Chest drain
Chest drain
A chest drain is a tube inserted into the pleural cavity which creates a one-way valve, allowing movement of air or liquid out of the cavity.Chest drain insertion is indicated in cases of:
- Pleural effusion
- Pneumothorax not suitable for conservative management or aspiration
- Empyema
- Haemothorax
- Haemopneumothorax
- Chylothorax
- In some cases of penetrating chest wall injury in ventilated patients
Insertion of a chest drain is relatively contraindicated in patients with any of the following:
- INR > 1.3
- Platelet count < 75
- Pulmonary bullae
- Pleural adhesions
Please note, all of the above represent only relative contraindications, addressing respiratory compromise in an emergency situation should always be on an individual case basis.
Once patient consent has been obtained and patient imaging assessed, the patient should be positioned in a supine position or at a 45º angle. The patient's forearm may be positioned behind the patient's head to allow easy access to the axilla. Identify the 5th intercostal space in the midaxillary line. Alternatively, positioning may be determined by ultrasound guidance, British Thoracic Society Guidance 'strongly recommend' use of ultrasound guidance in all cases of fluid within the pleura. The area should be anaesthetised using local anaesthetic injection (lidocaine, up to 3mg/kg). The drainage tube should then be inserted using a Seldinger technique. The drain tubing should then be secured using either a straight stitch or with an adhesive dressing.
Positioning can be confirmed by aspiration of fluid from the drainage tubing, by 'swinging' of the fluid within the drain tubing when the patient inspires and on chest x-ray.
Complications that may occur and which the patient should be advised of in the process of obtaining consent:
- Failure of insertion - the drain may be abutting the apical pleura, in which case it should be pulled back, or may be subcutaneous or in rare cases could enter the abdominal cavity. In both latter cases, the drain should be removed and re-sited.
- Bleeding - around the site of the drain or into the pleural space
- Infection
- Penetration of the lung
- Re-expansion pulmonary oedema
Re-expansion pulmonary oedema may be preceded by the onset of a cough and/or shortness of breath. In the event of concerns regarding re-expansion pulmonary oedema, the chest drain should be clamped and an urgent chest x-ray should be obtained. To avoid re-expansion pulmonary oedema, it is recommended that the drain tubing should be clamped regularly in the event of rapid fluid output i.e. drain output should not exceed 1L of fluid over a short period of time (less than 6 hours).
Removal of the chest drain is dependent upon the indication for insertion:
- In cases of fluid drainage from the pleural cavity, the drain should be removed when there has been no output for > 24 hours and imaging shows resolution of the fluid collection.
- In cases of pneumothorax, the drain should be removed when it is no longer bubbling spontaneously or when the patient coughs and ideally when imaging shows resolution of the pneumothorax.
- Drains inserted in cases of penetrating chest injury should be reviewed by the specialist to confirm an appropriate time for removal.
+PassMedicine Notes
A chest drain is a tube inserted into the pleural cavity which creates a one-way valve, allowing movement of air or liquid out of the cavity.
Chest drain insertion is indicated in cases of:- Pleural effusion
- Pneumothorax not suitable for conservative management or aspiration
- Empyema
- Haemothorax
- Haemopneumothorax
- Chylothorax
- In some cases of penetrating chest wall injury in ventilated patients
- INR > 1.3
- Platelet count < 75
- Pulmonary bullae
- Pleural adhesions
Please note, all of the above represent only relative contraindications, addressing respiratory compromise in an emergency situation should always be on an individual case basis.
Once patient consent has been obtained and patient imaging assessed, the patient should be positioned in a supine position or at a 45º angle. The patient's forearm may be positioned behind the patient's head to allow easy access to the axilla. Identify the 5th intercostal space in the midaxillary line. Alternatively, positioning may be determined by ultrasound guidance, British Thoracic Society Guidance 'strongly recommend' use of ultrasound guidance in all cases of fluid within the pleura. The area should be anaesthetised using local anaesthetic injection (lidocaine, up to 3mg/kg). The drainage tube should then be inserted using a Seldinger technique. The drain tubing should then be secured using either a straight stitch or with an adhesive dressing.
Positioning can be confirmed by aspiration of fluid from the drainage tubing, by 'swinging' of the fluid within the drain tubing when the patient inspires and on chest x-ray.
Complications that may occur and which the patient should be advised of in the process of obtaining consent:- Failure of insertion - the drain may be abutting the apical pleura, in which case it should be pulled back, or may be subcutaneous or in rare cases could enter the abdominal cavity. In both latter cases, the drain should be removed and re-sited.
- Bleeding - around the site of the drain or into the pleural space
- Infection
- Penetration of the lung
- Re-expansion pulmonary oedema
Re-expansion pulmonary oedema may be preceded by the onset of a cough and/or shortness of breath. In the event of concerns regarding re-expansion pulmonary oedema, the chest drain should be clamped and an urgent chest x-ray should be obtained. To avoid re-expansion pulmonary oedema, it is recommended that the drain tubing should be clamped regularly in the event of rapid fluid output i.e. drain output should not exceed 1L of fluid over a short period of time (less than 6 hours).
Removal of the chest drain is dependent upon the indication for insertion:- In cases of fluid drainage from the pleural cavity, the drain should be removed when there has been no output for > 24 hours and imaging shows resolution of the fluid collection.
- In cases of pneumothorax, the drain should be removed when it is no longer bubbling spontaneously or when the patient coughs and ideally when imaging shows resolution of the pneumothorax.
- Drains inserted in cases of penetrating chest injury should be reviewed by the specialist to confirm an appropriate time for removal.