Practical Procedures Tube thoracostomy: how to insert a chest drain

Introduction Pre-procedure assessment awake and cooperative patients, a suggest- Chest drain insertion (tube thoracostomy) There are no absolute contraindications to ed position is semi-decubitus on the bed at is an essential skill for hospital doctors chest drain placement. Before chest drain 45°, with the arm behind the head so as to dealing with certain pleural diseases. While insertion, it is good practice to identify expose the axillary area. aspiration may be appropriate in sponta- and correct any coagulopathy or bleeding The drain should ideally be inserted in neous pneumothorax and uncomplicated diathesis. A recent chest X-ray should be the ‘safe triangle’, which is delineated by pleural effusions, it is often inadequate. In available to the operator. The procedure the lateral border of the pectoralis major, such cases, and for other indications (Table should be explained to the patient and the anterior border of the latissimus dorsi 1), it may be necessary to insert a chest his/her consent sought. In addition to and a line horizontal with the nipple. drain. Traditionally, this is inserted in the local analgesia, conscious sedation with an Most clinicians insert the chest tube via pleural space percutaneously through opioid or a benzodiazepine should be con- an incision at this fourth or fifth intercos- blunt dissection and connected to a drain- sidered where the patient is haemody- tal space in the anterior axillary or mid- age device with an underwater seal. The namically stable. Vasovagal reactions are axillary line (Miller and Sahn, 1987). An procedure may be image-directed. Newer well described, especially in young patients. alternative approach may be required in chest drains based on a guide-wire tech- Patients given conscious sedation must be the presence of a loculated effusion. This nique have been developed with the dual appropriately monitored from a cardiores- will be governed by clinico-radiological aims of safety and ease of appropriate piratory perspective. assessment. placement. For evacuation of a pneumothorax, the The indications, technique and compli- Technique second intercostal space in the mid-cla- cations of tube thoracostomy will be When the decision has been made to vicular line has been suggested as an alter- reviewed here. The terms chest drain, insert a chest tube, the operator must native site; however, this requires dissec- chest tube and tube thoracostomy may be select the type of tube, the size of the tube, tion through the pectoralis muscle and considered synonymous for this article. the insertion site, and the insertion tech- leaves a visible scar. In the authors’ opin- nique to be used. The equipment required ion, this should be considered if a small Table 1. Indications for tube is listed in Table 2. bore chest tube is indicated or if the safe thoracostomy triangle is not accessible. Procedure The area of insertion is prepped with The first step involves positioning the 10% povidine-iodine solution (or chlo- Pneumothorax Spontaneous, iatrogenic, patient and choosing the insertion site. In rhexidine) and draped with sterile towels. tension Using 1% lidocaine, a 2–3 cm area of skin Penetrating chest trauma Table 2. Equipment for tube and subcutaneous tissue is anaesthetized. This will allow for the development of a Haemothorax thoracostomy subcutaneous tunnel through which the Parapneumonic effusion If complex Sterile gown and gloves chest tube will be placed to prevent air Empyema entry after the chest tube is removed. Local Antiseptic solution, i.e. povidine-iodine or anaesthetic is then infiltrated above a rib Malignant pleural effusion chlorhexidine to avoid the intercostal neurovascular bun- Pleuradiesis Recurrent malignant Sterile drapes dle. When air or pleural fluid is aspirated (thoracocentesis), the needle is withdrawn effusion Local anaesthetic, e.g. 1% or 2% lidocaine until it ceases. Further local anaesthetic is Chylothorax Syringes and needles infiltrated just above the parietal pleural, which is exquisitely painful when breached. Bronchopleural fistula Scalpel and blade Total infiltration of up to 30 ml 1% lido- Suture, e.g. 1/0 or 2/0 silk caine is allowable. Dr Shafick Gareeboo is Specialist Registrar Aspiration of air or pleural fluid con- in Respiratory Medicine and Dr Suveer Forceps (round tipped) or Kelly clamp for blunt firms the appropriate site. If aspiration is Singh is Consultant Physician in Respiratory dissection not successful, then imaging should be and Intensive Care Medicine, Department Chest drain sought. Ultrasound is the preferred form of Respiratory Medicine, Chelsea and of imaging. This can be done by the Westminster Hospital NHS Trust, Imperial Closed drainage system with connecting tubing bedside, allowing safe placement of the College School of Medicine, (sterile water if underwater seal used) drain at the same time. If complex pleu- London SW10 9NH Guide-wire and dilators for Seldinger drains ral disease is suspected, computed tomo- graphy (CT) scanning with contrast is Correspondence to: Dr S Singh Formal ‘cut down’ theatre instrument set recommended.

