1. Chest Drain Insertion Course

2. Chest Drain Insertion Background Indications Consent Complications
Preparation, anatomy and insertion
Chest drain management

3. Background
Why is this course relevant to you…?

4. Curriculum for Core Medical Training and
Acute Care Common Stem (Medicine)

5. Part 2.4 Procedural Competencies
The trainee is expected to be competent in performing the following procedures by the end of core training. The trainee must be able to outline the indications for these interventions. For invasive procedures, the trainee must recognise the indications for the procedure, the importance of valid consent, aseptic technique, safe use of local anaesthetics and minimisation of patient discomfort..
• Venepuncture
• Cannula insertion, including large bore
• Arterial blood gas sampling
• Lumbar Puncture
• Pleural tap and aspiration
• Intercostal drain insertion: Seldinger technique
• Ascitic tap
• Abdominal paracentesis
• Central venous cannulation
• Initial airway protection: chin lift, Guedel airway, nasal airway, laryngeal mask
• Basic & advanced cardiorespiratory resuscitation
• DC cardioversion
• Urethral catheterisation
• Nasogastric tube placement and checking
• Electrocardiogram
• Knee aspiration
• Temporary cardiac pacing by internal wire or external pacemaker

6. National Patient Safety Agency (NPSA)
Rapid Response Report
May 2008

7. The NPSA has received reports of 12 deaths relating to chest drain insertion and 15 cases of serious harm between January 2005 and March Many more are likely to be unreported.
The Medicines and Healthcare Products Regulatory Agency (MHRA) have received reports of nine incidents since 2003, all but one relating to the use of Seldinger type drains, which is now the most commonly used technique.

8. Indications - for chest drain insertion

9. Indications - for chest drain insertion
THINK
…is a drain necessary?

10. Indications - for chest drain insertion
Pneumothorax
Malignant pleural effusion (causing significant SOB)
Empyema & complicated parapneumonic pleural effusion
Traumatic haemopneumothorax
Postoperative e.g, thoracotomy, oesophagectomy, cardiac surgery

11. Indications - for chest drain insertion
Pneumothorax
Tension pneumothorax after initial needle relief
Persistent or recurrent pneumothorax after simple aspiration (x1)
Large (>2cm) secondary spontaneous pneumothorax
In any ventilated patient (including NIV)

12. Pneumothorax

13. Spontaneous Pneumothorax
If bilateral or haemodynamically unstable proceed to chest drain
Age >50yrs & significant smoking history or evidence of underlying lung disease on exam or CXR?
PRIMARY PNEUMOTHORAX NO
SECONDARY PNUEMOTHORAX
YES

14. Size >2cm and/or breathless
PRIMARY PNEUMOTHORAX
Consider discharge NO
Size >2cm and/or breathless
Aspirate (16 -18G cannula)
YES
Success
(<2cm & SOB improved)
YES
Chest Drain (Size 8 -14F) NO

15. SECONDARY PNEUMOTHORAX
Admit & Observe 24hrs NO
Size 1-2cm
Size >2cm or breathless
YES
Chest Drain
Aspirate
YES
Success (<1cm)
YES NO

16. Indications - for chest drain insertion
Pneumothorax
Tension pneumothorax after initial needle relief
Persistent or recurrent pneumothorax after simple aspiration (x1)
Large (>2cm) secondary spontaneous pneumothorax
In any ventilated patient (including NIV)
Remember..
Simple aspiration is recommended as first line treatment
for all primary pneumothoraces requiring intervention.
Ultrasound guidance is NOT needed for drain insertion
for pneumothoraces

17. Indications - for chest drain insertion
Pneumothorax
Tension pneumothorax after initial needle relief
Persistent or recurrent pneumothorax after simple aspiration (x1)
Large (>2cm) secondary spontaneous pneumothorax
In any ventilated patient (including NIV)
Malignant pleural effusion

18. Indications - for chest drain insertion
Pneumothorax
Tension pneumothorax after initial needle relief
Persistent or recurrent pneumothorax after simple aspiration
Large (>2cm) secondary spontaneous pneumothorax in patients >50 yrs
In any ventilated patient (including NIV)
Malignant pleural effusion
Remember..
Therapeutic pleural aspiration (up to 1.5 litres) will
provide symptomatic relief in most situations
Fluid aspiration or drainage require ultrasound guidance

