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Chapter: Paediatrics: Practical procedures

Paediatrics: Insertion of a chest drain

This procedure is used to drain a pneumothorax, pleural effusion or chy-lothorax.

Insertion of a chest drain




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.




   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®.




   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.


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