-cm incision parallel to the ribs at the predetermined site
Bluntly dissect through the subcutaneous tissues just above the rib (to protect neurovascular bundle)
Puncture the parietal pleura with the tip of the clamp while holding the instrument near the tip to prevent sudden deep insertion of the instrument and injury to underlying structures
Advance the clamp over the rib and spread to widen the pleural opening
Take care not to bury the clamp in the thoracic cavity, as spreading will be ineffective
Air or fluid will be evacuated
With a sterile gloved finger, perform a finger sweep to clear any adhesions and clots (i.e., perform a finger thoracostomy)
Tube Placement and Confirmation
Place a clamp on the distal end of the tube
Using either another clamp at the proximal end of the thoracostomy tube or a finger as a guide, advance the tube into the pleural space to the desired depth
Look and listen for air movement and bloody drainage
"Fogging" of the chest tube with expiration may also indicate tube is in the pleural space
Remove the distal clamp and connect the tube thoracostomy to an underwater seal apparatus with a collection chamber
Zip ties can be used to secure the connection between the thoracostomy tube and the underwater seal apparatus
Secure the tube to the skin with heavy, nonabsorbable suture
Apply a sterile dressing and secure it with wide tape
Obtain a chest x-ray
Reassess the patient
Complications
Persistent or Recurrent Issues
Improper placement of tube
Tube dislodgement
Kinking/compression of tube
Obstruction of tube with blood, tissue or fluid
Large primary air leak (air leak rate greater than air evacuation by tube)
Disconnection from underwater-seal apparatus
Bleeding
Local bleeding
Haemothorax (lung or intercostal artery injury)
Haemoperitoneum (liver or spleen injury)
Organ Injury
Stomach, colon or diaphragm
Lung
Liver or spleen
Infection
Local infection
Empyema
Other Complications
Pain at site
False passage
Subcutaneous emphysema
Re-expansion pulmonary oedema
Intercostal or long thoracic nerve injury
Anaphylactic or allergic reaction to surgical preparation or anaesthesia