Introduction
The pleural space is a thin, fluid filled space between the visceral and parietal pleura. In a healthy 70 kg individual, this space contains a few millilitres of serous pleural fluid, the function of which is to allow the pleurae to slide easily over the lungs during ventilation. The presence of air or fluid (pus, blood, chyle or excessive pleural fluid) impedes the normal function of the lungs, and depending on the symptoms and signs affecting the patient, will require chest drainage.
Usually, the pressure in the pleural space is less than atmospheric. This negative pressure helps maintain partial lung expansion and the magnitude of negativity changes during the respiratory cycle. In inspiration the pressure is approximately −8 cmH2O and in expiration this falls to −4 cmH20. A breach of the pleural cavity leads to development of a positive pressure in this space either equal to or more than atmospheric pressure, leading to a pneumothorax.
History
The earliest known reference to chest drainage dates back to the fifth century Hippocratic texts. Here conservative management of empyemas is described using plants and herbs, and open drainage for persistent infections is well documented including the surgical technique for doing this. Hippocrates gave detailed descriptions of using a scalpel to cut between the ribs, evacuating pus and leaving a hollow tube in for 2 weeks.
Since this, other physicians have described the technique including the leading French physician surgeon Guy de Chauliac in 1395. The first description of a closed chest drainage system was by Hewett in 1876.
Indications
The indications for chest drain insertion are to remove fluid, air or both from the pleural space. Table 9.1 shows the common indications for chest drainage.
Table 9.1 Common indications for chest drainage
| Traumatic haemothorax |
| Large spontaneous or traumatic pneumothorax |
| Benign or malignant pleural effusion |
| Chylothorax |
| Following cardiac or thoracic surgery |
Figure 9.1a shows a chest radiograph of a patient with a large pneumothorax following cardiac surgery, and Figure 9.1b shows the same patient post chest drain insertion. Figure 9.2a shows a chest radiograph of a patient with a left pleural effusion and Figure 9.2b shows the same patient post drain insertion.
Figure 9.1 (a) Radiograph of a patient with a large right pneumothorax (black arrows). (b) The same patient with a right sided chest drain in situ (white arrow) and reinflation of the right lung.
Figure 9.2 (a) Chest radiograph of a patient with a large right pleural effusion (black arrows) and (b) resolution of the effusion with the insertion of a right sided chest drain (black arrows).
Technique
The emergency insertion of a large bore chest drain for the relief of a tension pneumothorax is well described in the Advanced Trauma Life Support guidelines and there are many published step-by-step descriptions of the procedure.
The British Thoracic Society guidelines for the insertion of chest drains were originally developed in 2003 and subsequently updated in 2010. These guidelines were in effect aimed at training and guiding physicians to safely perform this procedure. Figure 9.3 shows the BTS guidelines as an algorithm.
Anatomical Landmarks
The BTS describes the triangle of safety within which chest drains should be placed (Figure 9.4). This triangle is the area bounded by the anterior border of latissimus dorsi and the lateral edge of pectoralis major with the base formed by a line superior to the horizontal line of the nipple.
The advantages of this position are to minimise potential damage to underlying nerve and vascular structures such as the long thoracic nerve and the lateral thoracic artery. Additionally, placement in this area may prevent excessive breast or muscle tissue dissection, reducing the risk of scarring. The presence of a loculated effusion may require a more posterior drain placement but this should be undertaken under the supervision of a specialist or under image guidance. Posteriorly placed drains are more likely to cause discomfort.
Figure 9.3 British Thoracic Society algorithm for the insertion of chest drains.
Figure 9.4 The triangle of safety. Anteriorly the lateral border of pectoralis major, laterally the anterior border of latissimus dorsi and inferiorly a line superior to the fourth nipple.
Preinsertion Preparation
All patients requiring a chest drain should be consented for the procedure (unless unable to do so due to their clinical status) and this consent should be recorded in the clinical notes. Appropriate premedication prior to the procedure can include midazolam or an opioid. Caution with these drugs should be exercised in patients with underlying respiratory disease.
Patients with abnormal coagulation or platelet defects should have these corrected before an elective drain insertion, and for those on warfarin the INR should be allowed to reach 1.5 or below if possible.
Patient Positioning
The ideal position for drain insertion is with the patient upright or at a 45° angle, with the arm on the affected side abducted and externally rotated and placed behind the patient’s head. This exposes the axillary area.
Prior to insertion it is imperative to undertake a clinical examination to confirm the presence of pleural fluid or pneumothorax and to confirm the side of the pathology on a recent chest radiograph. The only exception is in the case of a tension pneumothorax where clinical signs alone are sufficient.
The increasing use of thoracic ultrasonography to identify the presence of an effusion is highly recommended.
Procedure
1. Once the patient is positioned appropriately, the triangle of safety is prepped with antiseptic and draped. The entire procedure must be carried out in an aseptic manner to avoid infection ascending into the thoracic cavity. The rates of empyema following chest drain insertion after trauma are approximately 3% and lead to significant morbidity. One study has identified no infections in a group of 80 patients requiring a chest drain for trauma carried out in an aseptic manner.
2. The procedure equipment is usually available sterile and prepacked in most hospitals. Chest tubes are made of clear plastic and are available in a variety of sizes (diameters) based on the French scale (multiples of 4, e.g. 12F, 16F, 20F, up to 36F). These drains have multiple side holes to allow effective drainage and have a radio-opaque marker strip to help identification on chest radiography. Trocars are occasionally present within chest drains but the routine use of these is not recommended as they can cause undue visceral damage.
The kit should contain:
Sterile drapes
1% lidocaine (in a dose of up to 2 mg/kg)
20 ml syringe
Green and yellow needles (21–25 gauge)
Sterile skin preparation solution (chlorhexidene)
Scalpel
Curved instrument such as a Roberts’s clamp or Spencer Wells
Chest drain (sizes vary, usually 28F and larger for effusions and smaller for pneumothorax)
Skin suture (nylon or silk)
Chest drain tubing
Chest drain bottle primed with sterile water (underwater seal)
Dressing to cover drain insertion site.
3. Next, local anaesthesia is infiltrated using a small gauge needle and by raising a dermal bleb. Lidocaine in a safe dose (up to 2 mg/kg) or an alternative local anaesthetic is used. The next step is to freely aspirate either air in the case of pneumothorax or fluid in the case of an effusion to confirm the pathology. If neither can be done, a chest drain should not be inserted without further image guidance. Studies have shown that image guided placement of drains has a low complication rate of pneumothorax at 3% and a successful insertion rate of over 70%.
4. Once a successful aspirate has been obtained and the local anaesthetic deemed successful, a skin incision just above and parallel to the ribs is made. This incision should be similar in size to the diameter of tube being inserted and the operator’s index finger.
5. Much debate has been had about the size of the chest tubes used. General recommendations are to use a large bore tube in the setting of trauma or acute haemothorax, to facilitate drainage and monitor on-going losses (28–30F). Smaller drains are more comfortable and can be used for pneumothoraces. Blunt dissection into the pleural cavity, skirting the upper border of the ribs to avoid injury to the neurovascular bundle, should be performed, with a finger sweep manoeuvre into the pleural space, in particular with larger drains, to avoid injury to the lung parenchyma and other thoracic organs.
6. Once a chest drain is inserted into the pleural cavity it should be connected to an underwater seal and secured to the skin. A chest radiograph should be requested to assess the position.
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