This is just a quickie to support some local teaching in Virchester on ‘chest drain’ insertion, or ‘intercostal drains’ if you prefer additional consonants or ‘chest tubes’ if you are from the land of the Trump. Anyway chest drains are one of those procedures that are rare enough that we need to think about, but common enough that we really should be expert in. There is also no doubt that having a clinician stab you in the chest, slice you open and then insert a tube into your chest before tying it to your skin is an unpleasant experience; it’s also dangerous as numerous reports like this one from the National Patient Safety Advisory Service1 and others state2,3. People have done all sorts of things with drains, you may hear tales spouted on ATLS courses; kebabing the heart, doing a liver biopsy, putting them in backwards…… Many seem incredulous, but they are probably true as it seems that if it can be messed up then someone, somewhere probably will have done it.
Anyway, the point is that putting chest drains4 in requires a degree of preparation and training and that’s something that we are all interested in here at St.Emlyn’s. This post is based on our top tips and thoughts on putting them in, keeping them in and making the experience much better for you and your patient.
Size may not be as important as you think.
When I originally trained (back in the early days of ATLS) the edict was that big is best and to some extent that belief has continued to the current day, especially in trauma patients where blood is expected. This has often puzzled me as I work in both adult and paediatric practice and there is no way that I’m going to place a 36F drain in a 6 year old. Apart from anything else I’d probably have to remove a rib to do it, and yet the blood and air still comes out. So, I get that a big drain is good for big volumes and may clot less, but observational studies in trauma patients have suggested that smaller drains (28-32F vs 36-40F) may be just as effective5–9. How small you can go is uncertain but 36-40F are pretty huge and I’ve stopped using them in my patients. Smaller than this and there is little evidence, but having worked in paeds and adults I’m pretty confident blood does come out of smaller tubes. There was one study in swine that suggested 14F tubes may be OK, but it’s a small animal study and we would have to be very careful in extrapolating that to trauma practice10.
Not all trauma patients need big drains.
The tradition in trauma patients is that they should all get pretty big drains (36-40F), but we need to stop and think about that. As mentioned above we may not need to put huge drains in our trauma patients with blood in the chest, but what about simple pneumothoraces. I still come across docs who tell me that any traumatic pneumothorax needs an open technique, large bore chest drain, even if it’s just for air. We need to stop and think about that. Many pneumothoraces that I see have tiny amounts of intrapleural fluid and are pretty much all air. It seems nuts to then take a knife to these patients in what may then turn out to be some misguided mission to cause an intrapleural bleed as they nick an intercostal with poor technique (Ed – off the hobby horse please). So, before you automatically reach for the massive chest drain and scalpel, stop and ask what you are trying to achieve. If you are just trying to aspirate air then why not use a small Seldinger? Small bore seldinger placed chest drains have many advantages over the open technique11 and although they are widely used in our spontaneous pneumothorax patients they are less commonly seen (in the UK at least) when dealing with our trauma patients. We should stop and think about this as Seldinger drains are kinder for the patient but can still deliver what they may need, the drainage of air. Watch this excellent video from the fabulous Lauren Westafer. We don’t use Pigtails in Virchester, but the principles here are the same (we’re just not as curly).
A small word of caution though here. You can’t always rely on your chest X-ray to tell you exactly what’s going on in the chest and it’s easier to know what your looking at after a trauma CT (which to be honest most of our blunt and penetrating trauma patients get these days), or a well conducted ultrasound of the chest.
Occult Pneumothoraces don’t always need a drain
Now that we have entered where a much higher proportion of our trauma patients get CTs, it’s not uncommon for us to find small pneumathoraces that are not clinically obvious and which may well be invisible on plain chest X-ray12. There is increasing evidence that these patients can be managed without a chest drain if patients are closely observed13,14. For awake patients this is relatively straightforward, but there is a dilemma for the patient who is then going to be (or who already is) on positive pressure ventilation. Should they get a chest drain as a matter of course as some state15 if an occult (as in not visible on CXR and not clinically detectable) pneumothorax is detected? To my knowledge the RCT has not been done and many of the observational studies have small numbers of ventilated patients. There is some weak observational data out there16–21 that a proportion of patients can be managed conservatively, even if ventilated, but only if very closely observed. It’s almost certain that we did this many times in the past too. I have no doubt that I used to ventilate many patients with occult pneumothoraces as we never used to CT them (so did not know). I cannot imagine that they are a new phenomena, it’s just that we now know that they are there.
