INTERCOSTAL DRAINAGE

DR.TINKU JOSEPHASSISTANT PROFESSOR

DEPT OF PULMONARY MEDICINEDY PATIL MEDICAL COLLEGE

Contact (email)-: tinkujoseph2010@gmail.com

WHAT ARE THE ISSUES ? When to put a drain Site of insertion Choosing the drain Drainage system Clamping the chest drain Time & method of removal Trouble shooting

INDICATIONS

Pneumothorax primary spontaneous ptx Secondary spontaneous ptx Tension ptx(after initial needle aspiration) Malignant pleural effusion Empyema and complicated parapneumonic pleural

effusion Traumatic haemo pneumothorax Postoperative,eg: after oesophageal, cardiac,

pulmonary,mediastinal or pleural surgery. Treatment with sclerosing agents or pleurodesis Post pneumonectomy bronchopleural fistula

CONTRAINDICATION

Lung adherent to the chest wallUncorrected coagulopathy

SITE OF INSERTION ? Exact site depends on the location of abnormality. 5th ICS in mid axillary line is the site used most often. Earlier it was believed that air can be drained only

through anteriorly placed tube in 2nd ICS in mid-clavicular line.A tube placed too medially can injure internal mammary artery causing serious haemorrhage.

Experience has shown that a tube of proper size,inserted through 5th ICS in mid axillary line can drain effectively.

TRIANGLE OF SAFETY

Area bordered by the anterior border of latissmus dorsi,the lateral border of the pectoralis major, a line superior to the horizontal level of nipple,with its apex towards axilla

This is the usual site which corresponds to the 5th or 6th ICS in mid-axillary line

POSITION OF THE PATIENT

A chest tube can be inserted in supine,sitting or lateral position.

Most preffered is supine position,in which patient lies flat on the bed,slightly rotated to the opposite side,with ipsilateral arm behind her/his head.

Patients who are breathless may be asked to sit upright in the bed,leaning over a cardiac trolley with a pillow to place their arms

If chest tube is inserted to drain blood,pus or another fluid, the patient should be seated when the tube is inserted to ensure that the diaphragm is in the most dependent position and the fluid is collected in the lower part of the chest

When chest tube is placed for pneumothorax,the patient should be in recumbent position if anterior chest tube is placed, and should be in decubitus position if an axillary tube is placed

In case of loculated pathology it is good practice to do an USG or CT guided ICD.

MATERIALS REQUIRED Sterile gloves and gown Skin antiseptic solution, e.g.

iodine or chlorhexidine in alcohol Sterile drapes Gauze swabs A selection of syringes and

needles (21–25gauge) Local anaesthetic, e.g. lignocaine

(lidocaine) 1% or 2% Scalpel and blade Suture (e.g. “1” silk) Instrument for blunt dissection

(e.g. curvedclamp)

Guidewire with dilators (if small tube being used)

Chest tube Connecting tubing Closed drainage system (including sterile

water if underwater seal being used) Dressing

GUIDEWIRE TUBE THORACOSTOMY Easiest way to insert a chest tube. Usually done under the guidance of either USG or CT. This procedure uses the Seldinger technique with guide wires

& dilators. Skin,periosteum and parietal pleura are anesthetized and

incision is made in skin 18 gauge needle attached to a syringe is introduced into the

pleural space. Fluid or air is aspirated to confirm the diagnosis.

Syringe is removed and J wire is threaded through the needle in desired direction into the pleural space

Needle is then removed and smallest dilator is been inserted with a rotating movement, it is advanced into pleural space.

The first dilator is removed leaving the wire in place. Then the next size dilator is advanced over the guidewire

into the pleural space and removed. Finally chest tube containing the inserter is been threaded

over the guide wire. Once tube is in place inserter & guide wire are withdrawn. Tube is then clamped until it is attached to chest drainage

system. Tube is been anchored in place by means of purse string

suture. Incision is sutured without tension to avoid necrosis of skin Sterile dressing applied.

