Insertion of a chest tube to drain pneumothorax
Equipment required for chest drain insertion • • • • • • • • • • • • • • •
Eric Lim Peter Goldstraw
Intercostal chest tube drainage with an underwater seal is a simple and effective method of eliminating air from the pleural space. It is undertaken as an elective or urgent procedure. Emergency chest drainage for tension pneumothorax is undertaken using a widebore cannula in the second intercostal space (mid-clavicular line) of the affected side. Knowing when and how to place an intercostal chest drain safely is a valuable skill for all doctors. When to insert a chest drain Not all pneumothoraces require chest tube drainage. The average rate of absorption of air in the pleural space occurs at about 1%/day. Expectant management is a reasonable option for patients who are not compromised, with a small and non progressive spontaneous pneumothorax. Chest drain insertion is required for patients with moderate to large spontaneous pneumo-thoraces and pneumothoraces associated with trauma. Patients with a history of multiple pneumothoraces or who have undergone previous thoracic surgery may have adhesions. As a result, areas of lung can adhere to the chest wall. Under these circumstances, chest drain insertion by an inexperienced person may lead to inadvertent lung perforation. If difficulty is anticipated, expert advice or assistance should be sought.
Sterile gown and gloves Antiseptic solution Sterile gallipot for antiseptic solution Sponge-holding forceps Swabs Sterile disposable drape 10 ml syringe 21G needle 10 ml 1% lidocaine Scalpel with a No. 11 blade Roberts clamp Chest drain (the standard size is 28F) No. 2 silk stitch on a hand-held needle Drain bottle (primed with saline) Sterile connecting tubing
Opinions vary on the ideal size for a chest tube. It is influenced by the size and build of the patient. Its aim is to drain air. The flow in a chest tube is governed by the Fanning equation that relates turbulent flow to the fifth power of the radius of the tube. If the flow in the tube is not sufficient to drain the air leak, the lung will not expand fully. Therefore, the largest tube that can fit comfortably within the intercostal space should be used 1
posteriorly by the posterior axillary line, anteriorly by the lateral border of pectoralis major, and overlies the 3rd to 5th intercostal spaces. The surgical field is prepared with a generous coat of antiseptic solution and the intended spot marked by palpation; the antiseptic leaves an imprint as it dries. A small hole is cut in the centre of a sterile paper drape, which is applied to the chest wall, such that the antiseptic imprint lies within the centre of the hole. About 1–2 ml of 1% lidocaine is then injected to create a transverse wheal, to demarcate the length and position of the skin incision. The tip of the scalpel blade is used to make a skin incision large enough to admit the operator’s index finger comfortably. Blunt dissection can proceed painlessly through the subcutaneous fat up to deep fascia without the need for lidocaine. Once the deep fascia is reached, the intercostal space becomes distinctive. Further lidocaine, 8 ml, is used to create a field block by injecting multiple intercostal nerves. The needle is advanced to identify the rib immediately superior to the chosen intercostal space and ‘walked’ down the rib until soft tissue is felt. The needle is then angled 45° upwards and the syringe
Preparation and positioning All the necessary equipment should be available before scrubbing up (Figure 1). To alleviate the patient’s anxiety, it is helpful to explain the procedure, benefits and risks. The patient is then positioned lying, shoulder elevated and undressed to the waist with the arm abducted at 90° (Figure 2). The arm may be held behind the head, but this often results in a slow downwards drift as the patient becomes tired or experiences pain. Absorbent pads are placed under the patient to prevention soiling of the clothes or bed. How to insert a chest drain The position of the skin incision depends on which intercostal space the chest drain is introduced through. Usually the 4th intercostal space is chosen, just anterior to the mid-axillary line. The triangle (or more correctly quadrangle) of safety is bounded
Eric Lim is Specialist Registrar in Cardiothoracic Surgery at Papworth Hospital, Cambridge, UK. He qualified from Sheffield and trained in London and Cambridge. Peter Goldstraw is Consultant Thoracic Surgeon at the Royal Brompton Hospital, London, and Professor of Thoracic Surgery at Imperial College, London, UK. He was educated at Birmingham University and undertook his cardiothoracic training in Scotland and South Africa. His research interests are acute respiratory distress syndrome, lung volume reduction surgery, and the surgical treatment of lung malignancies.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 6:12