The bottom line is that we should remember that chest drains are not without their own risks and thus the decision to place a chest drain should be considered and not mandated..
Ketamine is fantastic
Chest drains can really hurt your patient. Let’s face it, for big tubes you are stabbing them, slicing them, poking them with your finger and then placing a tube between their ribs. It’s going to hurt and you should do something about this to mitigate the unpleasantness and so analgesia is key. No doubt you will try and anaesthetise the skin, muscles, fascia(?), and parietal pleura but it’s all too easy to get the local in the wrong place and to miss those tricky intercostal nerves in the exact space you are aiming for. Sure in the patient who is not too poorly, who can sit up and where you have lots of time I’m sure that you will be fabulous at this, but in the resus room, with the trauma patient who is lying down on the trolley it’s rather more difficult and I have witnessed some horrifically painful attempts to get through the ribs in patients who are clearly receiving little or no benefit from local infiltration. Folks the answer is, as almost always, ketamine22. The combination of analgesia and dysphoria is fantastic and can transform the experience for you and the patient. Good analgesia is the most important step in inserting large drains. So, for my patients, many of whom will already have had an opiate pain medication such as morphine, I supplement this with IV titrated ketamine and local infiltration of local anaesthetic, plus intra-pleural analgesia as described below. There is no other agent that works as well in this situation for nearly all patients.
Unless your patient is completely comatose or anaesthetised then you’re probably going to try and inject some local into the skin and over and above the rib spaces that you intend to put the drain through. This probably won’t work that well (see point 2), but you will no doubt try. What of the pleura though? You may or may not manage to capture the parietal pleura with the end of your needle and in many cases you might go through and into the thoracic cavity…with your needle and syringe……which contains local anaesthetic. My advice is to squirt some around if you do as it will act as a local anaesthetic to the pleura itself as the lung expands. Now clearly this is more effective if you are draining a pneumothorax as opposed to fluid, but in pneumothoraces the local spreads around the lung and gives some welcome analgesia. I tend to do this using 0.25% Bupivocaine or Chirocaine (being mindful of not overdosing the patient on local anaesthetics) either through the needle and syringe or down the chest drain once inserted. It helps with the discomfort the patient experiences when the lung re-expands. The evidence is not fantastic for this but intrapleural analgesia in post op patients is reasonably well established and this technique may make your patient more comfortable in the first few hours post insertion 23,24.
Learn how to tie.
You really don’t want your drain to fall out and so you do need to tie it in place. In all honesty there’s a few methods used to do this. Some are pretty simple, some more complex and in all honesty we’re not that fussed which one you use. The bottom line is that the drain needs to securely attached to the patient. That means a loop in the skin and then a series of tied loops around the drain at a distance. If you can combine this with mattress suture through the wound that will facilitate closure later then that’s also great. Perhaps the best example of this is the Jo’Burg knot as demonstrated by Neel Bhandheri25. It’s also worth noting that Neel can hand tie, as I can, and this makes a HUGE difference to the time it takes you to secure a drain. Honestly, if you’re serious about being an EM Resuscitationist learn how to hand tie26, not only will you be faster you will look 17% cooler in the resus room (fact).
Ultrasound is a fantastic resource and I rarely put drains in without it. For draining fluid, it’s incredibly helpful to know where to put the drain, and for non-traumatic effusions it’s very valuable in ensuring that you’re not putting the drain into a bit of tethered lung, or into a small loculated area. If you’re serious about being a great emergency physician then get yourself skilled up with chest ultrasound. There are some fabulous resources out there and we’d start with Matt and Mike over at the ultrasound podcast 27.
