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Ovid: Oxford Handbook of Respiratory Medicine

Authors: Chapman, Stephen; Robinson, Grace; Stradling, John; West, Sophie Title: Oxford Handbook of Respiratory Medicine, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Part 4 – Practical procedures > Chapter 67 – Chest drains Chapter 67 Chest drains P.686
Indications, drain types, complications Chest drain insertion is associated with significant morbidity and mortality, and careful consideration should be given to the precise indication for drainage. Ultrasound-guidance may be required for small or loculated effusions (e.g. empyema). Indications

  • Tension pneumothorax (following needle decompression)
  • Symptomatic pneumothorax with failed aspiration or underlying lung disease
  • Complicated parapneumonic effusion and empyema
  • Malignant pleural effusion for symptomatic relief and/or pleurodesis
  • Haemothorax
  • Traumatic haemopneumothorax
  • Rarely, for symptomatic effusions of other aetiology.

Contraindications

  • Inexperienced operator
  • Lung adherent to chest wall
  • Bleeding tendency (a relative contraindication; routine measurement of platelet count and clotting in the absence of risk factors is not required)
  • Post-pneumonectomy (not a contraindication, but discuss with cardiothoracic surgical team; imaging may be required for drain placement).

Types of chest drain Traditional trocar drains consist of a flexible plastic tube surrounding a metal rod with a blunt tip, and are available in a variety of sizes. When inserted incorrectly, or with excess force by an inexperienced operator, they can cause significant harm and even death. Blue, portex drains are inserted over a flexible plastic introducer in a similar manner to trocar drains; they are available in a range of sizes, up to 28F. Newer, Seldinger-style drains involve sliding the drain into the pleural cavity over a guide-wire. They are safer than trocar drains, but still require experience and care to be inserted safely and comfortably. Small (10–14F) drains are more comfortable and are adequate for the majority of situations. Large bore chest drains (28–32F) are only rarely required, e.g. secondary pneumothorax with large air-leak and/or surgical emphysema; acute haemothorax. Complications

  • Pain—very common. Opiate analgesia frequently required
  • Inadequate drain position—may require withdrawal or insertion of new drain
  • Surgical emphysema (in pneumothorax)—air leaks into subcutaneous tissues. May occur if tube blocked or positioned with holes subcutaneously, or with very large air leaks. See page 296 for management
  • P.687

  • Infection—empyema rate around 1%, perhaps higher in trauma patients
  • Organ damage (e.g. lung, liver, spleen, heart, great vessels, stomach)—particularly if sharp trocar used. Intrapulmonary placement results in significant, continuous bubbling and bleeding; this may occur in up to 6% of all drain insertions. Drainage of gastrointestinal contents suggests bowel perforation (or oesophageal rupture as the cause of the effusion)
  • Haemorrhage into drain—bloody pleural fluid is a common finding (e.g. in malignant effusions), but unexpected large volume drainage of frank blood suggests damage to organs or intercostal vessels. Clamp the drain and leave it in place. Urgent imaging and surgical referral
  • Re-expansion pulmonary oedema (page 297)
  • Vasovagal reaction
  • Sudden death due to vagus nerve irritation reported.

P.688
Insertion technique An assistant is required.

