Chest Drain

Question 1

What are the indications for chest drain?

Answer 1

• Pleural effusion
• Pneumothorax, not suitable for conservation management or aspiration
• Empyema
• Haemothorax
• Haemopneumothorax
• Chylothorax
• In some cases of penetrating chest wall injury in ventilated patients.

Question 2

What are the relative contra-indications for chest drain insertion?

Answer 2

• INR > 1.3
• Platelets <75
• Pulmonary bullae
• Pleural adhesions

In emergency situations, where there is respiratory compromise, these relative contraindications should be reviewed on case by case basis.

Question 3

Where do you insert a chest drain?

How would you carry out the process?

Answer 3

Triangle of safety

• 5th intercostal space (inferior nipple line)
• Midaxillary line (lateral border of latissimus dorsi muscle)
• Anterior axillary line (lateral border of pectorals major muscle)

Procedure

• Supine/angled at 45 degrees
• Forearm behind patient’s head to allow easy access to patient’s axilla.
• Find the triangle of safety. Alternatively, use ultrasound guidance in all cases of fluid within pleura.
• Anasthesia area with lidocaine (3mg/kg)
• Use seldinger’s technique to insert the tube
• Secure the draining tube using a straight stitch or with adhesive dressing.
• Confirm positioning by aspiration of fluid from draining tubing or by swinging of the fluid within the drain tubing when patient inspires and on chest x ray.

Question 4

What complications can arise as a result of a chest drain? What complications does the patient need to be made aware of whilst obtaining patient consent?

Answer 4

• Failure of insertion
• Bleeding
• infection
• Penetration of the lungs
• Re-expansion of pulmonary oedema
  > Patient may cough or have SOB prior to re-expansion of pulmonary oedema. If this occurs, chest drain should be clamped and an urgent chest x ray should be carried out. To avoid re-expansion of pulmonary oedema, clamp drain tubing regularly to ensure only 1L is removed every 6 hours.

Question 5

When do you remove a chest drain?

Answer 5

Removal depends on the indication for insertion.

• Pleural effusion –> remove when there has been no output for >24 hours and imaging shows resolution of pleural fluid.
• Pneumothorax –> remove when there is no longer any spontaneous bubbling or bubbling when the patient coughs and ideally when imaging shows resolution of pneumothorax.
• Penetrating chest injury - remove when lung specialist feels it appropriate.