We’d also recommend the British Thoracic Societies guidelines on pleural procedures and ultrasound from 201028.
For fluid I use USS to tell me the safest place to place a drain. This is especially important when you are aiming for pleural fluid. With loculated fluid or with lung tethered to the chest wall it can avoid a disaster. Similarly in patients who have a combination of collapse with pleural fluid the diaphragm can be pulled up and your blind technique may result in a spleen or liver biopsy. Not a great result for anyone involved so in brief, look before you incise.
When I’m aspirating pneumothoraces, I use ultrasound to ensure that the lung is truly up and the pneumothorax is fully aspirated before I take the cannula out and finish the procedure (or I give up when I realise it’s futile). This is pretty useful if you then find that on the chest X-ray there is a large PTX. If you know you were able to reduce it initially, and that it has then failed, then there is clearly no point in doing it again and you should proceed to a chest drain.
Aspiration/draining spontaneous pneumothoraces
The guidelines still suggest that aspirating small and moderate spontaneous pneumothoraces29 in patients without chronic lung disease is a good idea and I must admit to some satisfaction when this works. Again the mechanics of this are taught elsewhere but essentially you place a catheter in the chest cavity through the chest wall and then attach it to a 3-way tap and a 50ml syringe. You then suck and blow until you can’t get anymore out, then you remove the catheter and send the patient for a CXR to see if it worked.
I’ve a couple of thoughts with these patients. The first is that we often drain these anteriorly in the mid-clavicular line (though I kind of prefer the lateral approach in the triangle of safety if possible). This is fine from an anatomical point of view but it can be quite unnerving for the patient as you appear to stab them in the chest and then such the air out of them right in front of their face. It’s also quite difficult to manipulate as by the time you’ve got a 50ml syringe and a 3-way tap on the end of your catheter it’s about 30cm long and it’s unwieldy in front of the patient. The plunger pumping the air out of their thorax can’t be the most pleasant experience and it’s easy to kink with the weight of the syringe attached to the cannula.
To counter this we usually put a small piece of extension tubing between the catheter and the syringe so that it may be held more discretely by the patient’s side. It also means that you are not then swinging on a fairly fragile catheter in the chest, thus you are less likely to kink or dislodge it. You can also control the position of the catheter better so that you are more sure of whether you have aspirated everything. Try it and let me know. I think you and your patient will prefer it.
You can also use a small seldinger straight off as Kevin Reynard suggests in the comments below. I’ve done this in patients when I think that aspiration may fail (total pneumothaces for example). Thanks to my old boss and mentor Kevin for the suggestion 🙂 .
Do all chest tubes need prophylactic antibiotics?
For non-trauma drains, usually not unless indicated for a specific cause (eg. an underlying pneumonia). You should be giving prophylactic antibiotics to your penetrating trauma patients who get chest drains30–32. The picture for blunt trauma patients is less clear as studies have been a little too small and variable and a judgement could probably be made, although current guidelines would support their routine use. However, for a closed injury such as a moderate pneumothorax from a rib fracture, treated with a small seldinger placed chest drain under aseptic conditions in the ED it’s tricky to see how that equates to a tube in a patient with a penetrating injury.
Positioning the tube in the chest.
There are two things to think about with position. Direction and depth. As for depth then you really only need to put the drain in far enough to ensure the side holes are in the chest. In slim patients there may well be little distance between the chest wall and the pleura, in the obese it can be somewhat further! In general you can estimate this clinically but if not, or if you are worried then use your ultrasound to measure the distance between skin and the parietal pleura. Add this length plus the distance from the side holes to tip, plus at least a couple of centimeters to guide how far you need to insert. Remember that patients who are big on the outside may still be little on the inside and so they don’t need drains inserted further into the chest cavity.