2 Position for chest drain insertion.
© 2005 The Medicine Publishing Company Ltd
aspirated to ensure that the tip does not lie within the vessels of the neurovascular bundle before injecting 1% lidocaine, 2–3 ml. Using the same method, a further 2 ml is injected in the targeted intercostal space to block the intercostal nerve anteriorly and also in the intercostal nerve of the space above and below the targeted intercostal space (Figure 3). When the intercostal block is effective, the Roberts clamp (a heavy-duty, serrated large artery forceps) is used with gentle but firm pressure to spread the intercostal muscles apart. Dissection occurs superiorly, starting at the inferior aspect of the targeted intercostal space (to avoid the neurovascular bundle). The Roberts clamp should enter the pleural cavity easily once the deep fascia and muscle layer has been negotiated; a gush of air is normally audible at this point. The jaw of the Roberts clamp is opened to dilate the puncture site, followed by the index finger to dilate a tract into the pleural space. This is an important step. The tip of the finger detects any adherent lung tissue. If all is well, the tract is dilated in the process to admit a 28F chest drain comfortably. If this manoeuvre is not performed satisfactorily, it can become difficult to find the tract for the chest drain because the tissues retract to seal the path made by the Roberts clamp. Once satisfied that no lung tissue is adherent to the chest wall, a 28F drain is introduced into the pleural space without a trocar. To direct the drain to an apical or basal position, thoracic surgeons may leave the trocar engaged in the drain but with its sharp tip usually more than 2.5 cm (1") away from the tip of the chest tube to facilitate the initial direction of the chest tube. The drain and trocar can then be angled upwards within the thorax to achieve an apical position or directed postero-inferiorly to achieve a basal position. Once the first 5 cm (2") of the drain are directed within the thoracic cavity, the trocar is withdrawn. The drain is advanced continuously until a change in resistance is felt as the tip abuts the pleural apex or base of the diaphragm. Occasionally, pain is experienced in the neck and shoulder as the tip of the drain impinges on the apex. Withdrawal of the drain by 2.5 cm (1") ensures a perfectly apical position and alleviation of pain. At this point, make a mental note of the distance marker at skin level.
Securing the chest drain
3–4 locking knots
Double throw in a single direction to form a slip knot c
Complications Perforation of the lung is a potential complication of chest tube insertion. It usually occurs when a chest drain is forcibly inserted with the trocar fully engaged, such that the point sticks out from the tube. Warning signs are bleeding and a brisk air leak. Laceration to the intercostal artery can result in impressive haemorrhage. If this occurs, fluid resuscitation and clamping of the drain to tamponade the bleeding is warranted. Both these complications require consultation with a thoracic surgeon and usually necessitate surgical exploration.
Direction of dissection
Site for lidocaine intercostal nerve block 3
ANAESTHESIA AND INTENSIVE CARE MEDICINE 6:12
3–4 locking knots with sufficient tension to indent the tubing
Once the drain is sited, attach it to an underwater seal. Entry into the thoracic cavity is suggested by: • fogging of the tube • a respiratory swing • bubbling on coughing. The drain is then sutured with a No. 2 silk suture as a horizontal mattress suture, with a double throw to secure the initial tie (Figure 4). Check that the distance marker on the skin has not changed before tying a knot around the tubing to secure the chest drain. It is important to ensure that the tension on the knot is sufficient to indent the chest tube, to ensure that the drain does not displace. This suture also acts as a purse string to secure the wound after chest drain removal. It is standard practice to obtain a chest radiograph following chest drain insertion to: • ensure that the drain lies within the thoracic cavity • evaluate the position of the drain • ensure that the lung re-expands • screen for complications (such as a new effusion from intrathoracic bleeding).
Vein Artery Nerve
Cut here to remove the drain and pull on the sutures to seal the incision
Site for intercostal nerve blocks Anterior
© 2005 The Medicine Publishing Company Ltd