Chest Drain Insertion:( ICD ) Procedure, Management and Complications

Chest Drain Insertion 

Indications

• Treatment of a pneumothorax in a patient requiring positive pressure ventilation. 
• Treatment of a large pneumo/hydro/haemothorax. 
• Following needle decompression of a tension pneumothorax. 
• Management of broncho-pleural fistula. 
• Management of empyema. 
• Management of localized pneumothorax causing ventilatory compromise. 

Equipment preparation 

Depending upon the size, site and anticipated mature of the pleural collection, select an appropriate drain. Smaller drains are preferable for most indications. The exceptions requiring larger drains with multiple (>3) holes are:

• Bronchopleural fistulas with a large gas leak.
• Haemothoraces with ongoing bleeding. 
• Viscous/highly purulent empyemas. 

This procedure should always be performed with strict adherence to aseptic precautions. 

Suggested items :

• 2% chlorhexidine-based skin cleaning fluid and reservoir. 
• Sterile gauze. 
• Local anaesthetic, syringe and needle. Consider adjunctive systemic analgesia and sedation. 
• For seldinger technique :
• Bedside ultrasound 
• Needle and syringe 
• J-wire
• Scalpel
• Dilator
• Drain with stiffener 
• 3-way tap
• For blunt dissection/thoracostomy  techniques 
• Scalpel
• Blunt dissection forceps (e.g. Curved Robert's)
• Drain
• Collection bag/underwater seal drainage bottle/Heimlich valve
• Suture 
• Appropriate dressing 

Procedure 

Seldinger technique 

Though not obligatory, it is undoubtedly best practice to perform a thoracic ultrasound immediately prior to aspiration to define the anatomy avoid visceral injury. When aspirating small or complex collections, continuous ultrasound guidance is essential. 

Clean the area and apply sterile towels. 

Infiltrate a small volume of local anaesthetic into the subcutaneous and intradermal space, avoiding the neurovascular bundle which runs along the inferior border of the rib.

 

Insert the needle, whilst aspirating using a syringe, until air/fluid is freely withdrawn. Having entered the pleural space, disconnect the syringe and gently insert the J-wire, despite its soft tip, can puncture and damage visceral organs, in particular consolidated lung. Withdrew the needle, leaving the wire in situ. Make a small stabbing incision through the skin at the exit site of the wire.  This is most easily performed by placing the flat surface of a no 11 blade on the wire and sliding it into the skin. Insert the dilator into the pleural cavity over the wire; be cautious not to insert this too far and angle the tract formed towards the desired location (apical for simple pneumothorax: posterior-basal for fluid). Leave the dilator in place for a few movements, then remove, again leaving the wire in situ. Depending upon the drain design (straight, curved or pigtail ), ensure it is mounted on its stiffener ( if required ) and gently insert, over the wire, directing the tip as required.  Withdrew the wire and stiffener then connect to a closed 3-way tap. Aspirate via the tap to ensure adequate placement and anchor with a holding suture. Connect to the appropriate drainage device, having first obtained any desired specimens. Pad and stick to the skin using a small dressing, ensuring that the drain will not kink and that the 3 -way tap is accessible and will not cause a pressure injury. One possible technique is to stick the drain in line with the ribs directed anteriorly. 

Blunt dissection /thoracostomy techniques 

The site of drain insertion should usually be in the so-called 'safe triangle '. This is made up of the anterior border of latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and an apex below the axilla.

Infiltrate a small volume of local anaesthetic into the subcutaneous and intradermal space, avoiding the neurovascular bundle which runs along the inferior border of the rib. As an alternative, consider performing an intercostal nerve block in the relevant space and the space above and below. Perform a diagnostic aspiration to ensure air/fluid can be drained from the intended insertion site.

Make a 2-3 cm incision along the upper edge of the rib that make the inferior border of the relevant rib space. Using forceps, bluntly dissect into the pleural cavity. Insert a finger into the pleural cavity and perform a sweep. This act as a diagnostic examination, enhance the blunt dissection and can potentially break down loculations, if present. Take hold of the drain tip with the forceps by placing them in through the distal side hole and out through the end hole. Prior to drain insertion consider disconnecting the patient from any positive pressure ventilation to reduce the chance of intrapulmonary lung placement. Gently insert the drain with the forceps and release. Try to position the drain apically for a pneumothorax and posterior-basally for fluid. Be cautious of intrapulmonary and mediastinal drain placement. To ensure adequate position and to obtain any desired specimens, aspirate using a bladder-tripped syringe and connect to underwater sealed drainage bottle. Suture one end of the incision and place an anchoring suture around the drain. Avoid purse string sutures and use monofilament suture material. Pad and stick to the skin using a small dressing, ensuring that the drain will not kink. One possible technique is to stick the drain in line with the ribs directed anteriorly. 

Management 

Following insertion, obtain a CXR to assess the position. If functionally inadequate, regardless of radiological position, manipulate the drain accordingly or remove and, if necessary, re-insert. In difficult circumstances, seek radiological advice and consider CT guidance or thoracic surgical assistance. 

Draining fluid off at too high a rate can result in re-expansion pulmonary oedema. This is rare, especially in patients receiving positive pressure ventilation. The risk can be minimized by limiting drainage to a maximum of 1500ml/hr by clamping the drain. In all other instance, clamping of the drain, except transiently, should be avoided. Clamping has no place in the management of pneumothoraces.

For small drains, consider flushing 6-12 hourly with 5-10ml of 0.9% saline to assess and maintain patency. 

If connected to an underwater seal drainage bottle, the meniscus in the tube should transduce intrapleural pressure and swing with respiratory phase. If it does not, the drain is blocked, kinked or has become mislocated. Examine, flush and re-image as necessary. 

Removal 

• Remove the drain as soon as it is no longer required or has failed. Close the drain site with a suture if required. 

Complications 

• Bleeding from the intercostal vessels or a damaged viscous/organ. This is rare but can be fatal.
• Trauma to lung, heart, liver, or spleen. Again serious trauma is rare but can be fatal.
• Infection from superficial drain site infection to empyema and lung abcess.