Indications include drainage of air (pneumothorax), fl uid (effusion), blood
(haemothorax), or pus (empyema) from the pleural space.
Insertion technique
Use 28Fr drain (or larger) for haemothorax or empyema; 20Fr will
suffi ce for a pure pneumothorax. Seldinger-type drains with an integral
guidewire are now available. The drain is usually inserted through the
5th intercostal space in the mid-axillary line, fi rst anaesthetising skin
and pleura with 1% lidocaine. Ensure that air/fl uid is aspirated.
Make a 1–1.5cm skin crease incision, create a track with gloved fi nger
(or forceps) to separate muscle fi bres and open pleura.
Insert drain through open pleura without trochar.
Angle and insert drain to correct position (toward lung apex for
pneumothorax and lung base for haemothorax/effusion). CT scan or
ultrasound is useful for directing placement for small collections.
Connect to the underwater seal and keep bottle below level of heart.
Secure drain to chest wall by properly placed sutures.
Perform chest X-ray to ensure correct siting and lung reinfl ation.
Place on 5–10cmH2O (0.5–1.3kPa) negative pressure (low pressure
wall suction) if lung has not fully expanded.
Subsequent management
Do not clamp drains prior to removal or during transport of patient.
Drains may be removed when lung has re-expanded and no air leak is
present (no respiratory swing in fl uid level nor air leak on coughing).
Unless long-term ventilation is necessary, a drain inserted for a
pneumothorax should usually be left in situ during IPPV.
Remove drain at end-expiration. Cover hole with thick gauze and
Elastoplast®; a purse-string suture is not usually necessary. Repeat chest
X-ray if indicated by deteriorating clinical signs or blood gas analysis.
Complications
Morbidity associated with chest drainage may be up to 10%.
Puncture of an intercostal vessel may cause signifi cant bleeding.
Consider: (i) correcting any coagulopathy, (ii) placing deep tension
sutures around drain, or (iii) removing drain, inserting a Foley catheter,
infl ating the balloon, and applying traction to tamponade bleeding
vessel. If these measures fail, contact (thoracic) surgeon.
Puncture of lung tissue may cause a bronchopleural fi stula. Consider
suction (up to 15–20cmH2O), pleurodesis, high frequency ventilation, a
double-lumen endobronchial tube or surgery. Extubate if feasible.
Perforation of major vessel (often fatal); clamp but do not remove
drain, resuscitate, contact surgeon, consider double-lumen ET tube.
Infection: take cultures; antibiotics (staphylococcal 9 anaerobic cover);
consider removing/resiting drain.
Local discomfort/pain from pleural irritation may impair cough.
Consider simple analgesia, subcutaneous lidocaine, instilling local
anaesthetic, local or regional anaesthesia, etc.
Drain dislodgement; if needed, replace/resite new drain, depending on
cleanliness of site. Don’t advance old drain (infection risk).
Lung entrapment/infarction: avoid milking drain in pneumothorax.