What are the guidelines for inserting an intercostal drainage (ICD) tube?

Guidelines for Intercostal Drainage Tube Insertion

Small bore chest tubes (10-14F) should be the initial choice for most pneumothoraces and pleural effusions, as they are as effective as large-bore tubes while causing less patient discomfort. 1, 2

Indications for Chest Tube Insertion

• Pneumothorax

  • Large pneumothorax (≥3 cm apex-to-cupola distance or >30% of hemithorax)
  • Symptomatic pneumothorax (respiratory distress, significant pain, hypoxemia)
  • Secondary pneumothorax (except in patients who are not breathless with very small <1 cm or apical pneumothorax)
  • Tension pneumothorax (after needle decompression)
  • Failed simple aspiration or catheter aspiration
  • Patients requiring positive pressure ventilation

• Pleural Effusion/Fluid Collections

  • Malignant pleural effusions
  • Hemothorax
  • Empyema/pleural infection

Tube Size Selection

• Small bore tubes (10-14F):

  • First choice for most pneumothoraces and malignant effusions
  • Primary success rates of 84-97% reported with 7-9F tubes 1
  • Associated with less patient discomfort 1
  • Suitable for chemical pleurodesis

• Large bore tubes (20-32F):

  • Consider only when small tubes fail
  • May be needed for:
    • Persistent large air leaks exceeding capacity of smaller tubes
    • Significant hemothorax
    • Thick purulent collections (empyema)

Insertion Technique

Patient Preparation and Positioning

• Position patient appropriately:
  • For axillary approach: arm elevated above head
  • For lateral decubitus: affected side up with arm over head
  • For posterior approach: sitting upright leaning forward 1

Site Selection

• Small bore percutaneous drains: Insert at site suggested by ultrasound guidance 1
• Large bore surgical drains: Preferably place in mid-axillary line through the "safe triangle" 1, 2
  • Safe triangle: bordered by anterior border of latissimus dorsi, lateral border of pectoralis major, and horizontal line at level of nipple

Sterile Technique

• Full aseptic technique is essential to avoid wound site infection or secondary empyema (reported rate ~1%) 1, 2
• Use sterile gloves, gown, equipment, and sterile towels
• Perform thorough skin cleansing with betadine or chlorhexidine over a large area 1

Anesthesia

• Local anesthetic infiltration:
  • Raise dermal bleb with small gauge needle
  • Infiltrate deeper tissues including subcutaneous tissue, intercostal muscles, periosteum of rib, and parietal pleura
  • For adults: 0.25% bupivacaine (max 2 mg/kg) or 1% lidocaine (20-25 ml, max 3 mg/kg) 1
  • Consider intrapleural local anesthetic bolus for post-insertion pain control 1

Insertion Procedure

• Never use substantial force or a trocar for insertion (associated with major organ injuries) 1
• For Seldinger technique (preferred for small bore tubes):
  • Locate pleural space with needle and syringe
  • Insert guidewire
  • Dilate tract
  • Pass catheter over guidewire
  • Remove guidewire and connect to drainage system

Post-Insertion Management

Drainage System

• Connect to underwater seal drainage or commercial chest drainage system
• Consider adding a Heimlich flutter valve for ambulatory management of pneumothorax 1

Suction

• Suction is usually unnecessary initially
• If applied, use high volume, low pressure system (10-20 cm H₂O) 2
• Consider adding suction after 48 hours for persistent air leak 2

Important Precautions

• A bubbling chest tube should NEVER be clamped (risk of tension pneumothorax) 1
• Non-bubbling tubes should generally not be clamped 1
• If clamping is necessary, it should only be done under supervision of respiratory physician or thoracic surgeon, with patient in a specialized ward 1
• Immediately unclamp if patient becomes breathless or develops subcutaneous emphysema 1

Drainage Management

• For large pleural effusions, drain in a controlled fashion to reduce risk of re-expansion pulmonary edema 1
• Once radiographic confirmation of lung re-expansion is obtained, proceed with pleurodesis if indicated, without waiting for cessation of fluid drainage 1

Complications and Their Management

• Organ injury: lung, heart, major vessels, abdominal organs (more common with trocar use) 1, 3
• Infection: empyema (1-6% of cases) - use strict aseptic technique 1
• Subcutaneous emphysema: may indicate malpositioned/kinked tube 1
• Re-expansion pulmonary edema: avoid rapid drainage of large effusions 1
• Tube blockage: more common with blood or thick fluid collections
• Pain: use adequate local anesthesia and consider intrapleural analgesia 1

Removal Criteria

• Complete resolution of pneumothorax on chest radiograph
• No air leak (no bubbling in water seal chamber)
• Drainage <100-150 mL/24 hours (if hemothorax component) 2

Referral Criteria

• Pneumothoraces failing to respond within 48 hours should be referred to a respiratory physician 1
• Consider thoracic surgical consultation if air leak persists beyond 48 hours 2
• Earlier referral (day 2-3) for patients with underlying lung disease or large air leak 2

By following these guidelines, chest tube insertion can be performed safely and effectively while minimizing patient discomfort and complications.