MRCS

Chest Drains

Indication:

Pneumothorax
Pleural Effusion
Haemothroax
Chylothorax
Empyema
Post-operative

Relative Contraindications:
Coagulopathy
Diaphragmatic hernia
Pleural adhesions - I.e. risk of penetrating lung.

Insertion:
Explain and gain consent from patient.
Check recent imaging to confirm affected side.
Equipment:
Intercostal drain - 28-32fr for adults, 18fr child, 12-14fr newborn.
For simple pleural effusions - smaller seldinger drain can be used.
Instrument for blunt dissection - Roberts
Local anaesthetic
10ml syringe
Green needle
2.0 Silk on large curved hand needle
Scalpel 11 blade
Drape/Skin prep/Gown/Gloves/Gauze
Position:
Lie patient at 45 degrees with ipsilateral arm abducted (assistant maybe
necessary to support arm).
Attach pulse oximetry for monitoring.

Recommended texts: Oxford Handbook of Cardiothoracic Surgery

MRCS

Chest Drains

Insertion (cont.):

Area of insertion:
British thoracic society recommends inserting in "safe zone" Posterior to lateral border of pectoralis major, inferior to axilla, anterior to
latissimus dorsi and superior to horizontal line through nipple.
Source - http://thorax.bmj.com/content/58/suppl_2/ii53/F3.large.jpg
Classically texts advise 5th intercostal space mid-axillary line.
Use of ultrasound to guide positioning is also advised.

Technique:
Prepare and drape the skin.
Infiltrate local anaesthetic - initially create a small sub dermal bleb then continue
to infiltrate local anaesthetic through all layers down to parietal pleura.
Make a 2cm skin incision transversely in line with the intercostal space.
Bluntly dissect into the intercostal space.
Place an untied suture.
Open the pleura using a blunt tipped instrument such as a Roberts avoid pressure
on the inferior aspect of the overlying rib to avoid primary's neuromuscular bundle.
Gently sweep a finger within the pleural space to check for adhesions.
Guide the chest drain in bluntly into the pleural space - guide it apically for
pneumothorax and basally for fluid.
Connect the drain to an underwater seal.
Tie the previous suture and fix the drain using the free ends.

Post procedure:
Inform nursing staff regarding care i.e. need for suction, plan for CXR, when for
removal.
Arrange a chest radiograph to check placement and rule out complications.

Recommended texts: Oxford Handbook of Cardiothoracic Surgery

MRCS

Chest Drains

Complications:
Early:
Incorrect placement i.e subcutaneous, intraparenchymal
Injury to neighboring structures - liver, spleen, heart, aorta, intercostal arteries
Pain
Delayed:
Re-expansion pulmonary oedema
Surgical emphysema
Wound infection
Empyema

Managing Chest Drains:

Drainage Systems:
Underwater Seal
Can be used for any condition requiring chest drain i.e. safe when there is an air
leak.
Suction can be applied.
Must be kept erect and needs to be below the patients chest to prevent water
from being suctioned back into the patient.
Multifunction Drainage Systems
Typically formed of a collection chamber for fluid, a middle water seal chamber for
monitoring air leaks and a suction control chamber.
Heimlich
Valve

One way flutter valve.

Usually used when long term drainage is necessary i.e. palliation.
Portex
Ambulatory chest drainage system with incorporated heimlich valve.
Used for drainage of fluid.
Contra-indicated if there is a persisting air-leak.
Suction:
Used to help promote re-inflation and to more readily drain fluid.
Typically 2-3Kpa
Not appropriate/necessary in patient post pneumonectomy.
Clamping:
Generally clamping should be avoided and has been associated with causing
preventable deaths secondary to tension pneumothorax.
Certain scenarios clamping may be used (always discuss with seniors):
Massive haemothorax/effusion - if >1500ml is drained immediately on insertion
and the patient appears haemodynamically compromised then temporary
clamping can be advised to tamponade or to prevent re-expansion pulmonary
oedema.
Post pneumonectomy - can be clamped safely and some advocate intermittent
clamping to prevent mediastinal shift to the pneumonectomy side.
Recommended texts: Oxford Handbook of Cardiothoracic Surgery