As for direction then it seems that it’s probably less important than we once thought. In general we still point drains for pneumothoraces upwards and those for fluid downwards, and both posteriorly, but the evidence seems to be that it really doesn’t matter that much33,34,32 and a functioning chest drain should not be repositioned just because it does not look pretty on the X-ray.
Not a huge amount to say here apart from the utility of using two clear dressings (e.g. Tegaderm) to hold the tube next to the skin. This allows a clear dressing around the incision so that it can be inspected for signs of infection, swelling or leakage without having to interfere with the wound itself. Two clear dressings placed at right angles to each other does the job well as shown below.
This is pretty sticky too so can help a little with keeping everything in place, but the key is the transparency. You can see what’s going on even if you have to take the outer dressings off.
As I said at the beginning, this is a little bit of a random selection to support our local teaching. Most of it is supported by moderate to poor evidence and some of it is just my opinion. I accept that so take everything I say with the righful degree of scepticism you should apply to all #FOAMed* and think before you decide whether to adopt anything here by checking with your local team.
More importantly, what are your tips and tricks? Put them in the comments below and share them with your #FOAMed friends.
*Be sceptical of everything you read. Not just #FOAMed.
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References and further reading.
20 thoughts on “Chest drains & aspiration: Do it better with St.Emlyn’s”
Seldinger drains are great, and I use them a lot.
I’ve noticed that with open/surgical chest drains people are (a) not liberal enough with the LA and (b) don’t make a big enough hole.
If you’re ED and not au fait with a good horizontal or vertical mattress suture and the ability to hand tie, learn! It’s a useful skill to have, relatively easy to learn, and easy to practice (I learnt using polystyrene coffee cups and bananas).
Recently all the chest drains I’ve inserted have been in large patients – the 8cm introducer needle hasn’t been long enough to reach the pleura (even with a strong arm ????) – and even the open technique was challenging (my fingers aren’t that long either!). Any thoughts on these patients?
Yes, I think you’re right on the local anaesthetic and the big hole points.
Totally agree about hand ties. It makes putting chest drains and central/arterial lines SO much faster. Plus you look cooler doing it.
For the very large patients then I agree it’s tricky. If they are so big that you can’t get down to ribs then make a bigger hole! If it’s a problem of losing the track when you take your finger out in mountains of fat then you can use an airway bougie to keep the track open and railroad the drain over this. It’s one of the first things I ever learned through #FOAMed.
Link here. http://emcrit.org/misc/bougie-guided-chest-tube/ and here
Thanks Simon, full of top tips. I have a slightly different approach to aspirating ptx. Cannula can be too short, especially when the soft tissue recoil is taken into account, can slip and are easy to pull out, even with extension tubing. Maybe your patients are slimmer in Virchester (if so things have changed since I was there!). I do it through a small seldinger drain, which can be easily removed if successful and has the definitive drainage device in place if aspiration fails.
Yes. That’s a really good point and we have done the same over here (I’m going to add it to the blog post). I would also use a small seldinger straight off if I thought (Gestalt) that there was a significant likelihood of aspiration failure. As you rightly point out if failure occurs you are then a long way ahead in the patient’s journey and they don’t need a second procedure.
Thanks for the comments.
I (became we) had real difficulties inserting a drain into a trauma patient recently. The patient was an obese female with a pneumothorax (no significant fluid on CT). With the added breast tissue (held out of the way as well as could be achieved) and ketamine on board so still…. locating rib spaces was a problem.
I started with seldinger reaching the chest cavity at the full length of needle with pressure. Passed guide wire. Used the full selection of dilators. Passed drain… then the wire wouldn’t come out. Removed after the drain it had kinked. Happened again a couple of times (had tried changing position). Never seen that before
Converted to surgical drain. I couldn’t reach the pleural space with my finger (think size 5.5 gloves). Switched operators who just about managed but then still had real problems passing the tube.
Any tips for the larger patient?
USS first to judge the depth from skin to pleura to act as a guide as to how far you need to go.
Great summary of common sense advice Simon – will definitely be adding the small Seldinger for aspiration to my armoury (one of those “why didn’t I think of that before?” things – thanks Kevin!).