TROCAR TUBE THORACOSTOMY Initially requires a 2-4cm incision parallel to superior

border of the rib through the skin and subcutaneous tissues after LA.

Trocar is inserted between the ribs into the pleural cavity,with flat edge cephalad to prevent damage to intercostal vessels

The hand not applying force should be placed next to the chest wall to control depth of penetration

Once trocar is in pleural space,stylet is removed and chest tube with its distal end clamped is inserted into the pleural space.

Tocar is then removed.

Alternate trocar method uses a chest tube with a trocar positioned inside the tube

DISADVANTAGES More chances for puncturing lung & other vital

organs.

OPERATING TUBE THORACOSTOMY Most commonly practiced Patient should be given anxiolytic 10-15mins before the

procedure and liberal doses of LA be used. 3-4cm incision is made in the skin parallel to the chosen

intercostal space. The incision should be made down to the fascia overlying the intercostal muscle.

Once fascia has been incised the muscle fibers are spread with a blunt tipped hemostat

Incision is then made in the intercostal fascia just above the superior border of the inferior rib over which tube will pass

Parietal pleura is then penetrated using blunt tipped hemostat

Hole in the parietal pleura is then enlarged with operators index finger

Operator should then palpate adjacent pleural space to detect any adhesions.

Chest tube with its distal end clamped is then introduced with help of a hemostat into the pleural space

Tube is sutured in place(mattress sutures) as per BTS guidelines

Site is cleaned and sterile dressing applied

ADVANTAGES Safer then other methods Adhesions between lung & chest wall can be

removed. DISADVANTAGES Insertion of tube ectopically

SINGLE PORT THORACOSCOPYHopkins rod –lens telescope is loaded into the

most proximal port of chest tube. Under direct visualization the chest tube is placed into the costodiaphragmatic gutter and scope is been removed & tube fixed.

HOPKINS ROD - LENS TELESCOPE

CHOOSING THE CHEST DRAIN. SIZE MATTERS ??

MALIGNANT EFFUSION FOR PLEURODESIS

SMALL BORE TUBES 10-14F

HEMOTHORAX 28-32F

PNEUMOTHORAX 8-14F(SUCCESS RATE OF 84-97%)

EMPYEMAS 24-28F

PLEURAL DRAINAGE SYSTEMS• ONE WAY(HEIMLICH)VALVE this drainage system is by far the simplest Chest tube is attached to a one way flutter valve

assembly, which is constructed so that the flexible tubing is occluded whenever the pressure inside the tubing is less than atmospheric pressure & is patent whenever the pressure inside the tubing is above the atm pressure

When pleural pressure and pressure in the tube are negative flutter valve is closed and no air enters pleural space.

When pleural pressure becomes positive the tube is patent and air or fluid can egress from pleural space.

ADVANTAGE It is a simple & renders freedom of the patient from a

bulky drainage apparatus Patients can be sent home with the flutter valve in place

ONE BOTTLE COLLECTION SYSTEM Consists of one bottle that serves as both a

collection container and a water seal. Chest tube is connected to a rigid straw

inserted through a stopper into a sterile bottle

Enough sterile solution is instilled into the bottle so that tip of the rigid straw is approximately 2cms below the surface of saline solution.

Bottles stopper must have a vent to prevent pressure from building up when air or fluid coming from pleural space enters the bottle.

When pleural pressure is positive,the pressure in the rigid straw becomes positive,and if the pressure inside the rigid straw is greater than the depth to which straw is inserted into the saline solution,air(or liquid)will enter the bottle and will be vented to the atmosphere(or collect in the bottle).

If the pleural pressure is negative,fluid will be drawn from the bottle into the rigid straw and no extra air will enter the system.

