chest drain insertion and its management

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3/19/12

Mr.P.JANA

BACKGROUND
In current hospital practice chest drains are used in many different clinical settings and doctors in most specialties need to be capable of their safe insertion. All personnel involved with insertion of chest drains should be adequately trained and supervised.

chest drain for tension pneumothorax following trauma has been well described by the Advanced Trauma and Life Support (ATLS) recommendations in their instructors manual

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Indications for chest drain insertion

Emergency Pneumothorax In all patients on mechanical ventilation When pneumothorax is large In a clinically unstable patient For tension pneumothorax after needle decompression
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PRE-DRAINAGE RISK ASSESSMENT

Risk of haemorrhage: where possible, any coagulopathy or platelet defect should be corrected prior to chest drain insertion

The differential diagnosis between a pneumothorax and bullous disease requires careful radiological assessment. it is important to differentiate between the presence of collapse and a pleural effusion when the chest radiograph shows a unilateral whiteout

Lung densely adherent to the chest wall throughout the hemithorax is an absolute contraindication to chest drain insertion.
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EQUIPMENT

Sterile gloves and gown

Skin antiseptic solution, e.g. iodine or chlorhexidine in alcohol Sterile drapes Gauze swabs A selection of syringes and needles (2125gauge) Local anaesthetic, e.g. lignocaine 3/19/12 (lidocaine)1% or 2%

Equipment required for insertion of chest drains.

Laws D et al. Thorax 2003;58:ii53-ii59

Copyright BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.

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CONSENT AND PREMEDICATION

Prior to commencing chest tube insertion the procedure should be explained fully to the patient and consent recorded in accordance with national guidelines. Unless there are contraindications to its use, premedication (benzodiazepine or opioid) should be given to reduce patient distress.
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PATIENT POSITION

The preferred position for drain insertion is on the bed,slightly rotated, with the arm on the side of the lesion behind the patients head to expose the axillary area. An alternative is for the patient to sit upright leaning over an adjacent table with a pillow or in the lateral decubitus position.

The area for insertion is approximated by the fourth to fifth intercostal space in the anterior axillaryline at the horizontal level of the nipple. This area corresponds to the anterior border of the latissimus dorsi, the lateral 3/19/12 border of the pectoralis major muscle,

DRAIN INSERTION SITE

The most common position for chest tube insertion is in the mid axillary line, through the safe triangle. This position minimises risk to underlying structures such as the internal mammary artery and avoids damage to muscle and breast tissue resulting in unsightly scarring

For apical pneumothoraces the second intercostal space in the mid clavicular line is sometimes chosen but is not recommended routinely as it may be uncomfortable for the patient and may leave an unsightly scar.
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Safe triangle

You can isolate this area by palpating the ipsilateral clavicle, then working downward along the ribcage, counting down the rib spaces. Once the fourth to fifth intercostal space is felt, move your hand laterally toward the anterior axillary line.

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CONFIRMING SITE OF DRAIN INSERTION

A chest tube should not be inserted without further

image guidance if free air or fluid cannot be aspirated with a needle at the time of anesthesia. Imaging should be used to select the appropriate site for chest tube placement. A chest radiograph must be available at the time of 3/19/12

DRAIN SIZE
Small bore drains are recommended as they are more comfortable than larger bore tubes but there is no evidence that either is therapeutically superior. Large bore drains are recommended for drainage of acute haemothorax to monitor further blood loss. The use of large bore drains has previously been recommended as it was felt that there was an increase in the frequency of drain blockage, particularly by thick malignant or infected fluid. The majority of physicians now use smaller catheters (1014 French (F)) and studies have shown that these are often as effective as larger bore tubes and are more comfortable and better tolerated by the patient In the case of acute haemothorax, however, large bore tubes (2830 F minimum) continue to be recommended for their dual role of drainage of the thoracic cavity and assessment of 3/19/12 continuing blood loss

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ASEPTIC TECHNIQUE
Aseptic technique should be employed during catheter insertion. Prophylactic antibiotics should be given in trauma cases.

As a chest drain may potentially be in place for a number of days, aseptic technique is essential to avoid wound site infection or secondary empyema. Although this is uncommon.

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Use full barrier precautions (wash your hands and wear a sterile gown and gloves, protective eyewear, and a face mask).

Create a large, sterile field on the patients skin, using sterile gauze and 2% chlorhexidine solution. Drape the patient, exposing only the marked area. Using a 1% or 2% lidocaine solution and a 25-gauge needle, create a wheal of anesthetic in the cutaneous tissue at the marked spot. 3/19/12

Draw up more lidocaine solution in a 20-ml syringe. Using a 21gauge needle, anesthetize the deeper subcutaneo 3/19/12 us tissues

Using continued negative suction as the needle advances, with the needle beveled on top of the rib, confirm entry into the pleural space when a flash of pleural fluid enters the chamber of the syringe.

