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Chest Drain

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Chest Drain

Here's a quick run-through of the key points to know for this procedure, which can crop up at either level in the FRCA examination.

Indications

  • Pneumothorax*
  • Pleural effusion
  • Haemothorax
  • Empyema
  • Chylothorax

*Either traumatic, post-operative, as a result of invasive ventilation, or a tension pneumothorax that has already been decompressed with a needle.

Contraindications

  • Nil absolute

Relative

  • Coagulopathy
  • Local infection

Complications

  • Failure
  • Pain
  • Haemorrhage
  • Trauma to surrounding structures
  • Pneumothorax
  • Misplaced drain (including extra-pleural placement which may appear correct on a chest xray)
  • Infection
  • Blocked drain
  • Surgical emphysema

Equipment

  • Sterile drape and chest drain kit
  • Lidocaine
  • Chest drain
  • Scalpel
  • Artery forceps
  • Blunt forceps
  • Sutures
  • Needle holder
  • Gauze and dressing
  • Underwater seal
  • Sterile water

Site

Anterior approach

  • Second intercostal space
  • Mid clavicular line
  • Lateral to internal mammary artery
  • Better for apical air drainage

Lateral approach

  • Fifth or sixth intercostal space
  • Mid axillary line
  • Better for fluid
  • More likely to hit liver or diaphragm

Procedure

  • Monitoring
  • Confirm consent, identity, indications and contraindications
  • Adequate skilled assistance
  • Confirm diagnosis and site with ultrasound where possible
  • Sterile technique
  • Local anaesthetic
  • Skin incision of 2-3cm parallel to ribs in intercostal space, just superior to rib edge
  • Introduce closed forceps through incision into the pleural space
  • Sweep with finger to confirm pleural cavity entered and to check for lung tissue and adhesions
  • Insert drain using forceps
  • Aim cranially if draining air, posteriorly if draining fluid
  • Connect to underwater seal and confirm 'swing' in drain
  • Purse suture to secure drain
  • Dressing
  • Xray to confirm

Afterwards

  • Ensure drain kept below level of patient
  • Serial xrays to monitor progress and confirm placement

Indications to remove drain

  • No longer draining air or fluid
  • Lungs fully expanded on xray
  • No significant leak on coughing or valsalva manoeuvre
  • Some say to clamp drain for 24h then re-xray to confirm no reaccumulation

Contraindications

  • IPPV

Complications

  • Reaccumulation
  • Tension pneumothorax

Here's a really useful video

Cool tweets

Further reading

Thoracocentesis: the chest drain
The purpose of this chapter is to unite information which is otherwise spread across numerous sources. The main audience would probably be the supervisor of training who, upon arriving at work one morning, is greeted by an enthusiastic trainee brandishing the WCA form and demanding to undergo assessment. The supervisor, unprepared for this and possibly hung over, will be unlikely to agree unless a scripted resource is available for them where all the information necessary to answer the WCA questions is available. This chapter is that resource. All the important areas are covered.
Deranged PhysiologyAlex Yartsev
Underwater seal chest drain system
This is another favourite of the college. Specifically, in Question 24.2 from the second paper of 2012 they asked the trainees to label the diagram of one, and then to explain how it differs from a single-chamber system. This topic came up previously in Question 26.1 from the first paper of 2009. In short, the ICU trainee should be prepared to enter into a detailed discussion of chest drain systems.
Deranged PhysiologyAlex Yartsev