What is the procedure for an intercostal (between the ribs) drain insertion?

From the Guidelines

The intercostal drain procedure should utilize small bore tubes (10–14 F) as the initial choice for effusion drainage and pleurodesis, due to reduced patient discomfort and comparable pleurodesis success rates, as recommended by the BTS guidelines for the management of malignant pleural effusions 1.

Key Considerations

• The procedure involves placing a tube between the ribs into the pleural space to drain air, blood, or fluid from around the lungs.
• Proper patient positioning, local anesthesia, and sterilization of the area are crucial steps in the procedure.
• The tube is typically inserted at the 4th or 5th intercostal space in the mid-axillary line and connected to a drainage system.
• Patients require regular monitoring for complications such as infection, tube displacement, or subcutaneous emphysema.
• Pain management is important during and after the procedure, using local anesthetics like lidocaine 1-2% for insertion and oral analgesics such as acetaminophen or NSAIDs for ongoing comfort.

Important Guidelines

• The BTS guidelines for the management of malignant pleural effusions recommend small bore tubes (10–14 F) as the initial choice for effusion drainage and pleurodesis 1.
• The BTS guidelines for the management of pleural infection in children emphasize the importance of adequate training and supervision for personnel inserting chest drains 1.
• The BTS guidelines for the management of spontaneous pneumothorax recommend intercostal tube drainage in secondary pneumothorax, except in patients who are not breathless and have a very small pneumothorax 1.

Best Practices

• Chest drains should be inserted by adequately trained personnel to reduce the risk of complications 1.
• A suitable assistant and trained nurse must be available during the procedure 1.
• Analgesic use during the insertion of intercostal tubes remains poorly studied, but intrapleural local anaesthetic may be effective in reducing pain scores 1.

From the Research

Intercostal Drain Procedure

• The intercostal drain procedure is a method used to remove pleural fluid and air from the pleural space, with indications including malignant pleural effusions, pneumothorax, and empyema 2, 3.
• The procedure can be performed using different techniques, including the Seldinger technique and blunt dissection, with the choice of technique depending on the patient's condition and the size of the drain 4, 5.
• The use of imaging guidance, such as ultrasonography or computed tomography, is recommended to ensure accurate placement of the drain 4, 6.
• The drain is connected to a drainage system, which can include a flutter valve, underwater seal, or electronic system, and the optimal timing for tube removal is still a matter of controversy 4.

Complications and Risks

• The intercostal drain procedure can be associated with complications, including pneumothorax, pleural effusions, and organ injury 6, 5.
• The risk of pleural complications is higher with an intercostal approach compared to a subcostal approach, but most of these complications are minor and can be managed with minimal intervention 6.
• The use of ambulatory pleural catheters can be a safe and effective strategy for managing malignant pleural effusions, with minor complications related to prolonged drainage 5.

Management and Treatment

• The management of pleural effusions depends on the underlying etiology, with transudative effusions usually managed by treating the underlying medical disorder 3.
• Exudative effusions require drainage and may require pleurodesis to prevent recurrence, with malignant effusions usually drained to palliate symptoms 3.
• Empyemas need to be treated with appropriate antibiotics and intercostal drainage, with surgery may be needed in selected cases where drainage procedure fails to produce improvement 3.