If a pneumothorax is being evacuated, the syringe may only fill with air. Stop advancing the needle and inject any remaining lidocaine to fully anesthetize the parietal pleura. Withdraw the needle and syringe completely

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An incision 1.5 to 2.0 cm in length should be made parallel to the rib. Use the Kelly clamp or artery forceps to cut through the subcutaneous layers and intercostal muscles

The path should traverse diagonally up toward the next superior intercostal space. Once you have dissected through the subcutaneous tissues, find the surface of the rib lying below this space with the dissecting instrument. Then slide the instrument straight 3/19/12 up, until you find the top edge of the rib. Use this to

Once you reach the parietal pleura, gently push the dissecting instrument through it. You may also digitally penetrate the pleura to avoid puncturing adjacent lung tissue using your index finger to explore the tract. Once your finger enters the pleura, withdraw the Kelly clamp. Use your finger to palpate within the pleural layer and ensure that the lung falls away from the pleura. If it does not, this may 3/19/12 indicate the presence of

Once the distal tip of the tube has passed through the incision, unclamp the Kelly clamps or forceps and advance the tube manually.

Aim the tube apically for evacuation of a pneumothorax and basally for evacuation of any fluid.

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Securing the tube

Mattress or interrupted sutures should be used on both sides of the incision to close the ends. Use the loose ends of the sutures to wrap around the tube and tie them off, anchoring the tube to the chest wall. Tape the tube to the side of the patient and wrap a petroleum-based gauze dressing around the tube. Cover this gauze with several pieces of regular sterile gauze, and 3/19/12 the site with secure multiple pressure

Connect the distal end of the chest tube to a sterile pleural drainage system,Once the tube is connected, unclamp the distal end; if there is a pneumothorax, bubbling may be seen.

If there is a large pleural effusion, it will begin collecting. Do not re clamp the chest tube once released, unless the pleural drainage system is being changed. Reclamping the tube may lead to the redevelopment of a pneumothorax and may create a tension 3/19/12 pneumothorax

Radiogra ph Confirmat Once you have ion

secured the chest tube, obtain an anteriorposterior chest radiograph to confirm placement, 3/19/12

complications
The most important complications associated with chesttube insertion include bleeding and hemothorax due to intercostal artery perforation

perforation of visceral organs (lung, heart, diaphragm, or intraabdominal organs), perforation of major vascular structures such as the aorta or subclavian vessels, intercostal neuralgia due to trauma of neurovascular bundles, subcutaneous emphysema, reexpansion pulmonary edema, infection of the drainage site, pneumonia, and empyema.

There may be technical problems such as intermittent tube blockage from clotted blood, pus, or debris, or incorrect positioning of the tube, which causes ineffective drainage.
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MANAGEMENT OF DRAINAGE SYSTEM

A bubbling chest tube should never be clamped. Drainage of a large pleural effusion should be controlled to prevent the potential complication of re-expansion pulmonary oedema. In cases of pneumothorax, clamping of the chest tube should usually be avoided. If a chest tube for pneumothorax is clamped, this should be under the supervision of a respiratory physician or thoracic surgeon, the patient should be managed in a specialist ward with experienced nursing staff, and the patient should not leave the ward environment.

If a patient with a clamped drain becomes breathless or 3/19/12 develops subcutaneous emphysema, the drain must be

Closed system drainage

All chest tubes should be connected to a single flow

drainage system e.g. underwater seal bottle or flutter valve. Use of a flutter valve system allows earlier mobilisation and the potential for earlier discharge of patients with chest drains.

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Suction When chest drain suction is required, a high volume/low pressure system should be used. When suction is required, the patient must be nursed by appropriately trained staff Ward instruction Patients with chest tubes should be managed on specialist wards by staff who are trained in chest drain management. A chest radiograph should be performed after insertion of a chest drain.
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Timing of Chest-Tube Removal

The timing of chest-tube removal depends on the indication for insertion of the chest tube. For a pneumothorax, bubbling must have ceased and the lung must be fully expanded on chest radiograph before the tube can be removed. If suction is being used to evacuate a pneumothorax, most surgeons will use a trial of underwater seal to ensure that the lung stays expanded without suction. On the basis of available data, most surgeons would obtain a chest radiograph 12 to 24 hours after the last observed evidence of an air leak to ensure that the lung stays fully expanded before tube removal.

In cases of pneumothorax, there is no evidence that clamping

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a chest drain at the time of its removal is beneficial.

Technique of Tube Removal

When preparing to remove the tube, two people may need to participate so that one can instruct the spontaneously breathing patient and pull the tube while the other can quickly occlude the insertion site. Cut the skin sutures, using sterile technique. Have additional strong nylon or silk sutures ready in case additional sutures are required to seal the hole. Sterile petroleum-based and regular gauze should also be ready.

Instruct the spontaneously breathing patient to perform a forced Valsalva maneuver or to inhale to total lung capacity after a full exhalation. If the patient is being fully mechanically ventilated, removal should be timed to end-expiration. One operator can pull the tube out while the other quickly occludes the site with gauze, adds additional sutures to close the opening, and secures the site with a pressure dressing.
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A chest radiograph 12 to 24 hours after removal is recommended,This should be done sooner if there is clinical suspicion of a residual air leak or a new pneumothorax

Caution must be exercised when removing a chest tube from any patient receiving mechanical ventilation. This is of particular importance for patients with high oxygen or positive end-expiratory pressure requirements, chronic lung disease, or any additional reasons for persistent air leaks or recurrent pneumothoraces.

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