Thus water in the bottle seals the pleural space from air or fluid from outside the body

• ADVANTAGES:• Easy to carry & works well for uncomplicated

pneumothorax• DISADVANTAGES:• If large amounts of fluid is draining from patients pleural

space level of fluid will rise in one bottle system and therefore pressure will have to be higher & higher in the rigid straw to allow additional air or fluid to exit from pleural space

• If the bottle is inadverently placed above level of the patients chest,fluid can flow back into the pleural cavity.

TWO BOTTLE COLLECTION SYSTEM Preferred when substantial amounts of fluid is draining

from pleural space With this system, bottle adjacent to the patient acts as a

collection bottle for drainage, and second bottle provides the water seal and the air vent.

Degree of water seal does not increase as the drainage accumulates.

SUCTION & THREE BOTTLE COLLECTION SYSTEMS

Applying negative pressure to the pleural space helps in facilitating reexpansion of the underlying lung or to expedite removal of air or fluid from pleural space

Suction at a fixed level, usually -15 to -20cm H2o,can be applied to the vent on a one or two bottle collection system with an Emerson pump

In this system, suction is poorly controlled.

Controlled amount of suction can be applied to a three bottle collection system.

A vent on suction control bottle is connected to a vent on the water seal bottle.

Suction control bottle has a rigid straw. Suction is connected to a second vent on the suction control bottle.

When suction is applied to suction control bottle, air enters this bottle through it rigid straw if the pressure in the bottle is more negative than the depth to which straw is submerged.

Amount of negative pressure in the system is equal to the depth to which rigid straw in the suction control bottle is submerged below the surface as long as bubbles are entering suction control bottle through its rigid straw.

Air enters the suction control bottle from the atmosphere while its rigid straw is submerged at 20cm H2o.Thwe pressure in the suction control bottle is -20cm H20.

Same pressure exists in water seal bottle,since these two bottles are in direct communication.The pressure in drainage bottle is less negative than in other bottles

In this case depth of water seal is 2cm,so pressure in the drainage collection bottle and pleural space is --18cm H20.

Amount of negative pressure in the system can be adjusted by changing the position of rigid straw or depth of water in suction bottle.

INTRINSIC NEGATIVE PRESSURE IN CHEST TUBES If the distance from patients chest to the

top of collection apparatus is 50cms and tube is filled with liquid, there will be a negative pressure of 50cm H2o in the pleural space if no suction applied

Actual negative pressure applied to the pleural space from the entire system is the net vertical distance that the liquid occupies the tube(A-B)minus the level of fluid in the water seal(C) plus negative pressure applied through suction(D).negative pressure in chest is A-B-C+D

If there is no liquid in the tube, actual applied pressure will be suction pressure minus the depth of the water seal.

PLEUR EVAC UNIT

The drainage system is disposable,molded plastic unit with three chambers duplicating the classic three bottle system

CHOICE OF DRAINAGE SYSTEM Cost Indication of the chest drain Type of patient Water seal should be easily visualized Tube should be functional when no suction is applied Volume of collection chamber should be adequate and

markings should be such that drainage is easily quantitated.

Pop up valve to provide safety if pressure builds up in the system.

INJECTION OF MATERIALS THROUGH CHEST TUBES

Injection of a fibrinolytic or DNAase in a patient with a loculated complicated parapneumonic effusion

Tetracycline derivative or a different sclerosing agent through the chest tube in patients with malignant pleural effusion

This is usually done by taking chest tube apart and injecting material through a Toomey syringe.

This procedure compromises the sterility of the system and increases chances of pneumothorax.

THAL QUICK CHEST TUBE ADAPTER This unit consists of two adapters

separated by flexible tubing with a clamp.

On the proximal end there is a sideport with a short segment of connecting tubing to which attached a three way stopcock.

When one wishes to inject anything through the chest tube,the tube is clamped and material is injected through the three way stop cock

Indicated when a sclerosing or fibrinolytic agent is been injected.

