# Intercostal (Chest) Drain Insertion

## Overview

This module describes how to place an intercostal/chest drain, a tube used to remove air, fluid or pus from the intrathoracic space.

## Indications

### Emergency

### Urgent/Elective

## Contraindications

There are no absolute contraindications, but weigh up the risks and benefits in patients with:

## Patient information and consent

### How do I explain this procedure?

“I need to put a tube through the skin of your chest into the area around your lungs. This will help us to drain the air/fluid that is squeezing your lung and causing you to feel breathless.”

### What can my patient expect?

“I will inject something to make the area numb first, but you will still feel me pulling and working in the area; this may feel very uncomfortable. The tube may stay in your chest for a few days, until all the air/fluid has drained, and the area will be tender. Afterwards, I will remove the drain and leave a stitch in your chest.”

### What is my patient’s role?

“Let me know if you have any allergies or a bleeding tendency, or use blood thinners. Fearing blood or needles is normal, but tell me if you have fainted from it. Tell me if it is very painful. I need you to stay very still while I do the procedure, but once the bottle has been connected, it is important that you move around as much as possible to help the fluid/air to drain faster. If you struggle, you may also need a physiotherapist. After the drain has been removed, you need to come back in 10 days so that I can remove the stitch.”

## Preparation

Prepare a trolley with equipment. This procedure requires an assistant and good lighting.

### Documentation

### Equipment

## Site & Positioning

The patient should be positioned supine, seated or reclining, with the ipsilateral arm behind their head.

The chest drain should be

inserted

inserted

To mark the site, use a gentle nail marking or the tip of a needle cap to indent the skin. Do not use a pen as this will wash off with disinfectant.

in the triangle of safety, situated just below a patient’s armpit, bordered by:

## Procedure

Follow medical asepsis with sterile gloves.

## Troubleshooting

The dressing has come loose.

Ensure that the skin is dry before applying the dressing. If you are using strips of adhesive dressing, try longer pieces extending from front to back.

The drain has come out.

If the drain is still partially in situ, cut the sutures and advance the drain until it is in the correct position, then secure the drain again using a fresh suture under local anaesthetic. If the drain has come out completely, it is best to replace it with a fresh drain.

The drain is not swinging, bubbling or draining after insertion.

Advance or retract the drain depending on the depth of insertion. If unsuccessful, consider a clotted haemothorax if blood, or a loculated effusion and call a senior.

The x-ray shows that the drain is inserted too deeply or too shallow.

Cut the sutures and retract the drain until it is in the correct position, looking for swinging, bubbling or drainage, then secure the drain again with a fresh suture under local anaesthetic. Repeat the X-ray.

I have punctured the pleura, but I am unable to insert a finger into the space even after stretching the space.

Some patients have quite narrow intercostal spaces. If you are unable to advance your smallest finger, you may have to consider a smaller tube. Consult a senior.

I have a large patient with lots of adipose tissue and I have lost my tract.

Do not panic. If possible, call a senior. If not, attempt to trace the tract from the skin to the pleura using steps 12 and onwards above. If this is still unsuccessful, you might need to make a second incision, stretching the skin first and marking the spot directly over the intercostal space, then keeping the skin stretched taught during the process. It is essential to have an assistant.

I’m unsure how to remove a chest drain.

Cut the suture just before the first knot and unwind the suture around the tube, maintaining tension. Ask the patient to cough, exhale sharply, or Valsalva while you withdraw the tube in a smooth movement, still maintaining tension on the suture material. The wound should pull closed. Tie the suture off and cut the ends short.

## Risks

## References