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Insertion of a chest tube to drain pneumothorax
Technical Skills
Insertion of a chest tube to drain pneumothorax
Intercostal chest tube drainage with an underwater seal is a simple and effective method to eliminate air in the pleural space. It is undertaken as an elective or urgent procedure. Emergency chest drainage for tension pneumothorax is undertaken by a wide-bore cannula in the second intercostal space (mid-clavicular line) of the affected side. Knowing when and how to safely place an intercostal chest drain is a valuable skill for all doctors.
Eric Lim Peter Goldstraw
When to insert a chest drain Not all pneumothoraces require chest tube drainage. The average rate of absorption of air in the pleural space occurs at approximately 1% per day. Expectant management is a reasonable option for patients who are not compromised with a small and non-progressive spontaneous pneumothorax. Chest drain insertion is required for patients with moderate to large spontaneous pneumothoraces and pneumothoraces associated with trauma. Patients with a history of multiple pneumothoraces or who have undergone previous thoracic surgery may have adhesions. As a result, sections of lung can adhere to the chest wall. Under these circumstances, inexperienced chest drain insertion may lead to in advertent perforation, and expert advice or assistance should be sought.
Abstract Intercostal chest tube drainage with an underwater seal is a simple and effective method to eliminate air in the pleural space. The patient is then positioned lying, shoulder elevated and undressed to the waist, with the arm abducted at 90°. The fourth intercostal space just anterior to the mid-axillary line is usually chosen. The surgical field is prepared with antiseptic solution, and lidocaine is injected to create a transverse wheal to demarcate the length and position of the skin incision. The tip of the scalpel blade is used to make an incision large enough to comfortably admit the index finger. Blunt dissection is undertaken using a Roberts clamp. Once the deep fascia is reached, the intercostal space becomes distinctive. Further lidocaine is used to create a field block by injecting multiple intercostal nerves. After leaving adequate time for the intercostal block to work, the Roberts clamp is then used with gentle but firm pressure spreading the intercostal muscles apart. When the Roberts clamp enters the pleural cavity, a gush of air is normally audible. The jaw of the Roberts clamp is opened to dilate the puncture site, and then followed by the index finger to dilate a tract into the pleural space. Once satisfied that there is no lung tissue adhering to the chest wall, a 28 French gauge drain is introduced into the pleural space without a trocar. Once the drain is sited, it is attached to an underwater seal, and the drain is then secured with a silk suture.
Preparation and positioning It is always wise to ensure that all the necessary equipment is available prior to scrubbing up (Table 1). An explanation of the
Required equipment for chest drain insertion Sterile gown and gloves Antiseptic solution Sterile galipot for antiseptic solution Sponge-holding forceps Swabs Sterile disposable drape 10 ml syringe 21 F needle 10 ml 1% lidocaine Scalpel with a no. 11 blade Roberts clamp Chest drain (the standard size is 28 F)* No. 2 silk stitch on a hand-held needle Drain bottle (primed with saline) Sterile connecting tubing
Keywords chest drain; field block; pneumothorax
Eric Lim, FRCS (C-Th), is a Consultant Thoracic Surgeon at the Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK. He qualified from Sheffield (UK) and trained in London and Cambridge (UK). His clinical interests are bronchoplastic resections for cancer, distal airway reconstruction and extended resections for lung and mediastinal cancers. His research interests are systematic reviews and clinical trials in Thoracic Surgery, focusing on thoracic oncology (neuroendocrine tumours, small cell lung cancer), surgery for emphysema and pneumothoraces.
*The ideal size of chest tube is influenced by both the size of the patient and the amount of air leak. Full lung expansion requires chest tube drainage to match the size of air leak. Air drains by a mixture of laminar and turbulent flow (depending on Reynold’s number). Because laminar and turbulent flow rates are proportional to the fourth and fifth powers of the radius, respectively (Hagen–Poiseuille and Fanning equations), it is important to select the largest tube that can comfortably fit within the intercostal space. For further information, see Anaesthesia and Intensive Care Medicine 2006; 7: 98.
