CHAPTER 4. CHEST DRAIN INSERTION AND MANAGEMENT
NPSA recommendations34
Indications34
Cautions34
Contraindications35
Equipment35
Choosing the size of chest drain – the guidelines35
Position for drain insertion36
Site of drain insertion36
Practical procedure37
Post-procedure investigations43
Post-procedure care43
Complications43
Suggested reading43
Hippocrates (460–377 BC) first suggested thoracocentesis by making an incision in the chest wall. However, it was not until 1850 when Henry Ingersoll Bowditch (1808–1892) and Morill Wyman (1812–1903) at the Massachusetts General Hospital demonstrated the removal of fluid from the pleural space with the use of a trocar puncturing the chest wall.
INTRODUCTION
NPSA RECOMMENDATIONS
In 2008 the NPSA issued recommendations for chest drain insertion, having received reports of 12 deaths and 15 incidents of serious harm relating to this clinical procedure over a 3-year period. Common themes included inappropriate selection of the site for drain insertion, excessive insertion of the dilator giving rise to trauma, inexperienced doctors and/or poor supervision in performing the procedure, and a lack of familiarity with the Seldinger technique and/or the apparatus used. These short-comings resulted in the puncture of blood vessels with ensuing haemorrhage, or the perforation of major organs including the heart, lungs, liver and spleen.
For these reasons, the NPSA issued the following guidance relating to intercostal chest drain insertion using the modified Seldinger technique.
Drainage tubes should only be inserted by trained staff with relevant competencies and adequate supervision.
Due to the risk of damaging internal organs through poor positioning, the NPSA strongly supports the use of ultrasound when positioning a drain. The BTS also supports ultrasound-guided chest drain insertion.
Where practicable patients will be required to provide written consent prior to the procedure.
Furthermore, the NPSA re-iterated the BTS guidelines on chest drain insertion that are mentioned throughout this chapter.
INDICATIONS
• Pneumothorax:
— in any ventilated patient
— tension pneumothorax after initial needle relief
— persistent or recurrent primary pneumothorax after simple aspiration
— large secondary spontaneous pneumothorax in patients over 50 years.
• Pleural effusion (malignant or complicated parapneumonic effusion).
• Haemothorax.
• Empyema.
• Post-operative (e.g. post-cardiothoracic surgery) – this will not be covered as this should be managed by surgical teams intra-operatively.
CAUTIONS
The following differential diagnoses must be carefully evaluated with radiological guidance prior to considering chest drain insertion:
CONTRAINDICATIONS
Coagulopathy (recent aspirin/clopidogrel, heparin last 12 hours, international normalized ratio (INR) above 1.2, activated partial thromboplastin time ratios (APTRs) above 1.2).
Local sepsis over drain site.
Lack of consent.
EQUIPMENT
• Dressing pack.
Sterile gown, gloves and drapes.
• Chlorhexidine cleaning solution.
• Lidocaine.
• 1 × 20 mL syringe.
• Orange needle.
• Green needle.
• Seldinger chest drain kit, size 10–14 F (including chest tube, guidewire with dilators, introduce needle with port for guidewire, syringe, 3-way tap).
• Connecting tubing.
• Closed drainage system (with sterile water for underwater seal).
• Gauze.
• Scalpel and blade.
• Suture (e.g. ‘1’ silk).
• Clear sterile dressing.
• Skin pen.
• Sleek® adhesive tape.
CHOOSING THE SIZE OF CHEST DRAIN – THE GUIDELINES
An ongoing debate exists as to the optimal size of chest drain. BTS guidelines state that:
Small bore drains are recommended as they are more comfortable than larger bore tubes, but there is no evidence that either is therapeutically superior.
10–14 F catheters are commonly used sizes of drain by physicians, and can be inserted simply using the Seldinger technique. The NPSA estimates that approximately 85–90% of chest drains inserted in clinical practice are done so by the modified Seldinger technique.
The only exception to this recommendation applies to the drainage of acute haemothorax, in which large-bore drains (inserted by blunt dissection, 28–30 F minimum) are advised in order to monitor further blood loss. Given that this situation arises in the context of trauma (managed by the trauma team) rather than the other indications for chest drains (managed by general physicians), blunt dissection will not be covered in this review. Blunt dissection is, however, covered in Chapter 5.
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