What is the recommended process for chest drain insertion?

Recommended Process for Chest Drain Insertion

Chest drains should be inserted by adequately trained personnel using ultrasound guidance at the optimum site within the 'safe triangle', with small-bore drains preferred whenever possible to minimize patient discomfort while maintaining effectiveness. 1, 2

Pre-Insertion Preparation

• Patient Assessment:

  • Check for coagulopathy or platelet defects only in patients with known risk factors 1
  • Correct any coagulopathy before insertion when possible 1
  • Obtain chest radiograph and ultrasound to confirm diagnosis and mark insertion site 1

• Personnel Requirements:

  • Ensure a suitable assistant and trained nurse are available 1
  • Insertion should be performed by clinicians with appropriate training to reduce complications 1, 2

• Anesthesia Options:

  • General anesthesia is preferred for most children and those with respiratory compromise 1
  • If using conscious sedation, it must only be administered by those trained in airway management and pediatric resuscitation with full monitoring equipment 1
  • Use local anesthetic even with general anesthesia for post-procedure pain control 1

Anatomical Considerations

• Optimal Insertion Site:

  • Use the 'safe triangle' bordered by:
    • Anteriorly: lateral edge of pectoralis major
    • Posteriorly: anterior border of latissimus dorsi
    • Inferiorly: horizontal line at nipple level
    • Apex: below the axilla 2
  • Mid-axillary line between 4th and 5th intercostal space is ideal 2
  • Mark the site using ultrasound guidance 1, 2

• Patient Positioning:

  • For local anesthesia: Position patient slightly rotated with arm on affected side behind head 2
  • Alternative positions: upright leaning over table with pillow or lateral decubitus 2
  • For general anesthesia: Position flat on back 2

Insertion Technique

• Drain Selection:

  • Small-bore drains (8-12 FG) are preferred for most situations 1, 2
  • Large-bore drains only for hemothorax, very thick purulent effusions, or large air leaks 2

• Insertion Method:

  • Use sterile technique with gloves, gown, and sterile towels after effective skin cleansing 1
  • For small-bore drains: Use Seldinger technique at site suggested by ultrasound 1, 2
  • For large-bore drains: Place at site suggested by ultrasound, preferentially within the 'safe triangle' 1, 2
  • NEVER use substantial force or a trocar to insert a drain 1, 2
  • Avoid inserting too posteriorly or too low due to risk of vessel or organ injury 2

Post-Insertion Management

• Immediate Post-Insertion Care:

  • Perform chest radiograph to confirm proper tube position and rule out pneumothorax 1, 2
  • Connect to unidirectional flow drainage system (underwater seal bottle) kept below patient's chest level 1, 2
  • Secure drain properly to prevent dislodgment using non-absorbable suture and appropriate dressings 1, 2
  • Clamp the drain for 1 hour once 10 ml/kg are initially removed 1

• Ongoing Management:

  • Patients should be managed on specialist wards by staff trained in chest drain management 1
  • Never clamp a bubbling chest drain 1
  • Immediately unclamp and seek medical advice if patient complains of breathlessness or chest pain 1
  • Check for obstruction by flushing if there is sudden cessation of fluid drainage 1
  • Remove drain once there is clinical resolution 1
  • Replace drain if it cannot be unblocked and significant pleural fluid remains 1

Common Pitfalls and Complications

• Potential complications include pneumothorax requiring intervention (2.1%), bleeding (0.7%), and organ puncture or drain misplacement (2%) 3
• Avoid using small-bore drains for empyema as they have a higher failure rate (25.8%) due to blockage 4
• Never insert drains without appropriate imaging guidance as this increases risk of complications 1, 2
• Ensure proper drain fixation to prevent accidental dislodgment 1
• Consider chest tube insertion as an aerosol-generating procedure during infectious disease outbreaks, using appropriate PPE 2