Intercostal chest drains (ICD) are used for therapeutic purposes to remove air and/or fluid from the pleural space (e.g. pneumothorax and haemothorax in trauma cases).  ICD insertion is a complex procedure that should only be carried out by trained practitioners with skilled assistance, and trainees must perform it under supervision until competent. 

Contraindications

• Absolute contraindications include: unskilled practitioner without supervision 
• Relative contraindications include:
  • Respiratory compromise Significant bullous respiratory diseaseSignificant bleeding risk due to liver disease, anti-coagulation or risk of damage to major thoracic vesselsLocal skin infection (use alternative site where available)Non-emergency procedure OOHUncertainty regarding imaging appearances Raised hemi-diaphragm on ipsilateral side of planned ICD
  • Alternative procedure available

Complications

Complications include pain, drain blockage or dislodgement, infection (cellulitis or intrapleural infection), nerve damage, pneumothorax, re-expansion pulmonary oedema, visceral injury, significant bleeding, surgical emphysema, or unsuccessful procedure.

Surface Anatomy

The triangle of safety is bounded by the lateral border of pectoralis major, the anterior border of latissimus dorsi, and the level of the 5th intercostal space. Intercostal spaces contain muscles and a neurovascular bundle (vein, artery, nerve) running just beneath each rib. To reduce the risk of injury, chest drains should be inserted just above the rib’s superior margin. The long thoracic nerve courses along the lateral chest wall, so insertion should remain anterior to the mid-axillary line. The neurovascular bundles lie under each rib and descend more noticeably posteromedially, so the safest entry is above the rib and laterally.

Equipment

• Trolley with adjustable back or pillows
• Sharps bin
• Surgical gown, sterile gloves, face mask and surgical headcap
• Procedure trolley
• Universal aspiration pack 
• Surgical drapes and adhesive tape to keep drape in position
• Antiseptic solution (either Chlorhexidine topical spray or solution, Iodine based solution, or 2% chlorprep sponge applicators)
• 3 Sterile applicators (to hold sterile gauze)
• 1% Lidocaine 10-20mls depending on patient body weight
• 10ml syringe
• 50ml syringe for sample collection
• Blue, and 2 green needles
• Large bore chest drain kit (28Fr most frequently used)
• Drain tubing and underwater seal bottle
• Sterile water for underwater seal
• Sterile gauze
• Suture (e.g. 1.0 Silk)
• 11 blade
• Dressings
• Universal containers for pleural fluid if required for further investigation
• ABG syringe/sterile McCartney bottle for fluid pH if empyema suspected

Procedure

Preparation

1. Explain procedure and obtain written, informed consent.
2. Review patients’ clotting screen, platelet count, imaging and medications. 
3. Using a non-touch technique, open the sterile pack and procedural equipment onto the procedural trolley. Pour antiseptic skin wash into bowl. Prime underwater seal drainage bottle and tubing.
   • Fill the drain bottle to the marked ‘fill level’ using sterile water. The drain bottle and tubing can be placed on the floor near the patient, ensuring the tubing remains sterile (e.g. drain attachment end can be kept inside sterile bag or placed on trolley within sterile field). 
   • Ensure the end of the drain connects to the drain tubing prior to procedure commencement
4. Ensure patient position is correct and comfortable for them and the operator. Patients can be supine, sitting forward or reclining. 
   • Sitting position – Patient is sitting and leaning forward with legs over side of bed.  Bedside table and pillow can be used to support the patient and assist in arm elevation. Insertion site is usually more posterolateral than in the reclining position. 
   • Supine – May be necessary in cases of trauma e.g. spinal precautions.
   • Reclining – Patient leaning back in bed at approx. 45 degrees to the horizontal, with the arm ipsilateral to the planned ICD insertion site behind the patient’s head. Enhanced access to triangle of safety. 
5. Identify the chest drain insertion site. For cases in which pleural fluid in involved, direct ultrasound guidance is mandatory. The indentation from a blunt needle cap can be used to mark the insertion site.
6. Operator scrubs and gowns up, donning sterile gloves, surgical mask, and hat. Using 3 sterile applicators and a non-touch technique, apply the antiseptic skin wash to the patient, and allow their skin to dry. Whilst applying the drape over the patient, ensure a large enough sterile field is maintained to allow re-assessment of landmarks without contamination. Assistant may tape the corners of the drape to the patient’s gown. Fenestrated drapes may obscure anatomical landmarks.  
7. Local Anaesthetic – 
   • Create a skin bleb by infiltrating 1% Lidocaine with a blue needle perpendicular to the skin.
   • Green needle is then used to infiltrate deeper, into the subcutaneous tissues and onto the rib and pleura, aspirating as the needle is advanced.
   • The periosteum of the underlying rib should be anaesthetised whilst always keeping above the underneath rib.
   • Note the depth of the pleural space when infiltrated with the green needle. Aspiration of pleural air/fluid is useful to establish position.
   • Majority of lidocaine should be administered in the periosteum, pleura and pleural cavity
   • Administer analgesia (e.g. IV morphine) unless contraindicated
8. Perform procedural pause.
9. Clamp the furthest end of the chest drain, proximal to where the drainage tubing will be attached. To aid guidance of the tube through the chest, clamp forceps onto the insertion end of the chest drain, through the most proximal fenestration. Ensure the forceps tip does not extend beyond the end of the drain. 