Peter Goldstraw, FRCS, is Consultant Thoracic Surgeon at the Royal Brompton Hospital, London, UK, and Professor of Thoracic Surgery at Imperial College, London, UK. He was educated at Birmingham University, UK, and undertook his cardiothoracic training in Scotland and South Africa. His research interests are acute respiratory distress syndrome, lung volume reduction surgery and the surgical treatment of lung malignancies.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12
Table 1
520
© 2008 Published by Elsevier Ltd.
Technical Skills
Site for intercostal nerve blocks Posterior
Anterior
Intercostal muscle
Vein Artery Nerve
Figure 1 Positioning for chest drain insertion.
procedure, benefits and incumbent risks is often helpful to alleviate anxiety. The patient is then positioned lying, shoulder elevated and undressed to the waist, with the arm abducted at 90° (Figure 1). The arm may be held behind the head, but this often results in a slow downwards drift as the patient becomes tired or experiences pain. Absorbent pads are placed under the patient to prevention soiling of the clothes or bed.
Site for lidocaine intercostal nerve block Figure 2 Site for intercostal nerve blocks.
After leaving adequate time for the intercostal block to work, the Roberts clamp is then used with gentle but firm pressure to spread the intercostal muscles apart; dissect superiorly starting at the lower margin of the intercostal space (to avoid the neuro vascular bundle). The Roberts clamp should enter the pleural cavity easily once the deep fascia and muscle layer has been negotiated. A gush of air is normally audible at this point. The jaw of the Roberts clamp is opened to dilate the puncture site, and then followed by the index finger to dilate a tract into the pleural space. This is an important step. The tip of the finger will detect any adherent lung tissue, and the tract is dilated in the process to comfortably admit a 28 French gauge chest drain. If this manoeuvre is not performed satisfactorily, it can become difficult to find the tract for the chest drain as the tissues retract to seal the path made by the Roberts clamp. Once satisfied that there is no adherent lung tissue to the chest wall, a 28 French gauge drain is introduced into the pleural space without a trocar. To direct the drain to an apical or basal position, thoracic surgeons may leave the trocar engaged within the drain, but usually more than 2.5 centimetres away from the tip of the chest tube to facilitate the initial direction of the chest tube. The drain and trocar can then be angled upwards within the thorax to achieve an apical position or directed posteroinferiorly to achieve a basal position. Once the first 5 centimetres of the drain is directed within the thoracic cavity, the trocar is withdrawn. The drain is advanced continuously until a change in resistance is felt as the tip abuts the pleural apex or base of the diaphragm. Occasionally, pain is experienced in the neck and shoulder as the tip of the drain impinges on the apex. Withdrawal of the drain by 2.5 centimetres ensures a perfectly apical position and alleviation of pain. At this point, make a mental note of the distance marker at skin level. Once the drain is sited, attach it to an underwater seal. Entry into the thoracic cavity is suggested by: • fogging of the tube • a respiratory swing • bubbling on coughing.
How to insert a chest drain First decide into which intercostal space to introduce the chest drain. This will determine where you position the skin incision. The triangle (or more correctly quadrangle) of safety is bounded posteriorly by the posterior axillary line, anteriorly by the lateral border of pectoralis major and overlies the third to fifth inter costal spaces. Usually the fourth intercostal space is chosen, just anterior to the mid-axillary line. Prepare the surgical field with a generous coat of antiseptic solution and mark the intended spot by palpation; as the antiseptic dries, it leaves an imprint. Cut a small hole in the centre of a sterile paper drape and apply it to the chest wall such that the antiseptic imprint lies within the centre of the cut hole. Approximately 1–2 millilitres of 1% lidocaine is then injected to create a transverse wheal to demarcate the length and position of the skin incision. The tip of the scalpel blade is used to make a skin incision large enough to comfortably admit your index finger. It is surprising how anaesthetic is the subcutaneous tissue. Blunt dissection can proceed painlessly though the subcutaneous fat up to the deep fascia without any lidocaine. Once the deep fascia is reached, the intercostal space becomes distinctive. Further lidocaine (8 millilitres) is used to create a field block by injecting multiple intercostal nerves. The needle is advanced to identify the rib immediately superior to the chosen intercostal space and ‘walked’ down the rib until soft tissue is felt. The needle is then angled 45° upwards and the syringe aspirated to ensure that the tip does not lie within the vessels of the neurovascular bundle before injecting 2–3 millilitres of 1% lidocaine. Using the same method, a further 2 millilitres is injected in the targeted intercostal space to block the intercostal nerve anteriorly and also in the intercostal nerve of the space above and below the targeted intercostal space (Figure 2).
