Chest drain

Chest drains may be broadly divided into two groups:

  1. Small bore drains inserted via Seldinger technique (lower risk of serious complications and also lower pain scores)
  2. Large bore drains necessitating open insertion

Chest drain insertion in the ED is indicated in a patient with a moderate or large pneumothorax, visible haemothorax or hemo/pneumothorax.

Contraindications for chest drain insertion is generally rare but the only contraindication is severe coagulopathy (bleeding disorder, low platelets or using oral anticoagulant)

Important notes in chest drain insertion: –
  • The ideal position of your patient is lying flat or at 45 degrees, with their hand behind head, or abducted to 90 degrees if they are unconscious. Alternatively, a conscious patient may lean forward against a trolley table.
  • Strongly consider the use of pre-emptive IV benzodiazepines and/or opiates.
  • The preferred site is the ‘triangle of safety’, formed anteriorly by the lateral border of the pectoralis major, laterally by the lateral border of the latissimus dorsi, inferiorly by the line of the 5th intercostal space and superiorly by the base of the axilla
  • Large-bore drains (>24F) are recommended for draining blood and require blunt dissection.
  • Smaller bore drains are appropriate for clearly isolated pneumothoraces i.e. no accompanying haemothorax.
  • Prime the underwater seal with saline not sterile water, so that the drained blood is available for cell salvage in cases of massive blood loss.
  • Note, the underwater seal needs to remain below the insertion site at all times otherwise the contents start to empty into the chest.
  • Maximum dose of local anaesthesia is 3 mg/kg of 1% lignocaine
  • Confirm that the drain lies within the chest wall cavity by noting fogging and swinging of the tube.
  • Request a chest x-ray before the patient leaves the ED to indicate tube position and changing pathology.
  • if the drain points upwards for the haemothorax, or conversely downwards for pneumothorax — No action needed
  • Do not clamp the chest tube or apply suction
Chest drains in trauma: –
  • Observation (rather than chest drain) is acceptable in selected patients with a small traumatic pneumothorax.
  • A chest drain is indicated if a haemothorax is sufficiently large to be seen on the chest x-ray.
  • Unstable tension pneumothorax → Thoracostomy followed by the chest drain insertion and organise a prompt chest x-ray.
  • Stable patients with a tensioning pneumothorax are best served by a chest x-ray beforehand to confirm the diagnosis.
Regarding Tension pneumothorax: –
  • The most common radiological feature found with tension pneumothoraxes is: –
    • widened rib spaces and a flattened hemi-diaphragm on the affected side.
    • Mediastinal shift may be seen in severe cases
  • Decompression of a suspected pneumothorax should be performed before an ‎urgent radiograph: –
    • SpO2 < 92% on O2
    • Systolic BP< 90 mmHg‎
    • Respiratory rate < 10
    • Decreased level of consciousness on O2‎
    • Cardiac arrest
  • Spontaneous tension pneumothorax: Less than 25% of cases will have the ‘classical features’ of neck vein distension, tracheal deviation, hyper-resonance and cardiovascular instability
  • Management of primary tension pneumothorax → insert a large-bore cannula into the pleural space through the second intercostal space in the mid-clavicular line in children or 4th / 5th intercostal space in the mid-axillary line in adults, followed by chest drain insertion.