Insertion

Clinicians may have a favoured order for skin incision, blunt dissection and drain insertion. Ensuring it is undertaken safely, these variations are acceptable.

1. Blunt dissection – Create a 2-3cm incision through all layers of the skin parallel to the rib where the drain will be inserted. ‘Stay and Close’ sutures may be inserted. Large forceps (e.g. Kelly’s) should be used to bluntly dissect the s/cut tissues, until the upper border of the rib is reached, opening the pleura. A ‘give’ should then be felt or a hiss of air/flow of blood. Cautiously introduce a finger into the pleural cavity, sweeping to confirm non-adherence between the lung and chest wall. Beware of rib fractures, as these may pierce your glove. 
2. Drain insertion – Depth of insertion can be assessed by looking at the drain markings and the distance from lung apex to the incision. All holes along the length of the drain need to be within the pleural space. Holes that are in the s/cut tissue but are deeper than the skin, will cause surgical emphysema. Introduce the drain through the hole in the pleura and into the cavity, aiming the drain towards the apex. If a plastic introducer is supplied with the drain, this can facilitate positioning, however, ensure this is disconnected as it can damage the lung, heart or diaphragm. 
3. Attachments – connect the end of the drain onto the underwater drainage system and place the chest drain bottle below the patient. Ensure the water in the chest drain is bubbling or swinging, if uncertain, this movement can be emphasised by asking the patient to gently cough. 
4. Unclamp the chest drain and ensure the water in the bottle continues to swing with respiration. Pathology dependent, bubbling dur to air, or fluid/blood may be observed in the drain. 
   • Urgent cardiothoracic advice should be sought if >1500mls of blood is initially drained, or there is blood loss >200mls/hr. This may indicate bleeding from a large vessel or ongoing bleeding. 
   • The drain must be clamped if the patient is bleeding.
   • The drain must never be clamped for pneumothorax.
   • Rapid drainage of pleural fluid may occur, which can precipitate re-expansion pulmonary oedema. 
   • Hold onto the drain until it is securely sutured in place

5. Whilst the assistant holds the drain at the end where it is being cut off, insert a stay suture and a mattress suture than can be used to close the wound when the drain is removed. The tightly applied stay suture should slightly indent the drain. All knots must be around the base of the drain. Purse string sutures should not be used. 
6. Make a hole in the centre of some gauze and apply this around the drain tubing to minimise kinking at the skin. Apply an adhesive dressing over the gauze (BTS recommend mepore). Sleek tape can be used to reinforce any connecting components but should not be applied to patient skin.  
7. Dispose of clinical waste and sharps in the appropriate bins. 
8. Post-procedure chest x-ray should be performed and reviewed immediately. 

References

• Pleural Disease | British Thoracic Society | Better lung health for all [Internet]. www.brit-thoracic.org.uk. Available from: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/pleural-disease/

• ‌Technique 1 – Large-bore Chest Drain Insertion [Internet]. Nhs.scot. NHS Education for Scotland; 2016. Available from: https://learn.nes.nhs.scot/SCORM/Courses/Module0002353File0002550/chestdrains_14.htm

Written by Dr Amina Aslam (CTF)