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Chest drain size between the lung and pleural surface designed as small bore drains (12F), but The size of chest tube that is required var- before drain insertion. are now available in sizes up to 24F ies according to the indication for its The forceps are closed onto the tip of (ThalQuick). placement. the chest drain and used to direct the drain After local anaesthesia, thoracocentesis For pneumothoraces, it is increasingly into the desired position. This should ide- is performed until air or fluid is aspirated accepted, without formal randomized con- ally be apically in the case of a pneumo- confirming that the tip is lying in the trol trial evidence, that smaller drains (8– thorax and basally for an effusion. desired position in the pleural cavity. A 14 F) are as effective as large bore ones. Some chest drains are still accompanied guide-wire is then passed down the hub, Some would advocate larger sizes (20– by a metallic trocar. The latter may be and proximal control is maintained there- 24 F) in ventilated patients to facilitate retracted so that the sharp tip lies within after. The needle is removed, a small drainage but this is unproven. There was the drain. It can then be used to position superficial incision made and the tract no evidence for a size preference in out- the drain. The trocar should never be used enlarged with serial dilators. The drain is comes from drainage of non-malignant to create a tract. This obsolete technique then passed into the pleural cavity over the pleural infections in a recent multicentred requires significant force despite the sharp guide-wire. randomized controlled trial (Maskell et al, tip and has been associated with damage 2005). to essential intrathoracic structures Safe-T-Centesis Theoretical concerns of inadequate chest (Symbas, 1989). This new catheter (Radiologic-UK drain hole size or number suggest larger The location of the chest tube should Medical Ltd, Sheffield; current maximum bores (24–32 F) may be appropriate for be confirmed by the appearance of con- size 8 F; Figure 3) is placed over its own haemothorax or penetrating chest wall densation within the tube with respira- rigid introducer; this has a spring-loaded injury. tion, or by drained pleural fluid seen covered tip that retracts to reveal a cutting If pleurodesis is being contemplated, it within the tube. The chest tube should be edge while pressure is applied against the is advisable to use a drain of at least 12 F, inserted with the proximal hole at least resistance of tissues. As soon as the pleural with adequate holes, to allow drainage of 2 cm beyond the rib margin. The position surface is breached, that resistance is lost excess talc slurry (if that is the agent of of the chest tube with all drainage holes in and the spring-loaded covered tip hides choice). the pleural space should be assessed by There is often concern regarding tube palpation. Figure 1. Smiths Portex Seldinger chest drain kit blockage. The use of saline or heparin The drain is secured to the skin by a (12F). flushes is suggested but unstudied. There strong suture, i.e. 1/0 silk. If a large drain is, on the other hand, the theoretical risk is placed, a wound closure ‘mattress’ suture of introducing infection. Regular aspira- should be inserted. ‘Purse string’ sutures tion at the chest tube–drainage portal are no longer advised as they distort the interface may reduce blockage. incision. This is uncomfortable and leaves unsightly scars. Drain insertion The drain needs to be connected Blunt dissection technique securely to a pleural drainage system After local anaesthesia, a 2 cm superficial with unidirectional flow. This usually is skin incision is made parallel to the an underwater seal bottle with a side intercostal space, and should be per- vent. The advantage of this system is that Figure 2. ThalQuick chest drain kit. formed immediately above the rib in it allows pleural air loss to be observed in order to reduce the risk of neurovascular pneumothorax and accurate volume injury should the incision extend more measurements in pleural effusions, but it deeply than intended. Using additional requires inpatient management and lidocaine, the periosteum of the ribs restricts mobilization. Drainage bags above and below the site of insertion, as with flutter valves and vented outlets are well as the tissues of the intercostal space a more flexible alternative. Some centres at the site of insertion and the parietal use Heimlich flutter valves (one way) pleura, should be well infiltrated with with a small chest drain for simple anaesthetic. pneumothoraces. A forceps or Kelly clamp is used for blunt dissection to the intercostal space. It Guide-wire (Seldinger) technique should be gently advanced in the closed Certain chest drains can be inserted with a position until the pleura is breached and Seldinger technique (e.g. Seldinger chest then opened to spread the parietal pleura drain kit, Smiths Portex, Watford (Figure and intercostal muscles. A finger is insert- 1); Cook ThalQuick, Cook (UK) Ltd, ed through the tract created to ensure Letchworth (Figure 2)) avoiding the need proper position and lack of adhesions for blunt dissection. These were originally

