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Insertion of intercostal drain, Seldinger technique: animated demonstration

How to insert an intercostal (chest) drain using the Seldinger technique. Video demonstrates: how to identify a safe site for insertion; use of an introducer needle, guidewire, dilators, and intercostal drain; how to confirm drain position; and post-procedure care.

Equipment needed:

  • Sterile gloves

  • Sterile gown

  • Eye protection and mask

  • Sterile drapes

  • Ultrasound scanner, particularly if you will be aspirating fluid

  • Antiseptic

  • 1% lidocaine local anaesthetic

  • Syringe and needle for local anaesthetic

  • Syringe and needle for guidewire introduction

  • Scalpel

  • Guidewire

  • Dilator(s)

  • Chest tube

  • Drainage bottle with water seal

  • Silk suture or purpose-made adhesive dressing to keep chest tube in position

  • Wound dressing

Small-bore intercostal drains are suitable for most indications, including draining empyema. Larger bore intercostal drains should be considered in unstable trauma patients and pneumothorax complicating mechanical ventilation.[101]

Indications[101]

  • Traumatic haemothorax and/or pneumothorax

  • Pneumothorax failing other treatments

  • Simple drainage of large benign or malignant pleural effusions

  • Symptomatic pleural effusions in patients on mechanical ventilation

  • Talc pleurodesis

  • Pleural infection

  • Post thoracic cavity procedures (such as medical thoracoscopy, thoracic, oesophageal, and cardiac surgery amongst others).

Contraindications

Insertion of a large-bore chest tube using the open technique is more appropriate for patients with:

  • A traumatic pneumothorax

  • A haemothorax

  • Flail chest

  • Sucking chest wounds.

Clinicians should take care to ensure the diagnosis is correct, and not to insert a drain into a large bulla or diaphragmatic hernia (which is a differential diagnosis for a pneumothorax).

Lack of diagnostic imaging is a relative contraindication. British Thoracic Society guidelines strongly recommend that all insertions of chest drains for fluid should be under image guidance (ultrasound or computed tomography) except in an emergency.[101]

For elective procedures, warfarin should be stopped 5 days before the procedure, and confirmation that the international normalized ratio is ≤1.5 prior to the procedure.[101]

Complications

Potential complications of intercostal drain insertion are:[102]

Related to insertion:

  • Pain

  • Placement outside the pleural cavity - subcutaneous, intra-abdominal

  • Puncture of solid organ - liver, spleen, heart, lung, oesophagus

  • Puncture of an intercostal artery

  • Insertion on incorrect side

  • Surgical emphysema.

Related to the position of the drain:

  • Pain

  • Failure of the drain (e.g., dislodged/kinked/blocked)

  • Re-expansion of pulmonary oedema

  • Formation of a bronchopleural fistula

  • Pneumothorax.

Related to infection:

  • Wound infection

  • Empyema.

Haemothorax:

If the intercostal drain was inserted for a haemothorax and there is heavy bleeding, the patient may need a thoracotomy to control the bleeding vessel.

Pneumothorax:

If there is a massive air leak through the drain in a patient with a pneumothorax, you should suspect a major injury to the bronchus, and a thoracotomy is indicated.

Pleural effusion:

Drainage of a large pleural effusion should be controlled to prevent the potential complication of post-procedure pneumothorax. In general, a maximum of 1.5 L should be drained in one attempt.[101] However, if the patient develops symptoms (e.g., chest tightness, pain, persistent cough or worsening breathlessness) at a lower volume, the aspiration should be stopped.[101] The drain should be clamped promptly in patients with repetitive coughing or chest pain, to avoid re-expansion pulmonary oedema, a potentially fatal complication.[101]

Aftercare

The drain is connected to an underwater seal drainage system to prevent re-accumulation of fluid or air in the pleural cavity.

Check chest radiograph:

Request a chest radiograph to check the position of the chest drain, exclude complications such as pneumothorax or surgical emphysema, and assess the success of the procedure in the volume of fluid drainage or resolution of a pneumothorax.[101]

Monitoring:

Re-examine the patient and their drain after insertion and closely monitor them thereafter. After initial confirmation that the patient’s clinical condition is stable or has improved, and that the drain is draining, bubbling (if a pneumothorax), and swinging, intercostal drain observations should start and be recorded regularly. These should include:

  • Observations of the wound site

  • Volume/colour of fluid drained

  • Swinging/bubbling activity

  • Routine observations, including respiratory rate and oxygen saturations.

Drains should be checked daily and assessed for infection, fluid drainage volumes and the presence of respiratory swinging and/or bubbling. This should be documented on a dedicated chest drain observation chart.[101] Patients should be located on a ward with nursing staff who are experienced in managing patients with chest drains.

Potential problems:

  • Persistent bubbling: if the underwater seal drain continues to bubble there may be a persistent air leak

  • Persistent drainage of blood or fluid

  • Further fluid or blood collection: indicates an ongoing intrathoracic problem

  • Blockage: if the chest drain ceases swinging with inspiration, the tube may be blocked or no longer in a suitable position and should be checked. Never advance a chest drain catheter into the pleural cavity once the sterile field has been removed, due to the risk of infection

  • In cases where the patient is having respiratory difficulty after removal of a chest drain, an urgent chest x-ray is indicated to ensure the original cause for the drain has not recurred

  • Do not raise the drain above the patient’s chest height as this can cause the tube contents to reflux back into the pleural cavity

  • A bubbling drain should never be clamped unless in specific circumstances under consultant pleural supervision.[101]

Removal:

Timing of removal depends on the indication for the drain in the first place. A chest radiograph showing resolution of the problem is reassuring when deciding to remove the drain. Post-surgical drains could be removed after 24 to 48 hours, depending on drainage; however, a drain for a pneumothorax may be required for longer.

Removal requires the coordinated removal of the drain and closure of the skin with the placement of a dressing so that air cannot get into the pleural cavity.

The chest tube should be removed after a Valsalva manoeuvre has been performed by the patient. The removal should occur using a steady continuous pull followed by quick occlusion of the wound with a swab.[101] If there is further drainage of fluid (in a pleural effusion) from the chest drain site, it may be necessary to place a suture.

A chest x-ray should be requested after the drain has been removed to ensure there were no complications when removing the drain (e.g., air entering the pleural cavity). Do not clamp the chest drain in patients with a pneumothorax. There is no evidence to suggest that clamping a chest drain before its removal increases success or prevents recurrence of a pneumothorax and it may be hazardous.