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12
Direction of dissection
521
© 2008 Published by Elsevier Ltd.
Technical Skills
The drain is then sutured with a no. 2 silk suture as a horizontal mattress suture, with a double throw to secure the initial tie (Figure 3). Check that the distance marker on the skin has not changed before tying a knot around the tubing to secure the chest drain. It is important to make certain that the tension on the knot is sufficient to kink the chest tube to ensure that the drain does not displace. This suture will also act as a purse string to secure the wound after chest drain removal. It is standard practice to obtain a radiograph after chest drain insertion to: • ensure that the drain lies within the thoracic cavity • evaluate the position of the drain • ensure that the lung re-expands • screen for complications (such as a new effusion from intra thoracic bleeding).
Securing the chest drain
a d
3–4 locking knots
Pitfalls e
b
Double throw in a single direction to form a slip knot c
A potential complication that occurs during chest tube insertion includes perforation of the lung. This usually occurs when a chest drain is forcibly inserted with the trocar fully engaged, such that the point sticks out from the tube. Warning signs are bleeding and a brisk air leak. Laceration to the intercostal artery can result in impressive haemorrhage. If this should occur, fluid resuscitation and clamping of the drain to tamponade the bleeding is warranted. Both these complications require consultation with a thoracic surgeon and usually necessitate surgical exploration. ◆
Cut here to remove the drain and pull on the sutures to seal the incision
f
3–4 locking knots with sufficient tension to indent the tubing
Figure 3 How to secure the chest drain.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12
522
© 2008 Published by Elsevier Ltd.
Insertion of a chest tube to drain pneumothorax
Intercostal chest tube drainage with an underwater seal is a simple and effective method to eliminate air in the pleural space. It is undertaken as an elective or urgent procedure. Emergency chest drainage for tension pneumothorax is undertaken by a wide-bore cannula in the second intercostal space (mid-clavicular line) of the affected side. Knowing when and how to safely place an intercostal chest drain is a valuable skill for all doctors.
Eric Lim Peter Goldstraw
When to insert a chest drain Not all pneumothoraces require chest tube drainage. The average rate of absorption of air in the pleural space occurs at approximately 1% per day. Expectant management is a reasonable option for patients who are not compromised with a small and non-progressive spontaneous pneumothorax. Chest drain insertion is required for patients with moderate to large spontaneous pneumothoraces and pneumothoraces associated with trauma. Patients with a history of multiple pneumothoraces or who have undergone previous thoracic surgery may have adhesions. As a result, sections of lung can adhere to the chest wall. Under these circumstances, inexperienced chest drain insertion may lead to in advertent perforation, and expert advice or assistance should be sought.
Abstract Intercostal chest tube drainage with an underwater seal is a simple and effective method to eliminate air in the pleural space. The patient is then positioned lying, shoulder elevated and undressed to the waist, with the arm abducted at 90°. The fourth intercostal space just anterior to the mid-axillary line is usually chosen. The surgical field is prepared with antiseptic solution, and lidocaine is injected to create a transverse wheal to demarcate the length and position of the skin incision. The tip of the scalpel blade is used to make an incision large enough to comfortably admit the index finger. Blunt dissection is undertaken using a Roberts clamp. Once the deep fascia is reached, the intercostal space becomes distinctive. Further lidocaine is used to create a field block by injecting multiple intercostal nerves. After leaving adequate time for the intercostal block to work, the Roberts clamp is then used with gentle but firm pressure spreading the intercostal muscles apart. When the Roberts clamp enters the pleural cavity, a gush of air is normally audible. The jaw of the Roberts clamp is opened to dilate the puncture site, and then followed by the index finger to dilate a tract into the pleural space. Once satisfied that there is no lung tissue adhering to the chest wall, a 28 French gauge drain is introduced into the pleural space without a trocar. Once the drain is sited, it is attached to an underwater seal, and the drain is then secured with a silk suture.
