Chest drain insertion is associated with significant morbidity and mortality, and careful consideration should be given to the precise indication for drainage. Out-of-hours drain insertion should be avoided, unless an emergency. Ultrasound guidance should be used for all drains inserted for fluid but is not required for pneumothorax.
• Tension pneumothorax (following needle decompression)
• Symptomatic pneumothorax with failed aspiration or underlying lung disease or in ventilated patients
• Complicated parapneumonic effusion and empyema
• Malignant pleural effusion for symptomatic relief and/or pleurodesis
• Traumatic haemopneumothorax
• Following thoracic surgery
• Rarely, for symptomatic effusions of other aetiology.
• Inexperienced operator
• Lung adherent to chest wall
• Bleeding tendency (a relative contraindication; routine measurement of platelet count and clotting in the absence of risk factors is not required). For anticoagulated patients, do not drain until INR <1.5, unless life-threatening emergency
• Post-pneumonectomy (not a contraindication, but first discuss with cardiothoracic surgical team).
Types of chest drain
drains are inserted by sliding the drain into the pleural cavity over a guidewire. Whilst being the most frequently used, they still require experience and care to be inserted safely and comfortably. Sizes up to 36F are available. Blunt dissection drains (e.g. Portex drains) require gentle dissection of subcutaneous tissue and muscles to gain entry to the pleural space. Drains are then inserted, often over a flexible plastic introducer, into the pleural space. Available in sizes up to 36F. Traditional trocar drains should no longer be used, being associated with significant potential complications and even death. These drains consist of a flexible plastic tube surrounding a metal rod with a blunt tip.
Small (10–14F) drains are more comfortable and should be the default choice for the majority of situations. Large-bore chest drains (24–36F) are frequently uncomfortable and only rarely required, e.g. 2° pneumothorax with large air leak and/or surgical emphysema, acute haemothorax, and post-operatively.
• Pain—insertion should not be painful with good local anaesthetic technique. Subsequent pain common, and opiate analgesia may be required
• Inadequate drain position—may require withdrawal or insertion of new drain
• Surgical emphysema (in pneumothorax)—air leaks into subcutaneous tissues. May occur if tube blocked or positioned with holes subcutaneously, or with very large air leaks. See p. [link] for management
• Infection—iatrogenic pleural infection rate up to 2%, perhaps higher in trauma patients; wound infection
• Organ damage (e.g. lung, liver, spleen, heart, great vessels, stomach). Intrapulmonary placement results in significant continuous bubbling and bleeding; this may occur in up to 6% of all drain insertions. Drainage of GI contents suggests bowel perforation (or oesophageal rupture as the cause of the effusion)
• Haemorrhage into drain—bloody pleural fluid is a common finding (e.g. in malignant effusions), but unexpected large-volume drainage of frank blood suggests damage to organs or intercostal vessels. Clamp the drain, and leave it in place. Urgent imaging (± interventional radiology) and surgical referral
• Re-expansion pulmonary oedema (see p. [link])
• Vasovagal reaction
• Sudden death due to vagus nerve irritation reported.
Havelock T et al. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(suppl. 2):ii61–76.Find this resource:
New England Journal of Medicine. Videos in clinical medicine. http://www.nejm.org/multimedia/medical-videos.
An assistant is required. Use a dedicated procedure room when possible.
• Discuss procedure with patient, and obtain written consent (unless emergency situation)
• Insert IV cannula
• Consider giving analgesia. Conscious sedation (e.g. using midazolam) is rarely required and should include O2 saturation monitoring; be cautious in patients with severe underlying lung disease or respiratory failure; see p. [link]
• Position patient either in lateral decubitus position or lying head elevated at 30°, with insertion side of trunk rotated about 45° upwards and arm on insertion side behind their head. Alternative position is with patient sitting forward, leaning over a table
• Double-check correct side from chest examination and CXR
• Choose insertion site: ideally within ‘safe triangle’ (see Fig. 64.1), which avoids major vessels and muscles (boundaries: anteriorly, anterior axillary line, and border of pectoralis major; posteriorly, posterior axillary line and border of latissimus dorsi; inferiorly, horizontal to level of nipple in man or fifth intercostal space in woman). Avoid posterior approaches close to spine, as intercostal artery drops medially to lie in mid-intercostal space. Ultrasound guidance should always be used for fluid—either site marking immediately prior to drain insertion or real-time needle visualization using sterile ultrasound sheath and gel.
