Inserting a Chest Drain

Contents

The safe triangle is an anatomical space created by:

And the drain is usually inserted in the 4^th, 5^th, or 6^th intercostal space

Find a location in the safe triangle
Alternate locations include 2^nd intercostal space mid-clavicular line, and 7^th intercostal space, posteriorly, but these are less comfortable for the patient.
Using 10-20ml 1% lidocaine inject down at the pleural level, just above the rib (to avoid the neurovascular bundle), usually the 6^th rib
Then attempt to aspirate air of fluid – if you cant, then don’t insert the drain here! Wait 3 minutes, and try again
Then blunt dissect down to the level of the pleura (e.g. using scissors, using the opening action of the scissors to dissect, or using forceps)
Puncture the pleura with scissors or forceps
If you are using a large bore tube, you may need to insert a finger into your dissect to remove any adherent lung
Remove the metal part of the drip before inserting – you should already have done your dissection – don’t force it in!
Advance the drain slowly, using forceps if necessary. Stop if you hit serious resistance
Attached the other end of the drain to the underwater seal
- The long tube should be under the water, and should bubble with respiration
Medium and large bore tubes may require suturing around the entry site
Fix the chest drain in place with a tie around the tube
Request CXR to ensure the drain has been placed correctly

This is occasionally performed in the case of pleural effusion, to control the rate of drainage, as draining too fast can result in expansion pulmonary oedema.
You should never clamp a chest drain in the case of pneumothorax

Backwards flow of water seal towards chest cavity
Prolonged bubbling of the chest drain fluid
Blockage of the tube due to kinks, blood clot / other. There will be no ‘swinging’ or ‘bubbling’ in the seal fluid
Wrongly positioned chest drain – check the CXR

Check there is re-expansion on CXR
In pleural effusion you may want to clamp the drain, as you may want to re-insert it
In pneumothorax, clamping is not necessary as reinsertion is unlikely
Give the patient a strong analgesic (e.g. morphine)
Remove the tube during expiration, and suture the insertion site

Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy