# 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

1. Clinically unstable, trauma-related, or tension pneumothorax only after the tension has been released by needle thoracostomy

2. Hemo- or large pneumothorax

3. Esophageal rupture with gastric leak

### Urgent/Elective

1. Malignant pleural effusion

2. Pleurodesis—treatment with sclerosing agents

3. Recurrent pleural effusions

4. Complex parapneumonic effusion or empyema

5. Chylothorax

6. Post-operative care

## Contraindications

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

1. Uncorrected coagulopathy

2. Multiple pleural adhesions

3. Emphysematous blebs

## Patient information & 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

1. Patient notes

### Equipment

1. Sterile gloves

2. PPE, especially plastic apron, eye protection, and protective footwear

3. Alcohol-based hand rub

4. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

5. A suture pack
   A suture pack

   Should contain sterile gauze, a well or bowl, curved forceps/haemostats, scissors, needle holder, scalpel handle, and toothed forceps.

6. Skin disinfectant
   Skin disinfectant

   Commonly used preparations include 0.5-2% chlorhexidine in 70% alcohol (Steriprep), or 10% povidone iodine. There is no consensus on the superiority of one agent above another. Caution: chlorhexidine solutions may be associated with burns and skin breakdown in infants < 2 months old.

7. A size 2-0 suture. Use a Colt needle if available.

8. An aspiration needle (ideally blunt fill) and an injection needle

9. A 5-10 ml syringe

10. A vial of lignocaine (usually 2% with adrenaline)

11. An alcohol swab

12. A scalpel blade

13. Intercostal drain of

    appropriate size
    appropriate size

    36-40 French usually used for trauma to evacuate large clots

14. Drainage system
    Drainage system

    Most centres have box shaped plastic drainage systems which are already connected. If not, fill the glass drainage bottle with 300 ml of sterile water and connect the underwater drainage system.

15. Linen saver

16. Transparent dressing (Large Opsite/Tegaderm)

## 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:

1. The 5th intercostal space inferiorly

2. The lateral border of latissimus dorsi posteriorly

3. The lateral border of pectoralis major anterior

4. The base of the axilla as the apex of the triangle

## Procedure

Follow medical asepsis with sterile gloves.

1. Perform hand hygiene.

2. Place a linen saver under the patient’s arm.

3. Open the sterile pack and create a sterile field on a clean, dry surface. Use sterile gauze to pick up and rearrange items on the sterile field and dispose of it afterwards. Pour disinfectant into the well. Open the suture, scalpel blade, chest drain, dressing, needles and syringe onto the sterile field.

4. Place beside the field: sterile gloves, lignocaine, alcohol swab.

5. Perform hand hygiene and don sterile gloves.

6. Clean the incision site with gauze soaked in skin disinfectant, working from the centre outwards, covering an area at least 5 cm across. Don’t touch the non-sterile skin after cleaning, and dispose of the gauze immediately. Allow to dry.

7. Drape the incision site with a sterile sheet if available in the pack.

8. Draw up
   Draw up

   An assistant should clean the top of the lignocaine with an alcohol swab and hold it for you to draw it up.

   4-5 ml lignocaine with the blunt fill needle using an assistant. Discard the needle and attach the injection needle to the syringe. If using a dental syringe, use 1-2 dental cartridges.

9. Anaesthetise : Insert the needle at the incision site, aiming for the rib just below the incision site. Once you hit bone, aspirate to check for blood. Inject lignocaine while pulling back until just under the skin surface. Repeat this, aiming for the

   pleura
   pleura

   Provide sufficient anaesthesia to the pleura as this will ensure more comfort and cooperation from the patient.

   just above the rib.

10. Attach the scalpel blade to the scalpel handle using a needle holder. Never attempt to attach the blade using your fingers. Clamp the distal end of the intercostal drain.

11. Make a 2-3 cm incision through the skin parallel to the ribs, aiming for the

    top edge
    top edge

    Aiming over the top of the rib reduces the risk of injuring the neurovascular bundle, which lies underneath the edge of the rib.

    of the underlying rib.

12. Use curved forceps to

    bluntly dissect
    bluntly dissect

    Advance with the forceps closed, then open them to tear apart tissue. Close them and advance again. Repeat until you reach the pleural space.

    into the pleural space. You should feel a pop when you enter this space. It might be necessary to add some force. Warn your patient. Stretch the space open with your forceps.

13. Withdraw the forceps and quickly

    insert a small finger
    insert a small finger

    Do this quickly as large amounts of blood or fluid can suddenly be expelled from the chest cavity.

    into the incision, feeling and confirming that you are in the pleural space. This also loosens up any adhesions that might be causing the lungs to stick to the chest wall.

14. To

    insert the tube:
    insert the tube:

    use the curved forceps to grip the tip of the intercostal drain and insert it. Release the forceps and continue inserting the drain, guiding it posteriorly and superiorly, and ensuring all the drainage holes are well inside the chest (approximately 5-10 cm).

15. While holding the drain in place, connect the intercostal drain to the drainage system, unclamp it, and observe for bubbling, swinging, or

    drainage
    drainage

    If a large amount of blood or fluid (1-1.5 litres) drains in a very short amount of time, clamp the tube. If the fluid is blood, there might be an intrathoracic arterial injury. Call a senior and monitor the patient. If fluid, keep the tube clamped and defer further drainage for 24 hours to prevent fluid shifts from the intravascular compartment, resulting in haemodynamic instability.

    .

16. Note the depth of insertion on the intercostal drain before securing it.

17. Secure the drain: use a U-shaped or purse string stitch to suture the drain in place. Place the stitches about 2-3mm from the wound edges to prevent eversion of the wound margins after closure.

18. Cut off the needle and pull the suture through until the two ends are equally long. Knot them together halfway down the length of the suture. Thread the curved forceps through the visible stitch. Wind the suture around the base of the tube until reaching your knot. Ensure winding is tight enough to cause a slight kink in the tube. Grip the suture with the curved forceps and pull it through. Split the ends and wind them around the tube, knotting them together after each wrap. Complete the securing with several knots.

19. Gently tug on the tube to ensure that it remains in position. Check once again that the drain is still swinging, bubbling or draining.

20. Dress the wound with gauze and a

    transparent dressing
    transparent dressing

    Cut a slit in the dressing to make a space for the tube to protrude from the dressing, or use multiple dressings to close the site.

    .

21. Dispose of sharps and medical waste safely.

22. Take a chest X-ray as soon as possible after insertion to check for the position of the drain.

## 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

1. Minor bleeding and pain

2. Haemothorax or tension pneumothorax

3. Perforation of major vascular structures or organs

4. Surgical emphysema

5. Reexpansion pulmonary oedema

6. Local infection or pleural infection

7. Recurrent pneumothorax

8. Sharps injury to healthcare personnel

## References

1. Intercostal drain insertion. Oxford Medical Education. 2014. Available from: https://oxfordmedicaleducation.com/clinical-skills/procedures/intercostal-drain/

2. Burns EA, Korn K, Whyte J, Thomas J, Monaghan T. Chapter 18: Practical Procedures. In: Oxford American Handbook of Clinical Examination and Practical Skills, First Edition. 2011. New York: Oxford University Press.

3. Henning P. Underwater chest drain insertion. In Neonatology: A guide for doctors. Department of Paediatrics and Child Health and Stellenbosch University. Tygerberg Hospital South Africa. 2012. p. 162-163

4. Joolay Y, Horn A, et al.Insertion and removal of intercostal chest drain. In: Neonatal Guidelines and Drug Dosages. Division of Neonatal Medicine Groote Schuur Hospital. 2012. p. 133-134