Last Updated on December 29, 2018 by frcemuser

Indications

• Primary pneumothorax following unsuccessful aspiration.
• Secondary pneumothorax.
• Tension pneumothorax following needle decompression
• Haemothorax.
• Pneumothorax in a ventilated patient.
• Empyema and complicated parapneumonic effusions (pleural fluid pH<7.2).
• Malignant pleural effusion for symptomatic relief
• Large pleural effusions of other etiology.

Contraindications

• Inexperience with technique.
• Refusal by a competent patient.
• Deranged INR/platelets (stop warfarin and correct any coagulopathy).
• Local Infection
• Lung adherent to the chest wall.

Types of chest drain

• Seldinger chest drains are usually smaller drains which are inserted by advancing the drain over a guidewire.
• Large-bore drains are recommended for acute haemothorax to monitor blood loss and may also be necessary if a pneumothorax has failed to resolve despite a smaller drain.

Anatomy

• The 5th intercostal space anterior to the mid-axillary line for most situations.
• Chest drains should be inserted within the ‘triangle of safety’.With the arm abducted, the apex is the axilla, and the the triangle is formed by the:
  • Lateral border of the pectoralis major anteriorly
  • Anterior border of the latissimus dorsi posteriorly
  • Inferiorly, by a line superior to the horizontal level of the nipple and an apex below the axilla

Precautions

Ultrasound guidance: Recent research regarding the morbidity and mortality of chest drain insertion strongly recommends insertion of chest drains under ultrasound guidance.

Drain Insertion: The needle should be inserted just above the upper border of the rib to avoid the intercostal neurovascular bundle.

Confirmation: if the drain is correctly positioned it should swing with respiration and drain fluid or air.

Complications

• Pain (prescribe simple and/or opioid analgesia).
• Infection.
• Bleeding from intercostal vessels.
• Damage to intercostal nerves.
• Poor position of drain: may need withdrawing slightly.
• Blockage of drain: may require flush with 10 mL sterile saline.
• Organ damage: do not insert the sharp trocar into the pleural cavity.
• Bleeding: stop warfarin before insertion and correct any coagulopathy.
• Surgical emphysema may occur with pneumothorax.
• Re-expansion pulmonary oedema(rapid re-expansion of the lung may cause non-cardiogenic pulmonary oedema)

Needle thoracocentesis

Landmarks

• Second intercostal space (identified by tracing along from the angle of Louis on the sternum)
• Mid-clavicular line
• On the side of the pneumothorax

Post procedures

• Insert a definitive chest drain.
• Perform a CXR

Complications

• Bleeding or local haematoma
• Damage to the neurovascular bundle (runs below each rib)
• Re-tension due to tube kinking, dislodging, or failure to progress to a definitive chest drain
• Creation of a pneumothorax
• Lung laceration