INTERCOSTAL DRAINAGE

AND ITS MANAGEMENT

Terminology
Pneumothorax
accumulation of air in the pleural space
Haemothorax
accumulation of blood in the pleural
space
Haemopneumothorax
accumulation of air and blood in the
pleural space
Hydrothorax
accumulation of any other fluid (matter)
in pleural space

ICD INTERCOSTAL DRAINAGE

DEFINITION : THORACOSTOMY
Drainage of fluid / air / blood /chyle from the pleural space through
intercostal space

PURPOSE
Diagnostic
Therapeutic

Intrapleural Space
Visceral
pleura

Chest
wall

Lung

Zoom

Parietal
pleura

Intrapleural space

INDICATIONS

CONTRAINDICATIONS
DIAPHRAGMATIC HERNIA

PNEUMOTHORAX

REFRACTORY
COAGULOPATHY

HEMOTHORAX
EMPYEMA
CHYLOTHORAX

SEVERE PLEURAL ADHESIONS

FLAIL SEGMENT REQUIRING
VENTILATOR

ASSESSMENT OF
PATIENT
Pulse
Blood pressure
Hypotension
Respiratory rate and
effort
Tachypenia
Bradypenia
Labored
Retractions
Heart sounds--Muffled
(cardiac tamponade),

DIAGNOSTIC AIDS
CLINICAL SUSPICION IN CRITICAL
CASES
X-RAY CHEST
FAST ULTRASOUND
CT-SCAN

TECHNIQUE OF
INSERTION
Mostly EMERGENT Placement of tube is vital
to avoid complications

TECHNIQUE
PAINFUL PROCEDURE
Usually done under local anesthesia
May need additional pain killers

PREPROCEDURE PLAN
OBTAIN INFORMED CONSENT
INFORM THE PATIENT POSSIBILITY OF MAJOR
COMPLICATIONS
EXPLAIN THE MAJOR STEPS OF PROCEDURE AND
NEED FOR REPEATED X-RAYS

MATERIALS NEEDED
Chest tube with / without trocar
ICD TRAY No 11 / 23 Blade with handle, Large
Kellys clamps, Scissors
20 Ethilon / mersilk
Mask, gloves & gown
ROMO SEAL

SAFE ZONE
Lateral border of Pectorals major
Horizontal line inferior to Axilla
Anterior border of Lattisimus Dorsi
Horizontal line superior to nipple
5th INTERCOSTAL SPACE

SITE OF INSERTION

PROCEDURE Contd
Local area preparation
Sterile drapings
Incision along the upper border of the rib
Curved Clamp is used to develop the tract & then with the finger
Finger inserted into the pleural space for exploration
Large bore chest tube (3236 F ) is passed along the tract into the
pleural cavity
Tube is connected to underwater seal & secured with sutures
Check x-ray to be taken

CHEST TUBE DRAINS

Available from size 12 F 36 F
Large size tube are preferred in case of
effusions
Can be placed with / without trocar

CHEST DRAIN

UNDERWATER SEAL DRAIN

To Allow air to escape through drain BUT NOT TO
REENTER
Always be kept below the chest level of the
patient
NEVER CLAMP when there is active air leak in the
ICD to avoid TENSION PNEUMOTHORAX
ICD can be clamped, when there is need to shift the
patient from the bed another location (WHY?)
Moderate suction 20 mm of Hg especially in air leak

UNDERWATER SEAL DRAIN

Principles of Chest Tube Functioning

The idea is to create a one way mechanism
that will let out air of the pleural space and
prevent outside air from coming in.why
would this be a problem?
This is accomplished by the use of an
underwater seal. The distal end of the drainage
tube is submerged in 2cm of H2O.
Types of Drainage Systems
Glass Bottle System:
1 bottle
2 bottle
3 bottle

One bottle
system
Air out

From patient

For small pneumothorax

use only !

Water seal

Two bottle system

From patient
Air out

Collection
bottle
Water seal

Three bottle
system

Patient

3Ch.CDU system

Active
suction

Suction
control
chamber
Collectio
n
chamber

Underwater seal chamb

Nursing Responsibilities/Care of
Patient with Chest Tube
NEVER CLAMP AN INTERCOSTAL TUBE: WHY??
BECAUSE TENSION PNEUMOTHORAX

CAN DEVELOP IF CLAMP IS NOT

REMOVED
Keep
drainage system 2-3 feet below

patients chest
Keep tubing patent; make sure no kinks
or clots present
Observe and record amount of
drainage. >200cc/hr is heavynotify
physician.
Encourage ambulation as ordered.

Amount, Color, and Consistency

Consistency changes from thin, clear fluid

to milky could be evidence of evolving

infection
Changes in drainage from pure liquid to
red could indicate hemorrhage
Decreased drainage may be a sign of
tube displacement, kinked tubing, or a clot
may be obstructing the lumen of the tube
Sudden drainage increases could be
indicative of hemorrhage

 Care of patient s with Intercostal tubes

DRESSINGS:
CHEST XRAY
OBSERVATIONS:
Report immediately chest drainage of >200mls of blood in
1 to 2 hour time frame.
Continuous Sp02 monitoring. Keep Spo2 > 96%.
Observe the swings of fluid in the chest tube bottle.

ASSESS AND REPORT ANY

OF THE FOLLOWING
Sudden drop of Sp02 < 90%
Increased restlessness and anxiety of the patient.
Cessation of swing, or swing < 2cm.
Absent or decreased breath sounds on the side of
the pneumothorax.

 Contents of the chest bottle

Sterile solution that is not toxic to the lungs
Water / saline

ACUTE
Allergic reaction
Bronchopleural fistula
Cardiac injury
Hemorrhage
Hepatic injury
Infection
Intercostal
neurovascular injury
Lung laceration
Re-expansion
pulmonary edema
Splenic injury
Subcutaneous
emphysema

COMPLICATIONS

LATE COMPLICATIONS

Blockage of tube ( clot / lung )

Retained hemothorax
Empyema
Pneumo thorax after tube removal
Infection

When to remove ICD

When lung expansion is satisfied both clinically &
radiologically
No air leak
No bleeding or pus drainage
Clinically patient should be comfortable even after
clamping the ICD.

REMOVAL OF ICD
Explain procedure to patient and place in a
position of comfort
Remove sterile dressing. Cut suture
Ask patient to take a deep breath and hold
Then remove the tube and place a sterile piece of
gauze and airtight over the site.

CONCLUSION
Emergency life saving procedure
Maintaining the patency is critical to avoid
complicati0ns
Subcutaneous emphysema clog /insufficient negative
pressure

THANK YOU