Figure 6.1
Safe triangle
A more posteriorly located chest tube may be uncomfortable as the patient may lay on it, causing pain and kinking of the tube with subsequent clogging. In general the skin incision should not be placed posterior to the spina iliaca anterior superior.
If there is a need for a chest tube placed posteriorly (i.e. to drain an empyema), there should be padding placed on the chest tube to minimize discomfort and tube issues.
6.1.1 Monaldi Position
The so-called Monaldi position (V. Monaldi 1899–1969) using the second intercostal space in the midaxillary line for chest drain insertion should not be used in the author’s opinion. This chest tube position was previously used for draining apical pneumothoraces. These patients are frequently young with spontaneous pneumothoraxes and the incision is in a very visible location. If there are problems with the scar, such as a keloid, it is very unsightly. Additionally the intercostal space in the location is very narrow causing more pain related to the chest tube and is another reason to avoid this access.
The again and again quoted “Bülau-Position” does not exist! Gotthard Bülau (1835–1900) neither developed a drainage system nor described localization of a skin incision for chest tube insertion. He became famous as he was the first who used the Heber principle, a passive permanent suction, (see Chap. 5) in the conservative treatment of an empyema. He used the Heber drain successfully for the first time in 1875 in a carpenter suffering from a pleural empyema and published the methods in 1891 [3].
6.1.2 Posterior Suprascapular Access
Posterior suprascapular access is rarely used. The indication for this placement is in a postoperative patient with pneumothorax where there are adhesions to the chest wall. If there is concern for parenchymal damage using a more “conventional” access, this could be used. One must affirm there is a real need for a chest drain in this patient with an “apical pneumothorax” with symptoms or is the chest tube just treating a stuck lung for “cosmetic” reasons on the x-ray!
The fourth intercostal space is located two fingerbreaths below the nipple in men. In women the fourth intercostal space is at the level of the submammary fold. Skin incisions should not be placed posterior of the spina iliaca anterior superior.
6.2 Informed Consent
Medico-legal aspects are more and more important in daily clinical work. Thus, with the exception of an emergency procedure, informed consent has to be obtained from the patient. The discussion and documentation should include:
Indication for chest tube insertion
Therapeutic alternatives (if present)
Explanation of the procedure
Potential complications
Further clinical course
The consent must be documented in one of the commercial available forms. At least according to German law, a copy of this form has to be handed over to the patient.
6.3 Patient Positioning
It is crucial to remember that the insertion of a chest tube in many cases is an urgent or emergent procedure. This may be the first invasive for the patient after admission. The circumstances surround positioning and placement may be uncomfortable and traumatizing for the patient, which can make future interactions between patient and physician somewhat more difficult!
Patient positioning depends on the location chosen for drain insertion. The patient has to be positioned in a way that he feels comfortable, minimizes (additional) pain and in case of large effusion, dyspnea is not worsened.
Most often supine positioning will be chosen sometimes with the upper body elevated. Once the patient is in a safe and comfortable position, the arm of the side of intervention is placed next to the body or, in patients with sufficient energy and vigilance, behind the neck (Fig. 6.2).
Figure 6.2
Supine position
In patients with a large effusion, lateral decubitus positioning may be helpful. The patient is stabilized with pillows. This positioning helps to prevent contaminating the surrounding area with any fluid (Fig. 6.3).
Figure 6.3
Lateral decubitus position
If the intention is to place a chest tube in the suprascapular location, the patient is in a seated position with the physician standing behind him.
6.4 Instruments
A procedure set that includes all requires instruments and disposables is strongly recommended. This guarantees availability of all utensils at all times. In an emergency situation such a set may save important time! Whether this set is individually composed or delivered from a manufacturer Fig. 6.4 is not the issue. By using procedure sets adherent to a SOP used in most centers today this is a supported practice.
Figure 6.4
Procedure set for inserting a chest drain (Courtesy of B.Braun-Aesculap)
6.5 Different Types of Drains
Drains can be differentiated by material, diameter, configurations (straight or angled) as well as by the presence of a second lumen for irrigation Fig. 6.5 (details see Chap. 4).