Preparation and positioning It is always wise to ensure that all the necessary equipment is available prior to scrubbing up (Table 1). An explanation of the
Required equipment for chest drain insertion Sterile gown and gloves Antiseptic solution Sterile galipot for antiseptic solution Sponge-holding forceps Swabs Sterile disposable drape 10 ml syringe 21 F needle 10 ml 1% lidocaine Scalpel with a no. 11 blade Roberts clamp Chest drain (the standard size is 28 F)* No. 2 silk stitch on a hand-held needle Drain bottle (primed with saline) Sterile connecting tubing
Keywords chest drain; field block; pneumothorax
Eric Lim, FRCS (C-Th), is a Consultant Thoracic Surgeon at the Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK. He qualified from Sheffield (UK) and trained in London and Cambridge (UK). His clinical interests are bronchoplastic resections for cancer, distal airway reconstruction and extended resections for lung and mediastinal cancers. His research interests are systematic reviews and clinical trials in Thoracic Surgery, focusing on thoracic oncology (neuroendocrine tumours, small cell lung cancer), surgery for emphysema and pneumothoraces.
*The ideal size of chest tube is influenced by both the size of the patient and the amount of air leak. Full lung expansion requires chest tube drainage to match the size of air leak. Air drains by a mixture of laminar and turbulent flow (depending on Reynold’s number). Because laminar and turbulent flow rates are proportional to the fourth and fifth powers of the radius, respectively (Hagen–Poiseuille and Fanning equations), it is important to select the largest tube that can comfortably fit within the intercostal space. For further information, see Anaesthesia and Intensive Care Medicine 2006; 7: 98.
Peter Goldstraw, FRCS, is Consultant Thoracic Surgeon at the Royal Brompton Hospital, London, UK, and Professor of Thoracic Surgery at Imperial College, London, UK. He was educated at Birmingham University, UK, and undertook his cardiothoracic training in Scotland and South Africa. His research interests are acute respiratory distress syndrome, lung volume reduction surgery and the surgical treatment of lung malignancies.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12
Table 1
520
© 2008 Published by Elsevier Ltd.
Technical Skills
Site for intercostal nerve blocks Posterior
Anterior
Intercostal muscle
Vein Artery Nerve
Figure 1 Positioning for chest drain insertion.
procedure, benefits and incumbent risks is often helpful to alleviate anxiety. The patient is then positioned lying, shoulder elevated and undressed to the waist, with the arm abducted at 90° (Figure 1). The arm may be held behind the head, but this often results in a slow downwards drift as the patient becomes tired or experiences pain. Absorbent pads are placed under the patient to prevention soiling of the clothes or bed.
Site for lidocaine intercostal nerve block Figure 2 Site for intercostal nerve blocks.
After leaving adequate time for the intercostal block to work, the Roberts clamp is then used with gentle but firm pressure to spread the intercostal muscles apart; dissect superiorly starting at the lower margin of the intercostal space (to avoid the neuro vascular bundle). The Roberts clamp should enter the pleural cavity easily once the deep fascia and muscle layer has been negotiated. A gush of air is normally audible at this point. The jaw of the Roberts clamp is opened to dilate the puncture site, and then followed by the index finger to dilate a tract into the pleural space. This is an important step. The tip of the finger will detect any adherent lung tissue, and the tract is dilated in the process to comfortably admit a 28 French gauge chest drain. If this manoeuvre is not performed satisfactorily, it can become difficult to find the tract for the chest drain as the tissues retract to seal the path made by the Roberts clamp. Once satisfied that there is no adherent lung tissue to the chest wall, a 28 French gauge drain is introduced into the pleural space without a trocar. To direct the drain to an apical or basal position, thoracic surgeons may leave the trocar engaged within the drain, but usually more than 2.5 centimetres away from the tip of the chest tube to facilitate the initial direction of the chest tube. The drain and trocar can then be angled upwards within the thorax to achieve an apical position or directed posteroinferiorly to achieve a basal position. Once the first 5 centimetres of the drain is directed within the thoracic cavity, the trocar is withdrawn. The drain is advanced continuously until a change in resistance is felt as the tip abuts the pleural apex or base of the diaphragm. Occasionally, pain is experienced in the neck and shoulder as the tip of the drain impinges on the apex. Withdrawal of the drain by 2.5 centimetres ensures a perfectly apical position and alleviation of pain. At this point, make a mental note of the distance marker at skin level. Once the drain is sited, attach it to an underwater seal. Entry into the thoracic cavity is suggested by: • fogging of the tube • a respiratory swing • bubbling on coughing.
