1 Chest Drain Insertion Course
2 Chest Drain Insertion Background Indications Consent ComplicationsPreparation, anatomy and insertion Chest drain management
3 Background Why is this course relevant to you…?
4 Curriculum for Core Medical Training and Acute Care Common Stem (Medicine)
5 Part 2.4 Procedural CompetenciesThe trainee is expected to be competent in performing the following procedures by the end of core training. The trainee must be able to outline the indications for these interventions. For invasive procedures, the trainee must recognise the indications for the procedure, the importance of valid consent, aseptic technique, safe use of local anaesthetics and minimisation of patient discomfort.. • Venepuncture • Cannula insertion, including large bore • Arterial blood gas sampling • Lumbar Puncture • Pleural tap and aspiration • Intercostal drain insertion: Seldinger technique • Ascitic tap • Abdominal paracentesis • Central venous cannulation • Initial airway protection: chin lift, Guedel airway, nasal airway, laryngeal mask • Basic & advanced cardiorespiratory resuscitation • DC cardioversion • Urethral catheterisation • Nasogastric tube placement and checking • Electrocardiogram • Knee aspiration • Temporary cardiac pacing by internal wire or external pacemaker
6 National Patient Safety Agency (NPSA)Rapid Response Report May 2008
7 The NPSA has received reports of 12 deaths relating to chest drain insertion and 15 cases of serious harm between January 2005 and March Many more are likely to be unreported. The Medicines and Healthcare Products Regulatory Agency (MHRA) have received reports of nine incidents since 2003, all but one relating to the use of Seldinger type drains, which is now the most commonly used technique.
8 Indications - for chest drain insertion
9 Indications - for chest drain insertionTHINK …is a drain necessary?
10 Indications - for chest drain insertionPneumothorax Malignant pleural effusion (causing significant SOB) Empyema & complicated parapneumonic pleural effusion Traumatic haemopneumothorax Postoperative e.g, thoracotomy, oesophagectomy, cardiac surgery
11 Indications - for chest drain insertionPneumothorax Tension pneumothorax after initial needle relief Persistent or recurrent pneumothorax after simple aspiration (x1) Large (>2cm) secondary spontaneous pneumothorax In any ventilated patient (including NIV)
12 Pneumothorax
13 Spontaneous PneumothoraxIf bilateral or haemodynamically unstable proceed to chest drain Age >50yrs & significant smoking history or evidence of underlying lung disease on exam or CXR? PRIMARY PNEUMOTHORAX NO SECONDARY PNUEMOTHORAX YES
14 Size >2cm and/or breathlessPRIMARY PNEUMOTHORAX Consider discharge NO Size >2cm and/or breathless Aspirate (16 -18G cannula) YES Success (<2cm & SOB improved) YES Chest Drain (Size 8 -14F) NO
15 SECONDARY PNEUMOTHORAXAdmit & Observe 24hrs NO Size 1-2cm Size >2cm or breathless YES Chest Drain Aspirate YES Success (<1cm) YES NO
16 Indications - for chest drain insertionPneumothorax Tension pneumothorax after initial needle relief Persistent or recurrent pneumothorax after simple aspiration (x1) Large (>2cm) secondary spontaneous pneumothorax In any ventilated patient (including NIV) Remember.. Simple aspiration is recommended as first line treatment for all primary pneumothoraces requiring intervention. Ultrasound guidance is NOT needed for drain insertion for pneumothoraces
17 Indications - for chest drain insertionPneumothorax Tension pneumothorax after initial needle relief Persistent or recurrent pneumothorax after simple aspiration (x1) Large (>2cm) secondary spontaneous pneumothorax In any ventilated patient (including NIV) Malignant pleural effusion
