Chest Drainage Guidelines
Small-bore chest tubes (10-14F) should be used as the first-line option for chest drainage in most clinical scenarios to minimize patient discomfort while maintaining effective drainage. 1, 2
Drain Selection and Placement
- Small-bore chest tubes (8-14F) are as effective as larger tubes for most indications including pneumothorax and pleural effusions, while causing less pain and improving patient mobility 1
- Larger tubes may be necessary in specific situations such as hemothorax, large air leaks exceeding the capacity of smaller tubes, or when small tubes have failed 1
- The Seldinger technique is recommended for insertion of small-bore drains, as it is safer than trocar insertion methods 1, 2
- Chest tube insertion should be guided by imaging (ultrasound or CT) to ensure proper placement and avoid complications 2
- Trocars should never be used for chest tube insertion due to high risk of organ injury 1, 3
Insertion Technique and Safety
- Sterile technique is essential during insertion, including sterile gloves, gown, equipment, and thorough skin cleansing with betadine or chlorhexidine 1
- Never use substantial force when inserting a chest drain to avoid damage to intrathoracic structures 1
- A chest radiograph must be performed after insertion to confirm proper placement and rule out pneumothorax 1
- The recommended insertion site for most indications is the 5th or 6th intercostal space in the anterior axillary line 3
Securing the Drain
- The drain incision should be closed with a non-absorbable suture around the drain 1
- The drain must be well secured to prevent dislodgement using either:
- A stay suture criss-crossed up the drain (ensuring it's not too tight)
- Special dressings/fixation devices designed for chest tubes
- Steristrips and transparent adhesive dressing to allow site inspection 1
- The use of purse-string sutures remains controversial due to potential for painful scarring 1
Drainage System Management
- All chest tubes must be connected to a unidirectional flow drainage system kept below the level of the patient's chest at all times 1, 4
- Options for drainage systems include:
- A bubbling chest drain should never be clamped as this may lead to tension pneumothorax 4
- Suction should not be applied immediately after tube insertion but can be added after 48 hours for persistent air leak or failure of pneumothorax to re-expand 1
- When suction is required, high volume, low pressure (-10 to -20 cm H₂O) systems are recommended 1
Specialized Care and Referral
- Patients requiring chest drainage with suction should be managed on specialized units with appropriate medical and nursing expertise 1
- Pneumothoraces that fail to respond within 48 hours to treatment should be referred to a respiratory physician 1
- Patients discharged with indwelling pleural catheters should be referred to community nursing teams for ongoing support 4
Complication Prevention and Management
- Common complications include pain, drain blockage, and accidental dislodgment 2
- More serious complications include organ injury, hemothorax, infection, and re-expansion pulmonary edema 2
- When there is sudden cessation of fluid drainage, check for obstruction by flushing the drain 4
- If a clamped drain causes breathlessness or chest pain, it should be immediately unclamped and medical advice sought 4
- The overall complication rate for properly placed pleural drainage should not exceed 3% 3
Special Considerations for Indwelling Pleural Catheters
- Daily drainage is recommended for indwelling pleural catheters to increase pleurodesis rates 4
- Symptom-guided or alternate day drainage can effectively control breathlessness and chest pain 4
- Patient and caregiver education should include aseptic drainage technique, recognition of complications, and when to seek medical attention 4