11/13/24, 7\:19 PM Guide | Chest drain

Chest drain

Table of contents

Introduction

A chest drain (a.k.a. intercostal drain) involves inserting a plastic tube into the pleural cavity to drain air or
This guide provides a step-by-step approach to inserting a chest drain in an OSCE setting, it is NOT intended to be used to
guide patient care.

Indications

Pleural e

Indications for inserting a chest drain for a pleural e include\:
Large benign e
Malignant pleural e
Empyema and complicated parapneumonic e
Symptomatic pleural e

Pneumothorax

Indications for inserting a chest drain for a pneumothorax include\:
Large primary spontaneous pneumothorax causing breathlessness
Large secondary spontaneous pneumothorax in patients >50 years
Traumatic pneumothorax (including haemopneumothorax)
Persistent pneumothorax following simple aspiration
Pneumothorax in any ventilated patient

Procedure-speci

Other indications for inserting a chest drain include\:
Talc pleurodesis
Post-thoracic cavity procedures (e.g. medical thoracoscopy and thoracic, oesophageal, or cardiac surgery)

Gather equipment

Clean a procedure trolley using a disinfectant wipe.
Gather the equipment required for the procedure and place it on the clean bottom shelf of the trolley\:
Antiseptic solution with applicator (e.g. chlorhexidine applied with ChloraPrep™)
Sterile drapes, gown, and gloves
Sterile
Sterile gauze
5-10ml local anaesthetic, such as 1% lidocaine
23G (blue) or 25G (orange) needle
21G (green) needle
https\://app.geekymedics.com/osce-guides/clinical-procedures/chest-drain/ 1/711/13/24, 7\:19 PM Guide | Chest drain
10ml syringe x2
Seldinger chest drain kit (12F suitable for most indications)
Chest drain drainage bottles & tubes
Sterile water for chest drain bottle
Straight needle suture (non-absorbable 0 or 1/0 silk)
Scalpel (if not included in chest drain kit)
Transparent dressing
Appropriate containers to collect
Ultrasound machine with sterile ultrasound probe sheath (for e

Pre-procedure

Check for contra-indications

Check for any relative contra-indications prior to performing the procedure\:
Uncooperative patient
Local skin infection at the site of
Bleeding disorder, anticoagulants, or coagulopathy (including INR >1.5 or platelets \<50)
No safe site for chest drain identi
Unavailability of ultrasound operator (for pleural e
As these are relative contra-indications, if any are present, a senior decision maker should determine whether the risk
outweighs the bene
For example, if a patient is taking anticoagulants but requires a chest drain, it would be down to a senior decision maker to
determine whether to proceed immediately, proceed after a period without anticoagulants, or make alternative arrangements.

Review imaging

Ensure there is a recent chest x-ray or CT thorax which shows pleural e
For pneumothorax, assess the chest x-ray for a suitable location for the chest drain (generally the “triangle of safety”
– see
preparation).
For pleural e
Kingdom this would be someone with at least level 1 competency in thoracic ultrasound).

Introduction

Wash your hands using alcohol gel. If your hands are visibly soiled, wash them with soap and water.
Don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Example explanation
“ W e c a n s e e f r o m t h e x-r a y o f y o u r c h e s t t h a t t h e r e i s a l a r ge a m o u n t o f
l u n g s , w e n e e d t o d r a i n t h e a i r /
"
" W e d o t h i s b y
a n a e s t h e t i c t o r e d u c e t h e d i s c o m f o r t o f t h e p r o c e d u r e a n d c a n a l s o p r e s c r i b e p a i n k i l l e r s . T h e d r a i n u s u a l l y s t a y s i n p l a c e
f o r a d a y o r t w o , b u t o c c a s i o n a l l y r e q u i r e s u p t o 1-2 w e e k s t o f u l l y d r a i n t h e a i r /
"
https\://app.geekymedics.com/osce-guides/clinical-procedures/chest-drain/ 2/711/13/24, 7\:19 PM Guide | Chest drain
" T h e r e a r e a l w a y s r i s k s w h e n w e p e r f o r m a n i n v a s i v e p r o c e d u r e l i k e t h i s , r i s k s . T h e m o s t c o m m o n p o t e n t i a l c o m p l i c a t i o n s i n c l u d e b l e e d i n g, p a i n , l u n g c a v i t y , d a m a g e t o t h e n e a r b y o r g a n s , a n d f a i l u r e o f t h e p r o c e d u r e .
”
b u t w e b e l i e v e t h a t t h e b e n e
i n f e c t i o n , a i r o r b l o o d b e i n g i n t r o d u c e d i n t o t h e
Gain written consent to proceed with chest drain insertion.
Check if the patient has any allergies (e.g. latex, local anaesthetic).
Ask the patient if they have any pain before continuing with the clinical procedure.

