1. DR.TINKU JOSEPH SENIOR RESIDENT DEPT OF PULMONARY MEDICINE CMC VELLORE
INTERCOSTAL DRAINAGE
DR.TINKU JOSEPH
SENIOR RESIDENT
DEPT OF PULMONARY MEDICINE
CMC VELLORE

2. 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

3. 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

4. CONTRAINDICATION Lung adherent to the chest wall
Uncorrected coagulopathy

5. 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.

6. 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

7. POSITION OF THE PATIENT
A chest tube can be inserted in supine, sitting or lateral position.
Most preferred 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

9. 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.

10. 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. curved clamp)

11. MATERIALS REQUIRED Guidewire with dilators (if small tube being used)
Chest tube
Connecting tubing
Closed drainage system (including sterile water if underwater seal being used)
Dressing

12. TYPES OF CHEST TUBES
Pig tail, urinary catheter

13. TYPES OF CHEST TUBES

14. 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.

15. GUIDEWIRE TUBE THORACOSTOMY
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.

16. GUIDEWIRE TUBE THORACOSTOMY

17. 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.

18. TROCAR TUBE THORACOSTOMY
Alternate trocar method uses a chest tube with a trocar positioned inside the tube
ADVANTAGE
Tube can be placed in desired direction
DISADVANTAGE
More chances for puncturing lung & other vital organs.

20. 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

21. OPERATING TUBE THORACOSTOMY
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

25. OPERATING TUBE THORACOSTOMY
ADVANTAGES
Safer than other methods
Adhesions between lung & chest wall can be removed.
DISADVANTAGES
Insertion of tube ectopically

26. SINGLE PORT THORACOSCOPY
Hopkins rod –lens telescope is loaded into the most proximal port of chest tube.
Under direct visualization the chest tube is placed into the costo diaphragmatic gutter
scope is been removed & tube fixed.

27. HOPKINS ROD - LENS TELESCOPE

28. 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
BTS Recommendations

29. PLEURAL DRAINAGE SYSTEMS
ONE WAY(HEIMLICH)VALVE
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.

31. 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

32. 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.

33. 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

34. ADVANTAGES: DISADVANTAGES:
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 inadvertently placed above level of the patients chest, fluid can flow back into the pleural cavity.

35. 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.

36. SUCTION & THREE BOTTLE COLLECTION SYSTEMS
Applying negative pressure to the pleural space helps in facilitating re-expansion 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.

37. 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.

38. When suction is applied to suction control bottle, air enters this bottle through its 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.

39. 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.

41. PLEUR EVAC UNIT
The drainage system is disposable, molded plastic unit with three chambers duplicating the classic three bottle system

44. 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.

45. 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.

46. 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.

47. 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.

48. SECURING THE DRAIN

49. 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. 

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

52. 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.

53. CLAMPING
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. 

54. 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.

55. HOW TO DIFFERENTIATE- AIR LEAKS
Measure 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)

56. 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

58. 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

59. REPOSITIONING CHEST DRAINS
Use imaging assistance
Avoid pushing & pulling drains
Best is a fresh insertion
Avoid a previous site, choose a new one

60. 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

61. 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.
If blunt dissection is carried out and no sharp instruments are used, this risk can be reduced.

63. RECOMMENDATIONS FOR SAFE PRACTICE OF CHEST DRAIN INSERTION
Site: safe triangle in the midaxillary line
Imaging to be used to select appropriate site of insertion
USG guided insertion can ensure safety placement
Do not use substantial force
Small bore drains to be placed under imaging guidance with a guide wire(dissection not required)
Blunt dissection for large tube bore
CXR available at time of insertion except in case of tension pneumothorax
BTS GUIDELINESS
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