BTS GUIDELINES FOR

CHEST DRAIN INSERTION

DR.ZIAUDDIN A. KASHMIRI
ASSOCIATE PROFESSOR
DEPARTMENT OF ANESTHESIOLOGY ,
SURGICAL INTENSIVE CARE & PAIN MANAGEMENT
DOW MEDICAL COLLEGE , DOW UNIVERSITY OF HEALTH SCIENCES
CIVIL HOSPITAL KARACHI
AREA UNDER DISCUSSION
Consent
 Premedication
 Patient Position
Confirming site of tube insertion
 Drain insertion site
 Drain size
 Aseptic Techniques
 Anesthesia
 Insertion of chest tube
 Small bore
Medium bore
 Large bore
 Incision
 Blunt dissection
 Position of tube tip
 Securing the drain
 Instruction after the insertion ( CXR )
 Removal of the chest tube
Consent :

 Written & Informed Consent

 Explain the procedure
 Information leaflet

Premedication :
 It is a painful procedure with 9 – 10 VAS score
Benzodiazepine , Opioid .

Patient Position :
 On the bed , slightly rotated
 Arm on the side , behind the patient ‘s head to expose the axillary
area
Alternative Positions
 Patient sitting upright leaning on an adjacent table with a pillow
 Lateral decubitus position
Triangle of Safety (Safe Triangle )
 Anterior border of latissimus Dorsi
 Lateral border of Pectoralis Major
 Line Superior to the horizontal level of the nipple
 Apex below the axilla

Confirming site of tube Insertion

 If free air / fluid is not aspirated , tube should not be inserted without image
guidance
CXR must be available at the time of insertion
 Floroscopy , Ultrasound , CT
 Ultrasound Empyema / Pl. effussions .It is highly recommended if
the effusion is very small or initial blood aspiration failed.
Drain Insertion Site
 Mid axillary line ( Triangle of Safety )
 Minimizes risk to the underlying structure ( IMA )
 Avoid damage to muscles and breast tissues
 Avoid unsightly scarring
 For apical pneumothorax 2nd I.C space in the mid clavicular line
( not recommended routinely )
Drain Size
 Small bore drains are recommended ( more comfortable )
 Large bore Acute Haemothorax
 In Pneumothorax – ( 9F catheters have been used with 87% success
 In Haemothorax – (28 – 30 F )

A Septic Technique
 Sterile gloves , gown , equipments , sterile towels
 Iodine / Chlorhexidine
 Phophylatic A / B not necessary in spontaneous pneumothorax )
 In case of trauma Cephalosporine / Clindamycin

Anesthesia
 Local anesthetic Lignocaine (3 mg / Kg )
 Small gauge needle to raise dermal bleb then deeper infiltration of the
intercostal muscles and pleural surface
 Thick Chest Wall Spinal needle
Insertion of Chest Tube
 It should be inserted without substantial force
 Seldinger Technique
 Blunt dissection of the chest wall and into the pleural space

Small Bore Tube ( 8 -14 F )

 Guide wire by seldinger techniques
 Pneumothorax , Effusion
 Loculated empyemas
Medium Bore Tube ( 16 - 24 F )
 Seldinger Technique
 Blunt Dissection

Large Bore Tube ( > 24 F )

 Blunt dissection into the pleural space before insertion of a large bore chest
tube

Incision
 After the effect of anesthesia
 Incision should be just above and parallel to rib
 Slightly bigger than the operator’s finger and tube
Securing the drain Purse String Suture X
Stay and Closing Suture √
Mattress / Linear Suture
Size 1 Silk

Instruction after insertion

 Make sure that no eye of the tube is outside the patient’s body
 Inserted chest tube should be connected with the under water seal
 Patient should be nursed in special ward / I.C.U and managed by
trained staff
 CXR should be performed after insertion
 If not properly placed , do not try to push the tube after it is secured
.
Removal of the chest tube
 Pneumothorax Tube should not be clamped at the time of removal
 Chest tube removed in expiration with a brisk firm movement , assistant
ties closure suture
 Do not remove until bubbling has ceased
 CXR shows reinflation
 Clamping before removal is not needed
THANK YOU