  • Discuss procedure with patient and obtain written consent (unless emergency situation).
  • Insert IV cannula.
  • Consider sedation (e.g. midazolam 2–5 mg IV or diamorphine 2.5–5 mg IV) with oxygen saturation monitoring; be cautious in patients with severe underlying lung disease or respiratory failure.
  • Position patient lying with bed head at 30°, with insertion side of trunk rotated about 45° upwards, and arm on insertion side behind their head; stand behind the patient. Alternative position is with patient sitting forward, leaning over a table.
  • Double-check correct side from chest examination and CXR.
  • Choose insertion site: ideally within ‘triangle of safety’, which avoids major vessels and muscles (boundaries: anteriorly, anterior axillary line and border of pectoralis major; posteriorly, posterior axillary line; inferiorly, horizontal to level of nipple in man or fifth intercostal space in woman). More posterolateral approaches are safe but less comfortable for the patient when lying; avoid posteromedial approaches close to spine, as intercostal artery drops medially to lie in mid-intercostal space.
  • Sterile skin preparation. Wear sterile gloves and gown.
  • Infiltrate skin, intercostal muscle, and parietal pleura with 10 ml of 1% lidocaine. Aim just above the upper border of the appropriate rib, avoiding the neurovascular bundle that runs below each rib. The subcutaneous fat lacks pain receptors and does not require anaesthetic. The parietal pleura however is extremely sensitive; use the full 10 ml of lidocaine.
  • Verify that the site is correct by aspirating pleural fluid or air. Occasionally, a green (21G) needle may be too short in obese patients, and a longer needle is required. If unable to aspirate fluid or air, do not proceed with drain insertion; consider image-guided drainage.
  • Whilst waiting for anaesthetic to work, prepare drain and connections. Assistant should prepare underwater seal.
  • Insert drain:
    • Trocar drains Small (1 cm) skin incision parallel to rib. Consider horizontal mattress stitch across incision to facilitate later closure. Dissect intercostal muscles with blunt forceps (e.g. Spencer–Wells)—the fibres can be teased apart by opening and then removing the forceps; do not close forceps within the chest, this may damage underlying structures. This blunt dissection may take some time. Insert trocar and drain smoothly and gently—there should not be any significant resistance. Never apply force when inserting a chest drain. Once the chest wall has been entered, withdraw the trocar a few centimetres and insert the drain into the pleural cavity. Never insert the trocar blindly into pleural cavity. An alternative approach is to remove the trocar and grip the end of the chest tube P.689
      with blunt forceps, and use these to guide the tube into the chest. Aim towards the apex for a pneumothorax, and the lung base for a pleural effusion. (Note—in emergencies, or in patients with extreme obesity or subcutaneous emphysema, it may be appropriate to make a larger initial incision and insert an index finger to assist the drain track.)
    • Seldinger drains Gently insert the introducer needle and check that air or fluid can be easily aspirated through it with a syringe. Remove syringe. Smoothly insert the guide-wire through the introducer needle. Remove introducer needle. Slide plastic dilator around guide-wire to enlarge the entry-track. Remove the dilator and slide the drain into the pleural cavity over the guide-wire. Do not let go of the guide-wire at any time. Remove the wire when the drain is within the chest.
  • Connect the drain to underwater seal bottle via a three-way tap and tubing. If the drain is correctly positioned in the pleural space it should swing in time with respiration, and drain air or fluid.
  • Stitch and tape the drain in place on the chest wall.
  • Ensure adequate analgesia.
  • Warn the patient not to disconnect the tubing or lift the underwater bottle above the level of the insertion site on the chest; supply a ‘chest drain information leaflet’.
  • Obtain CXR to check position. The ‘ideal’ tube position (apex for pneumothorax, base for effusion) is not necessary for effective drainage, so do not reposition functioning drains on this basis. CT may be useful in confirming drain position in certain circumstances. Drains are often positioned in fissures, but in most cases this does not affect their functioning.
  • Small drains may need regular flush to ensure potency; prescribe 10 ml normal saline flush to drain tds.

Further information BTS guidelines for the insertion of a chest drain. Laws D, et al. Thorax 2003; 58 (suppl. II): ii53–ii59 P.690
Drain management General points

  • Patients should ideally be managed on a specialist ward by experienced nursing staff. ‘Chest drain observations’ should be charted regularly, including swinging, bubbling, and volume of fluid output
  • If drain water level does not swing with respiration, the drain is kinked (check underneath dressing, as tube enters skin), blocked, clamped, or incorrectly positioned (drainage holes not in pleural space; check CXR). Occluded drains may sometimes be unblocked by a 30 ml saline flush. Non-functioning drains should be removed (risk of introducing infection)
  • Suction is sometimes used to encourage drainage, although there is a lack of evidence regarding its use. Consider in cases of pneumothorax with persistent air leak, or following chemical pleurodesis. Suction should be high volume/low pressure, typically starting at a level of 5 cm H2O and increasing to 10–20 cm H2O. It is often painful and may not be tolerated by the patient.

To clamp or not to clamp? Never clamp a bubbling chest drain (risk of tension pneumothorax). Clamping may be considered in two situations:

  • To control the rate of drainage of a large pleural effusion. Rapid drainage of large volumes may result in re-expansion pulmonary oedema; clamping, e.g. for one hour after draining 1 litre, may prevent this
  • To avoid inappropriate drain removal in cases of pneumothorax with a slow air-leak, when bubbling appears to have ceased. Clamping of a drain for several hours followed by repeat CXR in such situations may detect very slow or intermittent air leaks. This is controversial, however, and should only ever be considered on a specialist ward with experienced nursing staff. If the patient becomes breathless, the drain should be immediately unclamped.

Drain removal Quickly and smoothly remove the drain whilst patient is breath-holding in expiration (although opinions on this differ—some recommend removal in maximal inspiration). Tie previously placed mattress suture, if applicable. Apply dressing. CXR to document lung position.

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