• Sterile skin preparation. Wear sterile gloves and gown
• Infiltrate skin, intercostal muscle, and parietal pleura with 10–20mL of 1% lidocaine (maximum 3mg/kg). Aim just above the upper border of the appropriate rib, avoiding the neurovascular bundle that runs below each rib. The subcutaneous fat lacks pain receptors and does not require anaesthetic. The parietal pleura, however, is extremely sensitive; use the full volume of lidocaine
• Verify that the site is correct by aspirating pleural fluid or air. Occasionally, a green (21G) needle may be too short in obese patients, and a longer needle is required. If unable to aspirate fluid or air, do not proceed with drain insertion; consider CT-guided drainage
• Whilst waiting for anaesthetic to work, prepare drain and connections. Assistant should prepare underwater seal
• Insert drain:
• Seldinger drains Gently insert the introducer needle, and check that air or fluid can be easily aspirated with a syringe. Remove syringe. Smoothly insert the guidewire through the introducer needle. Remove introducer needle, taking care not to let go of the guidewire at any time. Make a small skin incision ~5mm. Slide plastic dilator around guidewire to enlarge the entry track. Avoid excessive force; dilator should not be inserted >1cm into the pleural space. Remove the dilator, and slide the drain into the pleural cavity over the guidewire. Remove the wire when the drain is within the chest
• Blunt dissection drains Small (1cm) skin incision parallel to rib. Insert horizontal mattress suture across incision to facilitate later closure. Dissect intercostal muscles with blunt forceps (e.g. Spencer–Wells)—the fibres can be teased apart by opening and then removing the forceps; do not close forceps within the chest; this may damage underlying structures. This blunt dissection may take some time. Insert drain (facilitated by introducer) just into the pleural space smoothly and gently—there should not be any significant resistance. Never apply force when inserting a chest drain. Once the pleural space has been entered, insert the drain further while removing the introducer. An alternative approach is to remove any introducer and grip the end of the chest tube with blunt forceps, and use these to guide the tube into the chest. Aim towards the apex for a pneumothorax, and the lung base for a pleural effusion. (Note—in emergencies or in patients with extreme obesity or subcutaneous emphysema, it may be appropriate to make a larger initial incision and insert an index finger to assist the drain track)
• Connect the drain to underwater seal bottle via a three-way tap and tubing. If the drain is correctly positioned in the pleural space, it should swing with respiration and drain air or fluid
• Suture and tape the drain in place on the chest wall
• Ensure adequate analgesia
• Warn the patient not to disconnect the tubing or lift the underwater bottle above the level of the insertion site on the chest; supply a ‘chest drain information leaflet’
• Obtain CXR to check position. The ‘ideal’ tube position (apex for pneumothorax, base for effusion) is not necessary for effective drainage, so do not reposition functioning drains on this basis. CT may be useful in confirming drain position in certain circumstances. Drains are often positioned in fissures, but, in most cases, this does not affect their functioning
• Small drains may need regular flush to ensure patency; prescribe 10mL normal saline flush to drain tds.
• Patients should ideally be managed on a specialist ward by experienced nursing staff. ‘Chest drain observations’ should be charted regularly, including swinging, bubbling, and volume of fluid output
• If drain water level does not swing with respiration, the drain is kinked (check underneath dressing as tube enters skin), blocked, clamped, or incorrectly positioned (drainage holes not in pleural space; check CXR). Occluded drains may sometimes be unblocked by a 30mL saline flush. Non-functioning drains should be removed (risk of introducing infection)
• Suction is sometimes used to encourage drainage, although there is a lack of evidence regarding its use. Consider in cases of pneumothorax with persistent air leak or following chemical pleurodesis. Suction should be high volume/low pressure, typically starting at a level of 5cmH2O and increasing to 10–20cmH2O. It may be painful and not tolerated by the patient.
To clamp or not to clamp?
clamp a bubbling chest drain (risk of tension pneumothorax). Clamping may be considered in two situations:
• To control the rate of drainage of a large pleural effusion. Rapid drainage of large volumes may result in re-expansion pulmonary oedema; clamping, e.g. for 1h after draining 1.5L, may prevent this
• To avoid inappropriate drain removal in cases of pneumothorax with a slow air leak, when bubbling appears to have ceased. Clamping a drain for several hours, followed by repeat CXR, in such situations may detect very slow or intermittent air leaks. This is controversial, however, and should only ever be considered on a specialist ward with experienced nursing staff. If the patient becomes breathless, the drain should be immediately unclamped.
Predominantly used for domiciliary drainage of recurring malignant effusions, with drainage by patients, family members, or district nurses.
• Current BTS guidance for malignant pleural effusions advocates IPC use for completely trapped lung (pleurodesis unlikely to be successful) and for recurrent effusions post-pleurodesis
• Use as 1° therapy more controversial, although recent randomized trial (vs talc pleurodesis) demonstrates reduced hospital inpatient time (by 3.5 days) and decreased need for further pleural procedures, with similar improvements in dyspnoea and QoL. However, increased risk of pleural and soft tissue infection, symptomatic loculation, and catheter blockage.
• IPCs are 15.5/16F fenestrated silicone drains with a tunnelled subcutaneous portion and polyester cuff to prevent accidental removal and bacterial ingress
• Inserted as a day case. Essential to consider optimum site for insertion, particularly for women (discomfort with bra straps). Using ultrasound, the Seldinger technique is used to insert pleural portion of drain, and blunt dissection is used to insert subcutaneous portion
• Adapter enables connection of IPC valve to conventional drainage bottles when in hospital. If adapter not available and urgent pleural fluid sampling required (e.g. for possible pleural infection), a large-bore IV cannula without needle can be used to aspirate fluid aseptically through the valve mechanism
• To drain at home, a pre-vacuumed 500 or 1, 000mL drainage bottle is aseptically connected to the IPC valve, usually 1–3 times/week (dependent on rate of fluid accumulation)
• Spontaneous pleurodesis occurs in 30–70% (dependent on malignancy type and whether lung is trapped). Catheters can be removed if minimal drainage for 3–4 weeks, provided not blocked and minimal fluid remaining on imaging
• Essential for patients to have adequate education and access to support in case of complications
• Not considered a contraindication to chemotherapy.
Davies HE et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion. JAMA 2012;307(22):2383–9.Find this resource:
Fysh ETH et al. Indwelling pleural catheters reduce inpatient days over pleurodesis for malignant pleural effusion. Chest 2012;142(2):394–400.Find this resource: