INTERCOSTAL DRAIN

Insertion - Management
Dr T VAMSHIDHAR
DNB Cardiothoracic Surgery
CARE Hospitals
Basics/Introduction
Indications for ICD
Pre-Drainage risk assessment
Equipment
Consent & Premedication
Patient Position
Insertion of chest tube
Management
Removal of ICD
 Basics/Introduction
ICD = Intercostal Drainage
 Indications for Intercostal Drainage
Emergency Non-Emergency
1) Pneumothorax Malignant pleural effusion
In all mechanically ventilated patients Treatment with sclerosing
Large, or symptomatic pneumothorax agents or pleurodesis
Clinically unstable patient (hypotension, Recurrent pleural effusions
increasing O2 requirements) Complex parapneumonic
Tension pneumothorax (after needle effusion or empyema
decompression) Chylothorax
Pneumothorax secondary to chest trauma Postoperative After
2) Hemopneumothorax (e.g. post-trauma) Thoracotomy/ Cardiac surgery
3) Esophageal rupture with gastric leak into
pleural space
Contraindications
Absolute Relative

Lung Completely adherent Coagulopathies

to chest wall Multiple pleural adhesions
Patient Refusal
Pre-drainage Risk assessment

Hemorrhage- Coagulopathy

Pneumothorax vs Bullous disease

Collapse vs Pleural effusion

Lung adherence to chest wall

 Equipment
Sterile gloves and gown Suture (silk)
Skin antiseptic solution, Chest tube
Sterile drapes Connecting tubing
Gauze swabs Closed drainage system (including
A selection of syringes and needles sterile water if underwater seal
being used)
Local anaesthetic, e.g. lignocaine 2%
Scalpel and blade
Instrument for blunt dissection (e.g.
curved clamp)
Dressing
Chest tube
 Size according to internal diameter (French unit (Fr))
Numbers marked indicate distance inserted
Selection of chest tube
24F 36F for adults
16F, 20F, 24F for children
Smaller size for Pneumothorax
Bigger size for effusions
Transudate Vs Exudate
Consent and Premedication
Informed Consent
Pain medication
Anxiolytics
Emergency drugs loaded and kept ready
Pre-Procedure checklist
Right Patient
Right Site
Emergency Preparedness
Consents
Premedication
Vitals Monitoring
 Patient Position
Lying on bed
Ipsilateral arm behind head
Slight head up position
Exposure of Triangle of safety
Oxygen mask
Pulse oximetry
Chest tube Insertion
Securing the tube
Silk Sutures
Purse string sutures avoided
Y cut guaze dressing
 Drainage System

One bottle collection system

Two bottle collection system

Three bottle collection system

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 tube
inserted through a stopper into a sterile
bottle
Sterile saline is instilled into the bottle - tip of
the rigid tube is approximately 2cms below
the surface of saline solution.
Stopper, Vent
One bottle collection system

ADVANTAGES:
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 inadverently placed above level of the patients chest,fluid can
flow back into the pleural cavity
2 bottle collection system

Preferred when substantial amounts

of fluid is draining from pleural space
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.
3 bottle collection system

Controlled amount of suction can be

applied
A vent on suction control bottle is
connected to a vent on the water
seal bottle.
Suction is connected to a second
vent on the suction control bottle.
Pleur evac
Chest Radiograph
Ideally within 15-30 minutes after insertion
Ensure It is reviewed within 3hours by the Medical Officer.
Nursing Management
Observation of patient post insertion
Observation of drainage system
Observation of wound site
Securing the drain
Positioning of patient
Milking chest tubes
Pain management
Clamping
Changing drainage bottle
Patient transportation with ICD in situ
Flushing the tubes
Removal of ICD
Observation of Patient Post- removal of ICD
Observation of patient after insertion of
Intercostal drain
Checklist
Temperature
Pulse
BP
Respiratory Rate, Saturations
Patient position, Pain, Shortness of breath
Subcutaneous Emphysema
Observation of drainage system
Record volume and amount of drainage
Drain intermittently (max 1000ml clamp for 20-60min)
Re- Expansion pulmonary edema
Underwater seal kept upright
Record bubbling/swinging air column
Check looping/kinking of tubes
Observation of wound site
Daily inspection of wound
Daily change of dressing
Ensure dressing is dry
No signs of infection (redness,
swelling, discharge)
Securing the drain
Positioning of patient on bed
Tubing ideally horizontal on bed, before dropping vertically into
drainage bottle.
If tube coiled on the floor, lifted every 15-30min to ensure drainage
Milking of chest tubes
Creates negative intrathoracic pressure of -100 to -400cmH2O
Can entrap lung, bleeding, lung damage
Generally not recommended
Pain Management
Pain causes limited movement, prevent lung expansion delayed
recovery
Adequate analgesia
Clamping chest tubes
Usually should not be clamped.
Drain which is continuously bubbling should never be clamped
Clamping done in certain situations
Following rapid initial drainage of >1000ml in the first hour
When changing the drainage bottle
If the tube becomes accidental disconnected
While transferring a patient where the tubing does not reach
Following intra-pleural fibrinolytic instillation
Changing the drainage bottle
The chest drain unit should be changed if:
There is damage to the bottle or tubing
At least every 48 hours, to minimize the risk of infection
When drainage level reaches 700ml.

High fluid levels in the bottle increases resistance to further drainage

and may impact on the patients respiratory function, as greater effort
is required by the patient to breathe against an increasing pressure.
Transporting the patients with chest tubes

Drainage device kept lower than

patients chest
Suction can be discontinued for
short periods if necessary
Under supervision of medical
officer
 ICD Removal
Criteria
Absence of an air leak into the chest drain bottle, usually noted
when the patient exhales forcibly or coughs. In positive pressure
ventilation this will coincide with the expiratory phase;
Minimal drains
no evidence of respiratory compromise or failure;
no coagulation deficit or increased risk of bleeding;
radiological evidence of the absence of air or fluid accumulation
Instruction from medical officer
The procedure
 Ensure that effective analgesia has been administered,
Teach inhalation and breath-holding technique to ensure
cooperation;
Wash hands and don a protective apron;
Discontinue any suction;
Provide patient instructions;
Remove dressing;
Perform hand hygiene procedure and apply gloves;
Cut anchor suture (the suture holding the drain in place)
Instruct the patient to inhale and hold their breath.
Remove the drain firmly.
Ask the patient to breathe normally
Clean the wound and apply a dressing
Observation of patient after removal of chest
drains
Checklist
Temperature
Pulse
BP
Respiratory Rate, Saturations
Patient position, Pain, Shortness of breath
Subcutaneous Emphysema
Common Problems encountered Cause - Action
Chest drain Audit tool
Thank You