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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