- Home
- Medical books
- Pediatric pathology
- Paediatrics: Insertion of a chest drain
Paediatrics: Insertion of a chest drain
2021-03-05 12:00 AM
This procedure is used to drain a pneumothorax, pleural effusion or chylothorax.
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.