18 Indications - for chest drain insertionPneumothorax Tension pneumothorax after initial needle relief Persistent or recurrent pneumothorax after simple aspiration Large (>2cm) secondary spontaneous pneumothorax in patients >50 yrs In any ventilated patient (including NIV) Malignant pleural effusion Remember.. Therapeutic pleural aspiration (up to 1.5 litres) will provide symptomatic relief in most situations Fluid aspiration or drainage require ultrasound guidance
19 Indications - for chest drain insertionPneumothorax Tension pneumothorax after initial needle relief Persistent or recurrent pneumothorax after simple aspiration Large (>2cm) secondary spontaneous pneumothorax in patients >50 yrs In any ventilated patient (including NIV) Malignant pleural effusion Empyema & complicated parapneumonic pleural effusion
20 Pleural effusion and evidence of infectionUltrasound scan Diagnostic fluid sampling Fluid pH and microbiology Pus Chest Drain Gram stain or culture positive or pH <7.2 YES NO Observe, unless clinical indication for drain
21 Indications - for chest drain insertionPneumothorax Tension pneumothorax after initial needle relief Persistent or recurrent pneumothorax after simple aspiration Large (>2cm) secondary spontaneous pneumothorax in patients >50 yrs In any ventilated patient (including NIV) Malignant pleural effusion Empyema & complicated parapneumonic pleural effusion Traumatic haemopneumothorax
22 Indications - for chest drain insertionPneumothorax Tension pneumothorax after initial needle relief Persistent or recurrent pneumothorax after simple aspiration Large (>2cm) secondary spontaneous pneumothorax in patients >50 yrs In any ventilated patient (including NIV) Malignant pleural effusion Empyema & complicated parapneumonic pleural effusion Traumatic haemopneumothorax Postoperative e.g, thoracotomy, oesophagectomy, cardiac surgery
23 Consent
24 Consent Written formal consent should be takenIf possible, an information leaflet should be given before the procedure In the case of an emergency treatment may be carried out but must be explained as soon as the patient is sufficiently recovered to understand
25 Complications
26 Complications EARLY complications LATE complications
27 Complications EARLY complications PainHaemothorax (intercostal vessel injury) Lung laceration Cardiac penetration Diaphragm and abdominal cavity penetration Bowel injury (unrecognised diaphragmatic hernia) Tube placed subcutaneously Tube inserted too far Surgical emphysema
28 Malpositioned tube
29 Surgical emphysema
30 Surgical emphysema
31 Complications LATE complications Pleural infection / wound infectionPneumothorax after removal Blocked tube Displaced tube…. “it just fell out doctor!”
32 Complications Remember..There is no organ in the thoracic or abdominal cavity that has not been pierced by a chest drain. Asepsis is paramount Good fixation will save repeat procedures
33 Reducing risk - HaemorrhageNon-urgent pleural aspirations and chest drain insertions should be avoided in anticoagulated patients until INR <1.5
35 Pitfalls Differentiating between collapse and a pleural effusion when the chest radiograph shows a unilateral “whiteout”
36 Image guidance – BTS recommendationsA chest X-ray must be available at the time of drain insertion except in the case of tension pneumothorax. All chest drains for fluid should be inserted under image guidance
37 Image guidance – BTS recommendationsThe marking of a site using thoracic ultrasound for subsequent remote aspiration or chest drain insertion is not recommended except for large pleural effusions
38 Preparation - equipmentRemember.. You should be able to set up your own trolley. Have your equipment within easy reach during the procedure.
39 Preparation - equipmentAsepsis Sterile gloves, gown and drapes Skin sterilisation (‘chloraprep’ device)
40 Preparation - equipmentAsepsis Sterile gloves, gown and drapes Skin sterilisation (‘chloraprep’ device) Remember.. Asepsis is paramount. Drapes and Gown are mandatory.