Preparation

Positioning

There are three common patient positions for chest drain insertion, depending on the planned area of insertion and the
mobility and comfort of the patient\:
Patient lying on their back, semi-reclined, with their hand on the side of insertion behind their head.
Patient sitting upright and leaning forwards on the edge of their bed, with their bedside table locked in front of them, with
two pillows for the patient to rest their arms on.
Patient lying on their side, with their head on a pillow and both of their hands underneath their head.
Chest drain positioning\: lying on back

Identify the chest drain insertion site

For pneumothorax, ultrasound is not usually required, and you should insert the drain in the triangle of safety if the x-ray
con
For pleural e, ask the ultrasound operator to perform an initial scan. The operator should assess the side with the
e
A simple way to mark the area is to push a pen lid into the skin, twisting while trying to avoid causing the patient discomfort.
This marking will still be visible after cleaning the skin.
The triangle of safety
https\://app.geekymedics.com/osce-guides/clinical-procedures/chest-drain/ 3/711/13/24, 7\:19 PM Guide | Chest drain
The triangle of safety is an area of the axilla with the lowest rate of complications when performing an invasive pleural
procedure such as a pleural tap or chest drain.
Needles inserted outside of this area have a higher chance of perforating the lung, pericardium, heart, and liver, and thus
must be performed after careful review of imaging and/or under ultrasound guidance (for e
The triangle of safety is bordered by three anatomical landmarks\:
Pectoralis major
Latissimus dorsi
th
5 intercostal space (roughly at the level of the nipple)
The triangle of safety

Set up the sterile

1. Wash your hands and don an apron.
2. Remove the outer packaging from the sterile
3. Place the sterile
surface of the
4. Use an aseptic non-touch technique (ANTT) to place the chest drain kit, antiseptic solution, sterile drapes, needles, syringe,
sterile ultrasound probe cover (for e
5. Pour sterile water into the chest drain bottle up to the marking.
6. Wash your hands again.
7. Don sterile gloves and clean a ~20cm area of the patient’s skin around the site of insertion.
8. Apply sterile drapes to the patient, ensuring that only the cleaned area is visible.
9. Check the expiry date of the local anaesthetic and ask your ultrasound operator, or an assistant, to open the vial. Use a
needle and syringe to draw this up without sterile equipment touching a non-sterile surface.
https\://app.geekymedics.com/osce-guides/clinical-procedures/chest-drain/ 4/711/13/24, 7\:19 PM Guide | Chest drain
10. For pleural e
operator, holding onto it as you allow the rest of the sheath to cover the probe wire. Place the elastic bands supplied with the
sheath underneath the probe to prevent and hand it to your ultrasound operator, who should now also be wearing sterile
gloves.

In

1. Check the skin mark and feel the area to make sure that you are inserting the needle above a rib, to avoid causing damage to
the neurovascular bundle.
2. For pleural e
shifted.
3. Insert the 23-25G needle with local anaesthetic into the skin at a shallow angle (~15 degrees). As you inject between the
dermis and epidermis you should see a small, raised area called a "dermal bleb"
.
4. Leave this to take e
5. Using the 21G (green) needle, in
before you inject to check that you are not in a blood vessel.
6. After anaesthetising, check that the positioning is correct by slowly inserting the green needle while aspirating, stopping
when air or
Aim above a rib to avoid the neurovascular bundle