How to insert a chest drain First decide into which intercostal space to introduce the chest drain. This will determine where you position the skin incision. The triangle (or more correctly quadrangle) of safety is bounded posteriorly by the posterior axillary line, anteriorly by the lateral border of pectoralis major and overlies the third to fifth inter costal spaces. Usually the fourth intercostal space is chosen, just anterior to the mid-axillary line. Prepare the surgical field with a generous coat of antiseptic solution and mark the intended spot by palpation; as the antiseptic dries, it leaves an imprint. Cut a small hole in the centre of a sterile paper drape and apply it to the chest wall such that the antiseptic imprint lies within the centre of the cut hole. Approximately 1–2 millilitres of 1% lidocaine is then injected to create a transverse wheal to demarcate the length and position of the skin incision. The tip of the scalpel blade is used to make a skin incision large enough to comfortably admit your index finger. It is surprising how anaesthetic is the subcutaneous tissue. Blunt dissection can proceed painlessly though the subcutaneous fat up to the deep fascia without any lidocaine. Once the deep fascia is reached, the intercostal space becomes distinctive. Further lidocaine (8 millilitres) is used to create a field block by injecting multiple intercostal nerves. The needle is advanced to identify the rib immediately superior to the chosen intercostal space and ‘walked’ down the rib until soft tissue is felt. The needle is then angled 45° upwards and the syringe aspirated to ensure that the tip does not lie within the vessels of the neurovascular bundle before injecting 2–3 millilitres of 1% lidocaine. Using the same method, a further 2 millilitres is injected in the targeted intercostal space to block the intercostal nerve anteriorly and also in the intercostal nerve of the space above and below the targeted intercostal space (Figure 2).
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12
Direction of dissection
521
© 2008 Published by Elsevier Ltd.
Technical Skills
The drain is then sutured with a no. 2 silk suture as a horizontal mattress suture, with a double throw to secure the initial tie (Figure 3). Check that the distance marker on the skin has not changed before tying a knot around the tubing to secure the chest drain. It is important to make certain that the tension on the knot is sufficient to kink the chest tube to ensure that the drain does not displace. This suture will also act as a purse string to secure the wound after chest drain removal. It is standard practice to obtain a radiograph after chest drain insertion to: • ensure that the drain lies within the thoracic cavity • evaluate the position of the drain • ensure that the lung re-expands • screen for complications (such as a new effusion from intra thoracic bleeding).
Securing the chest drain
a d
3–4 locking knots
Pitfalls e
b
Double throw in a single direction to form a slip knot c
A potential complication that occurs during chest tube insertion includes perforation of the lung. This usually occurs when a chest drain is forcibly inserted with the trocar fully engaged, such that the point sticks out from the tube. Warning signs are bleeding and a brisk air leak. Laceration to the intercostal artery can result in impressive haemorrhage. If this should occur, fluid resuscitation and clamping of the drain to tamponade the bleeding is warranted. Both these complications require consultation with a thoracic surgeon and usually necessitate surgical exploration. ◆
Cut here to remove the drain and pull on the sutures to seal the incision
f
3–4 locking knots with sufficient tension to indent the tubing
Figure 3 How to secure the chest drain.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12
522
© 2008 Published by Elsevier Ltd.