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- Primary pneumothorax following unsuccessful aspiration.
- Secondary pneumothorax.
- Tension pneumothorax following needle decompression
- 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.
- 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.
- 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
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.
- Pain (prescribe simple and/or opioid analgesia).
- 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)
- Second intercostal space (identified by tracing along from the angle of Louis on the sternum)
- Mid-clavicular line
- On the side of the pneumothorax
- Insert a definitive chest drain.
- Perform a CXR
- 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