19. Indications - for chest drain insertion
Pneumothorax
Tension pneumothorax after initial needle relief
Persistent or recurrent pneumothorax after simple aspiration
Large (>2cm) secondary spontaneous pneumothorax in patients >50 yrs
In any ventilated patient (including NIV)
Malignant pleural effusion
Empyema & complicated parapneumonic pleural effusion

20. Pleural effusion and evidence of infection
Ultrasound scan
Diagnostic fluid sampling
Fluid pH and microbiology
Pus
Chest Drain
Gram stain or culture positive or pH <7.2
YES NO
Observe, unless clinical indication for drain

21. Indications - for chest drain insertion
Pneumothorax
Tension pneumothorax after initial needle relief
Persistent or recurrent pneumothorax after simple aspiration
Large (>2cm) secondary spontaneous pneumothorax in patients >50 yrs
In any ventilated patient (including NIV)
Malignant pleural effusion
Empyema & complicated parapneumonic pleural effusion
Traumatic haemopneumothorax

22. Indications - for chest drain insertion
Pneumothorax
Tension pneumothorax after initial needle relief
Persistent or recurrent pneumothorax after simple aspiration
Large (>2cm) secondary spontaneous pneumothorax in patients >50 yrs
In any ventilated patient (including NIV)
Malignant pleural effusion
Empyema & complicated parapneumonic pleural effusion
Traumatic haemopneumothorax
Postoperative e.g, thoracotomy, oesophagectomy, cardiac surgery

23. Consent

24. Consent Written formal consent should be taken
If possible, an information leaflet should be
given before the procedure
In the case of an emergency treatment may
be carried out but must be explained as
soon as the patient is sufficiently recovered
to understand

25. Complications

26. Complications
EARLY complications
LATE complications

27. Complications EARLY complications Pain
Haemothorax (intercostal vessel injury)
Lung laceration
Cardiac penetration
Diaphragm and abdominal cavity penetration
Bowel injury (unrecognised diaphragmatic hernia)
Tube placed subcutaneously
Tube inserted too far
Surgical emphysema

28. Malpositioned tube

29. Surgical emphysema

30. Surgical emphysema

31. Complications LATE complications Pleural infection / wound infection
Pneumothorax after removal
Blocked tube
Displaced tube…. “it just fell out doctor!”

32. Complications Remember..
There is no organ in the thoracic or abdominal cavity that has not been pierced by a chest drain.
Asepsis is paramount
Good fixation will save repeat procedures

33. Reducing risk - Haemorrhage
Non-urgent pleural aspirations and chest drain insertions should be avoided in anticoagulated patients until INR <1.5

34. Pitfalls
The differentiating between a pneumothorax and bullous disease requires careful radiological assessment.

35. Pitfalls
Differentiating between collapse and a pleural effusion when the chest radiograph shows a unilateral “whiteout”

36. Image guidance – BTS recommendations
A chest X-ray must be available at the time of drain insertion except in the case of tension pneumothorax.
All chest drains for fluid should be inserted under image guidance

37. Image guidance – BTS recommendations
The marking of a site using thoracic ultrasound for subsequent remote aspiration or chest drain insertion is not recommended except for large pleural effusions

38. Preparation - equipment
Remember..
You should be able to set up your own trolley.
Have your equipment within easy reach during
the procedure.

39. Preparation - equipment
Asepsis
Sterile gloves, gown and drapes
Skin sterilisation (‘chloraprep’ device)

40. Preparation - equipment
Asepsis
Sterile gloves, gown and drapes
Skin sterilisation (‘chloraprep’ device)
Remember..
Asepsis is paramount.
Drapes and Gown are mandatory.

41. Preparation - equipment
Asepsis
Sterile gloves, gown and drapes
Skin sterilisation (‘chloraprep’ device)
Anaesthesia
Syringes and needles
Local anaesthetic (1% lidocaine, up to 3 mg/Kg )

42. Preparation - equipment
Asepsis
Sterile gloves, gown and drapes
Skin sterilisation (‘chloraprep’ device)
Anaesthesia
Syringes and needles
Local anaesthetic (1% lidocaine, up to 3 mg/Kg)
Drain Kit
Seldinger chest drain kit – 12F (contains scalpel)
Chest drain tubing and bucket plus Sterile water (1L)

43. Preparation - equipment
Drain Size
Small bore drains are recommended as they are more comfortable than larger bore tubes.
No evidence that either is therapeutically superior.
Large bore drains are recommended for drainage of acute haemothorax

