What are the guidelines for the management of conditions requiring an intercostal chest drain?

Management of Intercostal Chest Drains

Small-bore chest drains (10-14 French) should be used as first-line therapy for pneumothorax and most pleural effusions, as they are equally effective as large-bore drains with fewer complications and better patient comfort. 1, 2, 3

Drain Selection and Insertion

Tube Size

• Small-bore drains (8-14 French) achieve primary success rates of 84-97% and are associated with shorter hospital stays compared to large-bore tubes 1, 2
• There is no evidence that large tubes (20-24 French) provide superior outcomes for pneumothorax management 1
• Large-bore drains may be necessary only when small tubes fail due to persistent air leaks exceeding tube capacity or when significant pleural fluid is present 1, 4
• The median drainage duration with small-calibre systems ranges from 2-4 days, comparable to larger systems 1, 4

Insertion Technique

• Insertion must be guided by imaging, preferably bedside ultrasound, to optimize placement and minimize complications 2, 3
• Use blunt dissection for tubes >24 French or Seldinger technique for smaller drains—never use trocar technique due to significantly increased injury risk 3, 5
• Strict aseptic technique is mandatory during insertion and all subsequent manipulations to prevent pleural infection, which occurs in 1-6% of cases 1, 2, 6

Drainage System Management

Suction Application

• Do not apply suction routinely; reserve it for incomplete lung re-expansion after 48 hours of drainage 1
• When suction is required, use high-volume, low-pressure systems (such as Vernon-Thompson pump or wall suction with pressure adaptor) delivering -10 to -20 cm H₂O 1
• Avoid high-pressure systems (either high or low volume) as they can cause air stealing, hypoxemia, or perpetuate air leaks 1
• Early suction application (before 48 hours) may precipitate re-expansion pulmonary edema, particularly in primary pneumothorax present for several days 1

Critical Safety Rules

• Never clamp a bubbling chest drain—this can convert a simple pneumothorax into life-threatening tension pneumothorax 1, 2, 6
• Clamping is only hazardous when the tube is actively bubbling; there is no evidence that clamping improves success rates or prevents recurrence 1
• Keep underwater seal bottles upright at all times to maintain proper function 1

Drain Maintenance

• Do not perform routine saline irrigation of intercostal drains—manipulation increases infection risk without proven benefit 2
• For multiloculated collections resistant to simple drainage, consider intrapleural fibrinolytic therapy rather than irrigation 2
• When administering fibrinolytics, clamp the tube for 1 hour after instillation, then remove within 12-72 hours if drainage is <250 ml/day 2

Management of Complications

Persistent Air Leak

• A persistent air leak is defined as continued bubbling through the drain 48 hours after insertion 1
• Apply suction after 48 hours if the leak persists 1
• Refer to thoracic surgery at 5-7 days for patients without underlying lung disease, or earlier (2-4 days) for those with underlying disease, large persistent leaks, or failure of lung re-expansion 1, 2

Pain Management

• Administer intrapleural local anesthetic (20-25 ml of 1% lignocaine) as a bolus at 8-hourly intervals after insertion 2, 6
• Use NSAIDs as primary systemic analgesia for chest wall pain 6
• Consider intercostal nerve blocks when pharmacological management is inadequate, preferably with ultrasound guidance 6
• Provide preemptive analgesia before drain removal 6

Surgical Emphysema

• Develops when air communicates with subcutaneous tissues, usually from malpositioned, kinked, blocked, or clamped tubes 1
• Treatment is typically conservative, but life-threatening cases may require tracheostomy or skin incision decompression 1

Specialist Referral Criteria

• Patients requiring suction should be managed in areas with specialist nursing experience 1
• Refer to respiratory specialists for persistent air leaks exceeding 48 hours or complex drain management 2, 6
• Seek early thoracic surgical opinion (3-5 days) for persistent air leak or failure of lung re-expansion 1

Common Pitfalls to Avoid

• Avoid routine use of chest drains when thoracentesis would suffice—this leads to avoidable drain insertions in up to 45% of cases with unnecessary complications 7
• Do not use large-bore drains initially; they increase complications without improving outcomes 1, 3
• Ensure adequate training in troubleshooting non-functioning drains, as inexperience can lead to incorrect assessment and additional unnecessary drain insertions 8
• Monitor for drain blockage, which can cause tension pneumothorax if unrecognized 8