SECURING THE DRAIN

Mattress suture 1 zero mersilk Complicated “purse string” sutures must not

be used as they convert a linear wound into a circular one that is painful for the patient and may leave an unsightly scar.A suture is not usually required for small gauge chest tubes.

CHEST DRAIN DRESSING Large amounts of tape and padding to dress

the site are unnecessary and concerns have been expressed that they may restrict chest wall movement or increase moisture collection.

A transparent dressing allows the wound site to be inspected by nursing staff for leakage or infection.

An omental tag of tape has been described

which allows the tube to lie a little away from the chest wall to prevent tube kinking and tension at the insertion site.

• Omental tag to support the tube while allowing it to lie a little away from the chest wall.

CLAMPING A bubbling chest tube should never be

clamped. Drainage of a large pleural effusion should

be controlled to prevent the potential complication of re-expansion pulmonary oedema.

In cases of pneumothorax, clamping of the chest tube should usually be avoided.

BUBBLING CHEST TUBE-DIFFRETIALS

• If tube is not inserted far enough into pleural space – one or more of holes in chest tube will be outside pleural space

• Air enters from atmosphere• In debilitated patients – with poor tissue turgor –

negative pleural pressure will cause air to enter pleural space around chest tube at insertion site

• Leaks in the system.

HOW TO DIFFERENTIATE- AIR LEAKS

• Measuring the level of pco2 in the air coming from chest tube

• Collected in syringe – blood gas analyzer• Pco2 >20mmHg (Bronchopleural fistula)• Pco2 <10mmHg (Atmospheric air)

If a chest tube for pneumothorax is clamped, this should be under the supervision of a respiratory physician or thoracic surgeon, the patient should be managed in a specialist ward with experienced nursing staff, and the patient should not leave the ward environment.

If a patient with a clamped drain becomes breathless or develops subcutaneous emphysema, the drain must be immediately unclamped and medical advice sought.

COMPLICATIONS Injury to the neurovascular bundle in the ICS Injury to lung parenchyma Injury to diaphragm and consequent injury to

intraperitoneal structures may occur Injury to heart and other vessels Massive bleeding Re expansion pulmonary oedema due to rapid

evacuation of fluid from the pleural cavity Empyema Skin excoriation and inflammation Subcutaneous emphysema & subcutaneous haematoma

REMOVAL OF THE DRAIN

Original indication Clinical progress Daily drainage should be <100ml. There should be no air leak No fresh or altered blood should be draining

from chest tube Radiological status-lung should be fully

expanded. End expiration/valsalva

REPOSITIONING CHEST DRAINS

Use imaging assistance Avoid pushing & pulling drains Best is a fresh insertion Avoid a previous site, choose a new one

Procedure for chest tube removal Gather supplies and explain procedure to patient

The clinician will remove the dressing and sutures

During peak exhalation, the clinician will remove the chest tube in one quick movement

Immediately apply a sterile gauze dressing containing petroleum to prevent air from entering pleural space

Monitor patient’s respiratory status

Arrange for chest X-ray to confirm lung reexpansion

Monitor patient’s respiratory status and SpO2 for 1-2 hours after removal

PATIENTS REQUIRING ASSISTED VENTILATION

During the insertion of a chest tube in a patient on a high pressure ventilator (especially with positive end expiratory pressure (PEEP), it is essential to disconnect from the ventilator at the time of insertion to avoid the potentially serious complication of lung penetration, although as long as blunt dissection is carried out and no sharp instruments are used, this risk is reduced.

TAKE HOME MESSAGE

RECOMMENDATIONS FOR SAFE PRACTICE OF CHEST DRAIN INSERTION

1. Site: safe triangle in the midaxillary line2. Imaging to be used to select appropriate site of

insertion3. USG guided insertion can ensure safety placement4. Do not use substantial force5. Small bore drains to be placed under imaging guidance

with a guide wire(dissection not required)6. Blunt dissection for large tube bore7. CXR available at time of insertion except in case of

tension pneumothorax BTS GUIDELINESS

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