44. Preparation - equipment
Asepsis
Sterile gloves, gown and drapes
Skin sterilisation (‘chloraprep’ device)
Anaesthesia
Syringes and needles
Local anaesthetic (1% lidocaine)
Drain Kit
Seldinger chest drain kit – 12F (contains scalpel)
Chest drain tubing and bucket plus Sterile water (1L)
Fixation
Suture (preferably 1.0 silk)
Clear adhesive dressing

45. Preparation - patient positioning (1)
Reclined on the bed with the arm on the side of the lesion behind the patients head to expose the axillary area (“safe triangle”)
Pneumothorax
Effusions marked whilst in this position

46. Preparation - patient positioning (1)
The “Safe triangle”
pectoralis major
latisimus dorsi
horizontal line of nipple

47. Preparation - patient positioning (2)
Sat upright leaning over a table (with a pillow)
Effusions marked whilst in this position
Remember..
For marked drain sites - the patient should be in the same position during drain insertion as
during drain site marking.
Ideally bedside scanning should be employed.

48. Anatomy

49. Insertion procedure
1. Asepsis
Clean the skin
Drape the area

50. Insertion procedure 1. Asepsis 2. Anaesthesia Clean the skin
Drape the area
2. Anaesthesia
Infiltrate with local anaesthetic (10-20ml, 1%)

51. Insertion procedure 1. Asepsis 2. Anaesthesia Clean the skin
Drape the area
2. Anaesthesia
Infiltrate with local anaesthetic (10-20ml, 1%, 3mg/kg, 10ml 1%=100mg)
Remember..
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
anaesthesia.

52. Insertion procedure - Seldinger technique
3. Components
Introducer needle + syringe
Guide wire
Dilator (with cuff / or restrictor)
Chest drain
Three way tap
Tube connecting piece

53. Insertion procedure - Seldinger technique

54. Insertion procedure - Seldinger technique
Remember..
The guide wire should be visible AT ALL TIMES.

55. Insertion procedure - tube positioning
The position of the tip of the chest tube should ideally be aimed apically for a pneumothorax or basally for fluid (use bevel of introducer needle)
However, any tube position can be effective at draining air or fluid and an effectively functioning drain should not be repositioned solely because of its radiographic position.

56. Insertion procedure - securing the drain
Suture and dress
Ideally 1:0 suture (silk)
Recommend using an ‘omental tag’
Omental tag

57. Insertion procedure - securing the drain
Suture and dress
Ideally 1:0 suture (silk)
Recommend using an ‘omental tag’
Remember..
Ensure your drain is well secured; having
to replace a drain is time consuming and
technically more difficult than the first time.
Omental tag

58. Now it’s in… what next?

59. Now it’s in… what next? Get a DOPS form!
Chest X-ray, to confirm position

60. Now it’s in… what next?
Chest X-ray, to confirm position

61. The drain isn’t bubbling..?

62. The drain isn’t bubbling..
Remember..
A CXR is a 2 dimensional image.
CT is needed for a suspected mal-positioned
drain

63. Chest drain management
CXR post insertion
Clamp off after 1.5L or earlier if SOB / chest pain – to avoid re-expansion pulmonary oedema
Always keep drain below the level of the patient - If lifted above chest level contents of drain can siphon back into chest
If disconnection occurs reconnect and ask patient to cough

64. Chest drain management
Daily fluid charting / drain assessment
Not draining? Kinked
Mal-position
Blocked – try 30ml saline flush
If the drain tip migrates out of the pleural space,
the same drain should not be repositioned
If a drain falls out the same drain tract should not
be used to site the replacement drain

65. Chest drain management
Suction
May have role in pneumothorax
Low pressure / high flow
ONLY on respiratory ward
Chest physician decision
Fibrinolysis
Not supported by evidence (MIST)
May have a role in those unsuitable for surgery

66. Chest drain removal – When?
Effusion Draining less than 200ml per day and radiological improvement
Pneumothorax - Radiological resolution and stopped bubbling for 24 hours
Empyema Clinical & radiological improvement
‘Minimal’ drainage
Drain no longer functioning

67. Chest drain removal – How?
Removal is with a brisk firm movement
Valsalva maneuver at full inspiration
Dressing +/- ‘Steri-strips’
Sutures not usually needed

68. Discharge instructions for PTx

69. If you’re unsure ask for help...

70. Any questions?