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ing collapsed lung. It has been suggested most common complication of tube thora- that the tube should be clamped for up to costomy (Baldt et al, 1995). A CT scan 1 hour after draining 1 litre. should be obtained if either a patient’s There is no need to clamp drains for plain films or clinical course is consistent pneumothoraces unless raising the drain- with chest tube malposition. age container above the level of percutane- Other reported complications include Figure 3. Safe-T-Centesis (6,8F) catheter. ous drain insertion. insertion site infection, empyema, lung The use of suction has been suggested in parenchyma perforation, diaphragmatic the cutting edge, thus protecting any cases of non-resolving pneumothorax and perforation, subcutaneous placement, per- underlying structures from damage. A following chemical pleurodesis. This should foration of the right ventricle, right atrium, marker at the proximal end of the intro- be done via an underwater seal using a high and abdominal organs (spleen, liver, stom- ducer changes from red to white signifying volume/low pressure system (e.g. Vernon- ach, colon), cardiogenic shock from chest loss of resistance. Thoracocentesis is Thompson pump) until full drainage is tube compression of the right ventricle, achieved at this moment, as confirmed by complete. Pressures between 10 and 20 kPa mediastinal perforation and bleeding from the aspiration of air or fluid in the attached are appropriate. intercostal artery injury. Re-expansion pul- syringe. The pleural drain is fed over the monary oedema has been described. introducer, which is then removed. The Removal of the chest drain Treatment is supportive. chest drain is secured and connected to a Chest tubes should be removed when the There appears to be no role for the use of drain device. original indication for placement is no prophylactic antibiotics for chest tube This procedure is potentially safer than longer present or the tube becomes non- insertion or while the chest tube is in other described techniques, and possibly functional. The exact timing is dependent place. quicker. However, its applicability is cur- on the clinical progress. Further information regarding national/ rently limited to drainage of simple effu- Opinion is divided as to whether a chest international guidelines on the indications sions because of the very small chest drain tube placed for pneumothorax in a patient for tube thoracostomy may be obtained sizes. continuing to require mechanical ventila- from societies such as the British Thoracic tion may be removed if no air leak is Society (http://thorax.bmjjournals.com/ Uresil Tru-close thoracic vent present. Although somewhat controversial cgi/content/full/58/suppl_2/ii53) and the This device for the treatment of a simple in patients with pneumothorax, many cli- American College of Chest Physicians pneumothorax is a small unit that fits nicians favour clamping the chest tube for (www.chestnet.org). BJHM firmly to the patient and allows early 4–6 hours before removal in order to iden- ambulation, without the need for an tify a persistent air leak. underwater seal. The thoracic vent uses a In preparation for removal, the suture The authors would like to thank Dr Pallav L Shah for kink-resistant catheter and a signal dia- anchoring the chest tube to the skin is cut, reviewing the manuscript. phragm to facilitate insertion and moni- and a gauze dressing is available. Following Conflict of interest: none. toring resolution of the pneumothorax. inspiration, the patient performs a valsalva Hence, it is akin to thoracocentesis using manoeuvre and the tube is removed with a Venflon, attached to a small one-way simultaneous covering of the insertion site Baldt MM, Bankier AA, Germann PS et al (1995) Complications after emergency tube valve compartment. As the relative nega- with the gauze dressing. The mattress thoracostomy: assessment with CT. Radiology tive pressure of the pleural space is suture inserted previously is tied to close 195: 539–43 breached, the signal diaphragm moves, the wound. Maskell NA, Davies WH, Nunn AJ et al (2005) UK Controlled trial of intrapleural streptokinase for confirming placement. The introducing pleural infection. N Engl J Med 352: 865–74 trocar is removed and the unit secured to Complications Miller KS, Sahn SA (1987) Chest tubes: indications, the skin until further movements of the Complications of chest tube placement, technique, management, and complications. Chest 91: 258 diaphragm cease. This suggests resolution excluding recurrent pneumothorax, are Symbas PN (1989) Chest drainage tubes. Surg Clin of the underlying pneumothorax, which infrequent. Chest tube malposition is the North Am 69: 41–6 should be confirmed by imaging before removal. KEY POINTS Management of the drain n Preparation of the patient position, site, equipment and analgesia are crucial. A chest X-ray needs to be performed after the procedure to ensure satisfactory posi- n Size and number of drainage pores on a chest tube may facilitate drainage of empyema and tion of the drain. In the case of a large haemothorax. pleural effusion, it is wise to control drain- n A ‘non-swinging’ chest tube is either misplaced, blocked, connected to suction or has achieved its age in order to prevent re-expansion pul- role. monary oedema. This rare but potentially serious complication may occur depending n Newer equipment may facilitate ‘tailoring’ to specific indications. on the extent and duration of the underly-

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