Section B:
Pleural Interventions: Chest Drain Insertion
Ahmed Yousuf1 and Najib M. Rahman2
1 Glenfield Hospital, Leicester, UK
2 Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
A chest drain is a tube inserted through the chest wall into the pleural space to remove air (pneumothorax), pus (empyema), blood (haemothorax) or fluid (effusion). The drains can be small (8–18 Fr) or large bore (20–28 Fr, also known as a surgical drain). For large‐bore chest drain insertion see Chapter 11.
Use of ultrasound‐guided drain insertion for pleural effusion allows accurate detection of pleural effusion and reduces the incidence of failed procedures and complications (Box 10.1).
Chest drain insertion (Seldinger technique)
The technique was first described in 1953 by Sven‐Ivar Seldinger, a Swedish radiologist. It is an over‐wire technique for percutaneous insertion of catheters (e.g. chest drain, vascular access).
Pre‐drain insertion
Before insertion of a chest drain, all operators should have adequate training and supervision. The following points should be noted before drain insertion:
- Confirm side of effusion clinically and radiologically (latest CXR/CT scan/ultrasound scan for pleural effusion – if trained in chest ultrasound).
- Ensure there are no absolute contraindications to drain insertion (Box 10.2).
- Obtain informed written consent after explaining the indication and risks (bleeding, infection, pneumothorax in case of pleural effusion, damage to vital organs).
- Position the patient appropriately (Figures 10.8 and 10.9).
- Ensure all the necessary equipment is available (Box 10.3).
- Check the patient’s observations (blood pressure, heart rate, oxygen saturations). If the patient is hypoxic or haemodynamically unstable (unless resulting from the condition that requires chest drain insertion), postpone the procedure until the patient’s condition has stabilised.
- For pleural effusion, identify the side and safe site of drain insertion with ultrasound (if the operator or supervising doctor is trained to do so).
- Ensure the patient has a working cannula in case he/she requires emergency intravenous medications.
- Ensure there is another person to act as assistant to help with the procedure or, in case of emergency, to call for help.
- For pleural effusion, identify the side and safe site of drain insertion with ultrasound (if the operator or supervising doctor is trained to do so).
Figure 10.8 The patient is sitting up and leaning over a table. The red shaded area is the ‘no fly zone’ for chest drain insertion which should be avoided in most cases. A study showed that intercostal arteries are exposed within the intercostal space in the first 6 cm lateral to the spine.
Figure 10.9 Decubitus position; the safety triangle is shaded blue.
Source: Havelock (2010). Reproduced with permission of BMJ Publishing Group Ltd.
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