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Insertion of intercostal drain, open technique: animated demonstration

Equipment needed

• Sterile gloves

• Sterile gown

• Eye protection and mask

• Sterile drapes

• Ultrasound scanner to guide insertion of drain especially when aspirating fluid, unless in an emergency[103]Asciak R, Bedawi EO, Bhatnagar R, et al. British Thoracic Society Clinical Statement on pleural procedures. Thorax. 2023 Jul;78(suppl 3):s43-s68. https://www.doi.org/10.1136/thorax-2022-219371 http://www.ncbi.nlm.nih.gov/pubmed/37433579?tool=bestpractice.com [104]Nakitende D, Gottlieb M, Ruskis J, et al. Ultrasound for confirmation of thoracostomy tube placement by emergency medicine residents. Trauma (United Kingdom). 2015;19(1):35‐8.

• Antiseptic

• 1% lidocaine local anaesthetic

• Syringe and needle for local anaesthetic

• Scalpel

• Artery forceps

• Chest tube

• Drainage bottle with water seal

• Silk suture to keep chest tube in position

• Wound dressing.

Contraindications

Lack of diagnostic imaging is a relative contraindication.

• Diagnostic imaging can help make sure that you have the correct clinical diagnosis and that you do not accidentally insert a drain, for example into a large bulla or diaphragmatic hernia.

• When a chest drain is inserted for non-emergency drainage of fluid, chest x-ray, ultrasound, or CT image guidance can help ensure correct positioning.[104]Nakitende D, Gottlieb M, Ruskis J, et al. Ultrasound for confirmation of thoracostomy tube placement by emergency medicine residents. Trauma (United Kingdom). 2015;19(1):35‐8. [105]Jenkins JA, Gharahbaghian L, Doniger SJ, et al. Sonographic identification of tube thoracostomy study (SITTS): confirmation of intrathoracic placement. West J Emerg Med. 2012 Sep;13(4):305-11. https://www.doi.org/10.5811/westjem.2011.10.6680 http://www.ncbi.nlm.nih.gov/pubmed/22942927?tool=bestpractice.com [103]Asciak R, Bedawi EO, Bhatnagar R, et al. British Thoracic Society Clinical Statement on pleural procedures. Thorax. 2023 Jul;78(suppl 3):s43-s68. https://www.doi.org/10.1136/thorax-2022-219371 http://www.ncbi.nlm.nih.gov/pubmed/37433579?tool=bestpractice.com

Indications

• Traumatic chest injury causing pneumothorax, haemothorax, haemopneumothorax, flail chest, or a sucking chest wound/open pneumothorax.

• Drainage of thick, viscous fluid.

• The choice between wide-bore (open technique) and narrow-bore (Seldinger technique) intercostal tube will depend on the clinical scenario.

Complications

Complications specific to insertion of a wide-bore intercostal drain are:

• Bleeding.

• Inadvertent damage of the intercostal neurovascular bundle, which may result in bleeding. The intercostal vessels can bleed briskly if damaged.

• Malposition.

• Iatrogenic damage to abdominal viscera or the thoracic organs, which can occur with incorrect placement of the drain or an unsafe technique. A drain that is poorly positioned may not treat the problem effectively and may require re-siting.

• Pain.

• Drain failure.

• Infection (chest wall or empyema).

• Bronchopleural fistula.

Do not use the trocar supplied with most chest tubes as an introducer, or to force the chest drain into the pleural cavity, due to the risk of damaging internal structures.

Aftercare

Document the procedure in the notes, along with the depth of the drain and if any complications arose during the procedure.

Request a chest x-ray to check the position of the chest drain and to exclude complications such as pneumothorax or surgical emphysema.[103]Asciak R, Bedawi EO, Bhatnagar R, et al. British Thoracic Society Clinical Statement on pleural procedures. Thorax. 2023 Jul;78(suppl 3):s43-s68. https://www.doi.org/10.1136/thorax-2022-219371 http://www.ncbi.nlm.nih.gov/pubmed/37433579?tool=bestpractice.com An x-ray will also indicate the success of the procedure by showing the volume of fluid drained or resolution of a pneumothorax.

Re-examine the patient and the drain after insertion. After confirming that the patient is clinically stable (or is improving), and the drain is draining, bubbling, and swinging, then start recording observations regularly. Observations should include:

• Observations of the wound site

• Volume/colour of fluid drained

• Swinging/bubbling activity

• Routine patient observations, including respiratory rate and oxygen saturations

• A repeat chest x-ray - may be necessary to assess progress.

Make daily observations and document findings, preferably on a dedicated chart. Patients should be on a ward with nursing staff who are experienced in managing patients with chest drains.

Potential problems include:

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

• Persistent blood or fluid drainage: persistent collection of high volumes of fluid or blood indicate an ongoing intrathoracic problem.

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

• 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.

• The drain should never be clamped in patients with a pneumothorax, unless specifically instructed by a respiratory consultant.[103]Asciak R, Bedawi EO, Bhatnagar R, et al. British Thoracic Society Clinical Statement on pleural procedures. Thorax. 2023 Jul;78(suppl 3):s43-s68. https://www.doi.org/10.1136/thorax-2022-219371 http://www.ncbi.nlm.nih.gov/pubmed/37433579?tool=bestpractice.com A chest drain for pleural effusion may be clamped initially if more than 1.5 litres of fluid is within the pleural cavity, but this is not usually required after the initial drainage period.