I can’t remember the last time a used a tube bigger than 28F, if ever – I don’t know if that was a location of training thing but I always thought that was plenty big enough. And I observe a lot more closed traumatic pneumothoraces than I did – they seem to do OK.
And hand ties are cool (it was the handle of an iron for my practice).
I agree. David. The really big drains at 36-40F just seem enormous.
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Great article thanks guys! A few thoughts: Here in South Africa, chest drains are probably the commonest ‘major’ procedure we do in Emergency care – and we do ALOT. I would estimate in my smallish rural unit we insert about 30+ a month, more than 90% of which are for penetrating trauma. I find the recommendation on antibiotics quite surprising – cant argue with the evidence but this is certainly not common practise here and not in any of the standardised protocols in my province. There is obviously a huge lack of evidence in the South African setting and we would need to identify the actual infection complication rate,but in my anecdotal experience, we dont get many comebacks for sepsis.
As long as the initial wound is handled and closed correctly and the procedure itself is done aseptically we find they generally do well.
Great tip on the intra pleural anesthesia! Hand ties are a must.
Thanks Anne. I’m always grateful for my SA colleagues who have a HUGE amount of experience in this area. Really interesting about the infection issue. Is that in the penetrating patients as well (of which you have many)? Do you give ABs to stabbings and gunshots?
Stab wounds – no, not routinely. Gunshots: case by case – if they are truly penetrating into chest cavity, ie severe enough to cause a pneumo/heamothorax – would probably give. We see very few GSW chests in this town though (luckily!!) – weapon of choice seems to be a knife.
Some ramblings on chest drain dressing’s
Let me know what you think
I agree with Simon, it pays to close the incision line as much as you can, to prevent venting. I like the concept of the Jo’Burg knot, but do insure the person removing the drain understands the suturing concept.
Do have a look at the commercial options – we use the Hollister vertical drain dressing in Middlemore with good success, but the Opsite Visible drain dressing is comparable.
Tegaderm sandwiches work, (and when they work they aren’t easy to remove and redress )
They may not adhere that well to clammy patients, think about applying skin prep first.
Also if the drain site leaks the skin can macerate as the fluid is trapped often you end up with a soggy tegaderm which will eventually fall off; This can mitigated by closing the incision and using a dressing either an alginate or simple non-adherent dressing cutting to create a Y – thought this does reduce direct visualization of the incision it will absorb any exudate
For DIY dressing I prefer the trouser leg using fabric tape, you will over time see several variations on this
I use this
Using 3×3 Elastoplast
Cut into 20cm strips , then create 3 tailed dressing by making 2 cuts in the bottom half of the tape
Secure the top of the dressing with the top half of the Elastoplast and wrap the tails around the tube and on to the patient’s skin below the chest tub
Repeat this by attaching tape from above, below and from the side of the tube insertion site. This will secure the tube and the dressing.
It may be worth securing tube to patient further with ½” zinc tape down the entire dressing and on to tubing, but this reduces your visibility of the tube
Also I would advocate over taping the connection between the drain & the drainage system
Finally anchoring as below the tubing to flank in way to arrest a tug when the patent moves or is moved, but in a position not to interrupt flow or create a pressure injury
Hi all. The “Joburg” is actaully not. It was originally written up by Dr Richard Muller then Head of Trauma Tygerberg Hospital in Cape Town in the local journal CME in the 80s. We were all taught the technique as med students.
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Hi – EM trainee here. Wonderful tips that I shall keep in mind. Is seldinger vs open a personal choice? Is there a definite “right/wrong” type of drain in different scenarios? Seldinger for traumatic pneumothoraces preferred vs open for hemothoraces?
In theory any drain can be inserted using a seldinger technique if you have enough time and enough dilators. In practice traumatic HTX drains are usually open. There is also an issue of familiarity. Trainees now get much less exposure to open drains than we did in the pre-seldinger era and so personal preference may also be influenced by human factors and familiarity.