What is the proper procedure for inserting an intercostal drainage (ICD) tube?

Proper Procedure for Inserting an Intercostal Drainage Tube

The optimal approach for intercostal drainage tube insertion is through the 4th or 5th intercostal space in the mid-axillary line for most indications, using a small-bore tube when possible to minimize patient discomfort, with ultrasound guidance to improve safety and efficacy. 1, 2

Patient Preparation and Positioning

• Anesthesia:

  • Use local anesthetic (0.25% bupivacaine or lidocaine) infiltrated into the skin, subcutaneous tissue, intercostal muscles, periosteum of the rib, and parietal pleura 2
  • Maximum dose: 2 mg/kg for bupivacaine or 3 mg/kg for lidocaine 2
  • For pediatric patients or those who cannot tolerate the procedure under local anesthesia, consider sedation or general anesthesia 2

• Position:

  • For conscious patients: slightly rotated with arm on affected side behind head to expose axillary area 2
  • Alternative positions: upright leaning over a table with pillow or lateral decubitus position 2

Site Selection

• For pneumothorax without hemothorax: 2nd or 3rd intercostal space in the mid-clavicular line 2
• For hemothorax or pleural effusion: 4th or 5th intercostal space in the mid-axillary line 2, 1
• Safe triangle: Area bordered by anterior border of latissimus dorsi, lateral border of pectoralis major, and a line superior to the horizontal level of the nipple 2
• Avoid posterior placement due to risk of intercostal artery injury (arteries run in middle of intercostal spaces posteriorly) 2

Imaging Guidance

• Ultrasound guidance should be used whenever possible to:
  • Confirm the optimal insertion site 2
  • Reduce complications 2
  • Improve success rates (96% vs 73-84% without imaging) 2

Tube Size Selection

• Small-bore tubes (including pigtail catheters) should be used whenever possible to minimize patient discomfort 2
• Large-bore tubes (24-28F) may be necessary for:
  • Large bronchopleural fistulas 3
  • Patients requiring positive pressure ventilation 3
  • Hemothorax or empyema 2

Insertion Technique

1. Preparation:

   • Ensure proper equipment is available (sterile field, tube, drainage system) 2
   • Mark the insertion site with an "X" if using ultrasound guidance 2

2. Sterile technique:

   • Clean the area with antiseptic solution
   • Drape the area with sterile towels

3. Anesthesia:

   • Infiltrate local anesthetic at the marked site using a small gauge needle 2
   • Ensure adequate anesthesia of all tissue layers including the pleura 2

4. Incision:

   • Make an incision one intercostal space below the intended insertion site
   • Incision should be large enough to accommodate the tube (approximately 2-3 cm)

5. Insertion:

   • Use blunt dissection technique (preferred) or Seldinger technique 3
   • Avoid trocar technique due to higher risk of complications 3, 1
   • Dissect through subcutaneous tissue and intercostal muscles
   • Enter the pleural space at the upper border of the rib to avoid neurovascular bundle 2
   • Insert finger to confirm entry into pleural space and clear adhesions
   • Guide the tube into position using a curved clamp

6. Direction:

   • For pneumothorax: direct tube anteriorly and superiorly
   • For fluid drainage: direct tube posteriorly and inferiorly

Securing the Tube

• Use a robust securing technique to prevent dislodgement 4
• Modified "Jo'burg" technique is recommended for military settings and patient transfers 4
• Standard approach:
  1. Place a purse-string suture around the insertion site
  2. Use a mattress suture through the skin adjacent to the tube
  3. Wrap suture around tube and tie securely
  4. Apply sterile dressing around the tube

Connection to Drainage System

• Connect to underwater seal drainage system without initial suction 3
• For tension pneumothorax, avoid applying suction initially 3
• If lung fails to re-expand, apply minimal suction and gradually increase while monitoring 3

Common Pitfalls and Complications

• Malposition: Occurs in approximately 20% of cases, more common with lateral approach (25%) than ventral approach (9.5%) 5
• Interlobar placement: Significantly higher risk with lateral approach 5
• Other complications: Pain, drain blockage, accidental dislodgment, organ injury, hemothorax, infections (11% overall) 3
• Never clamp a bubbling chest tube as this can lead to tension pneumothorax 3

Post-Insertion Management

• Obtain chest radiograph to confirm tube position
• Monitor for air leak, drainage volume, and respiratory parameters 3
• Discontinue suction once lung has re-expanded 3
• Observe for 5-12 hours before repeating chest radiograph to ensure pneumothorax has not recurred 3

By following this structured approach to intercostal drainage tube insertion, you can maximize success rates and minimize complications, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.