Paediatrics: Insertion of a chest drain

Insertion of a chest drain

Indications

This procedure is used to drain a pneumothorax, pleural effusion or chy-lothorax. In an emergency (most commonly due to a tension pneumotho-rax), drainage should first be performed by inserting 21–23G butterfly into the affected side at the second intercostal space in the mid-clavicular line. The butterfly tubing can be placed under water following insertion; alter-natively, a 3-way tap can be attached allowing aspiration with a syringe. Once the child is stable, a formal chest drain should be inserted.

Equipment

•   Antiseptic solution: e.g. 0.5% chlorhexidine.

•   Local anaesthetic: e.g. 1% lidocaine, needle, and 10mL syringe.

•   Intercostal drain: size ranges from 8–12Fr for newborns up to 18Fr for young adults.

•   Straight surgical scalpel blade, artery forceps, and suture.

•   Sterile dressing pack (including gauze, gloves, drapes).

•   Underwater drainage system and suction pump.

•   Steri-Strips^® and plastic transparent dressing, e.g. Tegaderm^®.

Procedure

•   Lie the child supine with the affected side raised by 30–45° using a towel.

•   Raise the arm towards the head.

•   Suitable sites are the fourth intercostal space in the mid-axillary line (be careful to avoid the nipple), and second intercostal space in mid-clavicle line.

•   Chest drain insertion should be performed using strict aseptic technique.

•   Wash hands and put on sterile gloves, gown, +/– surgical mask.

•   Clean skin over the insertion site with antiseptic solution.

•   Prepare sterile field, then infiltrate small amount of local anaesthetic into the tissues down to the pleura.

•   Wait 1–2min, then make a small skin incision with the scalpel just above and parallel to rib. Note: Blood vessels lie just below each rib.

•   Using artery forceps make a blunt dissection down to and through the parietal pleura.

•   Using forceps clamp chest drain and then insert into pleural space. Most clinicians remove the trocar before insertion.

•   Aim to push the chest drain tip towards the lung apex. In the event of a small pneumothorax aim the tip in the direction of the pneumothorax remembering to aim anteriorly (air rises in the ill child lying supine).

•   Connect the drain tightly to the underwater drainage system, unclamp drain, and apply negative pressure of 5–10cmH₂O. Bubbling should start to occur.

• Using single sutures close skin wound closely around chest drain. Do not use a purse string suture as this will increase scarring.

• Apply zinc oxide tape to chest drain and fix to skin using sutures.

• Perform a CXR to check drain position and pneumothorax or effusion drainage.

• Remove drain when confident it is no longer required, e.g. pneumothorax has resolved and there has been no bubbling for >24hr. This is done by releasing holding sutures, then rapidly removing drain followed by immediate pressure and gentle rubbing with a gauze swab to close the underlying tissues. Apply Steri-Strip^® across skin incision to provide air-tight seal. Perform a CXR to confirm that a significant pneumothorax has not re-accumulated.

• Note: If pleural fluid is required for diagnostic purposes only, then simple needle aspiration at the above sites is the technique of choice.