Insert the chest drain

1. Attach the introducer needle from the chest drain kit to a 10ml syringe.
2. Using the same tract from which you just successfully aspirated, advance the introducer needle while aspirating, stopping
0.5cm after air or
downwards for e
to drain
3. Take note of the depth of the needle when it enters the pleural space.
4. Remove the syringe, and quickly place your thumb over the open end of the needle hub.
https\://app.geekymedics.com/osce-guides/clinical-procedures/chest-drain/ 5/711/13/24, 7\:19 PM Guide | Chest drain
5. Gently pass the Seldinger guidewire down the hub of the needle, directing upwards for pneumothorax, and downwards for
e
6. Gently remove the needle, keeping hold of the guidewire.
7. Make a small skin incision with a scalpel at the insertion site, pointing the sharp edge away from the wire. Tip\: from this point,
until the guidewire is removed, you need to make sure that you are always holding the guidewire. Hold it next to the skin when
the dilator is out, and at the end of the dilator or drain when inserting them. Failure to do so could result in serious
complications.
8. Warn the patient that they may experience a pushing and pulling sensation.
9. Pass the dilator over the guidewire, twisting gently when you reach the skin, until the dilator has passed 1cm beyond the
depth at which the needle began to aspirate pleural contents (which you noted in step 3).
10. Remove the dilator. If you are using a >12F drain, you may have a larger dilator to insert to dilate the tract further.
11. Pass the drain over the guidewire and through the skin to a depth of 5-10cm, ensuring that the last drainage hole is well
within the pleural space.
12. Remove the wire and hold your thumb over the end of the drain.
13. Attach the three-way tap from the chest drain kit to the end of the drain.
14. Using a syringe, aspirate from the three-way tap to ensure the drain is working, then close the three-way tap.

Securing and connecting the drain

1. Insert the straight needle suture into the skin next to the drain at a shallow angle, coming out of the skin after around 1cm.
2. Cut the needle o
stays in place during patient movement.
3. Apply a transparent dressing over the drain so that the insertion site is visible.
4. Attach the drain to the chest drain bottle tubing.
5. Open the three-way tap so that the air or

To complete the procedure...

Explain to the patient that the procedure is now complete.
Thank the patient for their time.
Dispose of PPE and other clinical waste into an appropriate clinical waste bin.
Prescribe appropriate analgesia, prophylactic anticoagulation, and 6-8 hourly 30ml saline
Inform the patient that the underwater seal draining bottle must stay below the level of the chest drain insertion site.
Inform the nursing stavital
signs.
If draining
pulmonary oedema. This can be achieved by partially opening the 3-way tap so that
more than 400mL is drained every 8 hours.

Investigations

of the procedure.
Request a post-procedure chest x-ray and check this yourself for drain position, ensuring this is performed within a few hours
If the patient has an e
required investigations\:
Biochemistry\: LDH & protein\: 2-5ml in a plain container or serum blood collection tube depending on local policy.
https\://app.geekymedics.com/osce-guides/clinical-procedures/chest-drain/ 6/711/13/24, 7\:19 PM Guide | Chest drain
Microbiology\:
culture bottles also.
Cytology\: cytological examination and di

Documentation

Place the consent form in the patient’s notes.
Document details of the procedure in the patient’s notes including\:
Your personal details including your name, job role and GMC number
The date and time the procedure was performed
That you have gained written consent
The indication for chest drain
The length of the chest drain inserted
Type of suture used
Colour of the
Instructions on when to open and close the three-way tap
Any complications
What investigations have been requested, and who is responsible for checking the results

Reviewer

Dr Praveen Bhatia
Respiratory Consultant

References

1. British Thoracic Society. B T S C l i n i c a l S t a t e m e n t o n P l e u r a l P r o c e d u r e s . June 2022. Available from\: [LINK]
2. British Thoracic Society. B T S G u i d e l i n e f o r P l e u r a l D i s e a s e . June 2022. Available from\: [LINK]
3. Thorax. P l e u r a l p r o c e d u r e s a n d t h o r a c i c u l t r a s o u n d \: B r i t i s h T h o r a c i c S o c i e t y p l e u r a l d i s e a s e gu i d e l i n e 2 0 1 0 . August Available from\: [LINK]
2010.
4. MedCourse. A i m a b o v e a r i b t o a v o i d t h e n e u r o v a s c u l a r b u n d l e . Licence\: [CC BY-SA].
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/clinical-procedures/chest-drain/ 7/7