Makindo Medical Notes

🫁 Chest drain insertion = life-saving procedure for draining air (pneumothorax) or fluid (haemothorax, effusion) from the pleural space. ⚠️ Wait for a chest X-ray in most cases, except when tension pneumothorax is strongly suspected → immediate decompression.

🛡️ Precautions

• Only competent staff (or trainees under direct supervision) should perform.
• Strict aseptic technique to minimise infection risk.

⛔ Contraindications

• Coagulopathy → correct if possible, but not an absolute contraindication (drains can be life-saving).
• Always weigh risk vs benefit in unstable patients.

📍 Absolute Indications

• 🚨 Tension pneumothorax
• 🩸 Haemothorax
• 💔 Traumatic arrest (bilateral drains)

📍 Relative Indications

• Pneumothorax with underlying lung disease or failing conservative management.
• Rib fractures + positive pressure ventilation.
• Profound hypoxia/hypotension + unilateral chest signs (esp. penetrating trauma).
• Large haemothorax detected on FAST ultrasound.

👨‍⚕️ Teaching pearl: In trauma, if in doubt and the patient is in extremis, insert the chest drain without waiting for imaging.

🧰 Equipment

• Sterile gown + gloves, antiseptic solution, drapes.
• 1% lidocaine for local anaesthesia.
• Scalpel, suture (1/0 or 2/0 silk), blunt dissection clamp/forceps.
• Appropriate size chest tube + underwater seal drainage system (or flutter valve).
• Guidewire + dilators if using Seldinger technique.

📏 Chest Drain Size

• 🌬️ Pneumothorax → small-bore (8–14 Fr) effective, even in ventilated patients.
• 🩸 Haemothorax / trauma → larger bore (24–32 Fr) to avoid clot blockage.
• 💊 Pleurodesis → ≥12 Fr for adequate slurry drainage.

📍 Site of Insertion

• Safe triangle: bounded by anterior border of lat dorsi, lateral border of pec major, line above nipple (5th intercostal space).
• A practical tip: “last axillary hair” often overlies the safe site.
• ⚠️ Always incise just above a rib to avoid the neurovascular bundle.

🪛 Insertion Technique

• Consent, wash hands, gown, drape.
• Infiltrate local anaesthetic (10–20 ml lidocaine) down to pleura → aspirate to confirm position.
• Traditional blunt dissection:
  • 2 cm incision above rib → blunt dissect with clamp → enter pleural space.
  • Insert finger → confirm entry, break adhesions.
  • Pass drain with clamp into pleural cavity → connect to underwater seal.
• Seldinger technique (less traumatic): needle → guidewire → dilator → drain over wire.
• Suture drain in place, U-stitch for removal, confirm with chest X-ray.

💧 Drainage Systems

• Simple underwater seal = one-way valve for air/fluid escape.
• Flutter valve (Heimlich) = alternative in some trauma/ambulatory cases.

📈 Monitoring

• Chest X-ray post-procedure to confirm placement.
• ⚠️ Large effusions → limit drainage (~1 L initially) to prevent re-expansion pulmonary oedema (clamp for 1 hr after 1 L).
• Suction (–10 to –20 cmH₂O) may be used if non-resolving pneumothorax or following pleurodesis.
• Non-swinging tube = consider blockage, misplacement, or completion of role.

🗑️ Removal

• Remove once indication resolved + no air leak/ongoing drainage.
• Controversial: clamping for 4–6 hrs pre-removal to check for air leak.
• Removal technique: cut suture, Valsalva manoeuvre, withdraw tube, close with mattress suture, apply gauze.

⚠️ Acute Complications

• Intercostal vessel laceration → haemothorax.
• Lung laceration (esp. adhesions).
• Diaphragm/abdominal penetration (too low).
• Stomach/colon injury (unrecognised hernia).
• Subcutaneous placement or too deep insertion.
• Tube dislodgement if poorly secured.

⚠️ Late Complications

• Blocked tube (clots, kinking).
• Retained haemothorax.
• Empyema.
• Recurrent pneumothorax post-removal (poor technique).

📚 References

• LITFL – Chest Drain Insertion
• British Thoracic Society Guidelines
• NCBI – Chest Tube Insertion