Paediatrics: Insertion of a chest drain

Insertion of a chest drain

Indications

This procedure is used to drain a pneumothorax, pleural effusion or chylothorax. In an emergency (most commonly due to a tension pneumothorax), drainage should first be performed by inserting 21–23G butterfly into the affected side at the second intercostal space in the mid-clavicular line. The butterfly tubing can be placed underwater following insertion; alternatively, a 3-way tap can be attached allowing aspiration with a syringe. Once the child is stable, a formal chest drain should be inserted.

Equipment

• Antiseptic solution: e.g. 0.5% chlorhexidine.
• Local anaesthetic: e.g. 1% lidocaine, needle, and 10mL syringe.
• Intercostal drain: size ranges from 8–12Fr for newborns up to 18Fr for young adults.
• Straight surgical scalpel blade, artery forceps, and suture.
• Sterile dressing pack (including gauze, gloves, drapes).
• The underwater drainage system and suction pump.
• Steri-Strips^®and plastic transparent dressing, e.g. Tegaderm^®.

Procedure

• Lie the child supine with the affected side raised by 30–45° using a towel.
• Raise the arm towards the head.
• Suitable sites are the fourth intercostal space in the mid-axillary line (be careful to avoid the nipple), and the second intercostal space in the mid-clavicle line.
• Chest drain insertion should be performed using a strict aseptic technique.
• Wash hands and put on sterile gloves, gown, +/– surgical mask.
• Clean skin over the insertion site with an antiseptic solution.
• Prepare sterile field, then infiltrate a small amount of local anaesthetic into the tissues down to the pleura.
• Wait for 1–2min, then make a small skin incision with the scalpel just above and parallel to rib. Note: Blood vessels lie just below each rib.
• Using artery forceps make a blunt dissection down to and through the parietal pleura.
• Using forceps clamp chest drain and then insert into pleural space. Most clinicians remove the trocar before insertion.
• Aim to push the chest drain tip towards the lung apex. In the event of a small pneumothorax aim the tip in the direction of the pneumothorax remembering to aim anteriorly (air rises in the ill child lying supine).
• Connect the drain tightly to the underwater drainage system, unclamp the drain, and apply a negative pressure of 5–10cmH₂O. Bubbling should start to occur.
• Using single sutures close the skin wound closely around the chest drain. Do not use a purse-string suture as this will increase scarring.
• Apply zinc oxide tape to the chest drain and fix it to the skin using sutures.
• Perform a CXR to check drain position and pneumothorax or effusion drainage.
• Remove drain when confident it is no longer required, e.g. pneumothorax has resolved and there has been no bubbling for >24hr. This is done by releasing holding sutures, then rapidly removing drain followed by immediate pressure and gentle rubbing with a gauze swab to close the underlying tissues. Apply Steri-Strip^®across skin incision to provide an air-tight seal. Perform a CXR to confirm that a significant pneumothorax has not re-accumulated.
• Note: If pleural fluid is required for diagnostic purposes only, then simple needle aspiration at the above sites is the technique of choice.