41 Preparation - equipmentAsepsis Sterile gloves, gown and drapes Skin sterilisation (‘chloraprep’ device) Anaesthesia Syringes and needles Local anaesthetic (1% lidocaine, up to 3 mg/Kg )
42 Preparation - equipmentAsepsis Sterile gloves, gown and drapes Skin sterilisation (‘chloraprep’ device) Anaesthesia Syringes and needles Local anaesthetic (1% lidocaine, up to 3 mg/Kg) Drain Kit Seldinger chest drain kit – 12F (contains scalpel) Chest drain tubing and bucket plus Sterile water (1L)
43 Preparation - equipmentDrain Size Small bore drains are recommended as they are more comfortable than larger bore tubes. No evidence that either is therapeutically superior. Large bore drains are recommended for drainage of acute haemothorax
44 Preparation - equipmentAsepsis Sterile gloves, gown and drapes Skin sterilisation (‘chloraprep’ device) Anaesthesia Syringes and needles Local anaesthetic (1% lidocaine) Drain Kit Seldinger chest drain kit – 12F (contains scalpel) Chest drain tubing and bucket plus Sterile water (1L) Fixation Suture (preferably 1.0 silk) Clear adhesive dressing
46 Preparation - patient positioning (1)The “Safe triangle” pectoralis major latisimus dorsi horizontal line of nipple
47 Preparation - patient positioning (2)Sat upright leaning over a table (with a pillow) Effusions marked whilst in this position Remember.. For marked drain sites - the patient should be in the same position during drain insertion as during drain site marking. Ideally bedside scanning should be employed.
48 Anatomy
49 Insertion procedure 1. Asepsis Clean the skin Drape the area
50 Insertion procedure 1. Asepsis 2. Anaesthesia Clean the skinDrape the area 2. Anaesthesia Infiltrate with local anaesthetic (10-20ml, 1%)
51 Insertion procedure 1. Asepsis 2. Anaesthesia Clean the skinDrape the area 2. Anaesthesia Infiltrate with local anaesthetic (10-20ml, 1%, 3mg/kg, 10ml 1%=100mg) Remember.. A chest tube should not be inserted without further image guidance if free air or fluid cannot be aspirated with a needle at the time of anaesthesia.
52 Insertion procedure - Seldinger technique3. Components Introducer needle + syringe Guide wire Dilator (with cuff / or restrictor) Chest drain Three way tap Tube connecting piece
53 Insertion procedure - Seldinger technique
54 Insertion procedure - Seldinger techniqueRemember.. The guide wire should be visible AT ALL TIMES.
55 Insertion procedure - tube positioningThe position of the tip of the chest tube should ideally be aimed apically for a pneumothorax or basally for fluid (use bevel of introducer needle) However, any tube position can be effective at draining air or fluid and an effectively functioning drain should not be repositioned solely because of its radiographic position.
56 Insertion procedure - securing the drainSuture and dress Ideally 1:0 suture (silk) Recommend using an ‘omental tag’ Omental tag
57 Insertion procedure - securing the drainSuture and dress Ideally 1:0 suture (silk) Recommend using an ‘omental tag’ Remember.. Ensure your drain is well secured; having to replace a drain is time consuming and technically more difficult than the first time. Omental tag
58 Now it’s in… what next?
59 Now it’s in… what next? Get a DOPS form!Chest X-ray, to confirm position
60 Now it’s in… what next? Chest X-ray, to confirm position
61 The drain isn’t bubbling..?
62 The drain isn’t bubbling..Remember.. A CXR is a 2 dimensional image. CT is needed for a suspected mal-positioned drain
63 Chest drain managementCXR post insertion Clamp off after 1.5L or earlier if SOB / chest pain – to avoid re-expansion pulmonary oedema Always keep drain below the level of the patient - If lifted above chest level contents of drain can siphon back into chest If disconnection occurs reconnect and ask patient to cough
64 Chest drain managementDaily fluid charting / drain assessment Not draining? Kinked Mal-position Blocked – try 30ml saline flush If the drain tip migrates out of the pleural space, the same drain should not be repositioned If a drain falls out the same drain tract should not be used to site the replacement drain
65 Chest drain managementSuction May have role in pneumothorax Low pressure / high flow ONLY on respiratory ward Chest physician decision Fibrinolysis Not supported by evidence (MIST) May have a role in those unsuitable for surgery
66 Chest drain removal – When?Effusion Draining less than 200ml per day and radiological improvement Pneumothorax - Radiological resolution and stopped bubbling for 24 hours Empyema Clinical & radiological improvement ‘Minimal’ drainage Drain no longer functioning
67 Chest drain removal – How?Removal is with a brisk firm movement Valsalva maneuver at full inspiration Dressing +/- ‘Steri-strips’ Sutures not usually needed
68 Discharge instructions for PTx
69 If you’re unsure ask for help...
70 Any questions?