By DR Low Li Yam

Common Indications
Drainage of large pneumothorax(greater than 25%) Drainage of fluid from pleural cavity Flail chest segment requiring ventilator support, severe pulmonary

contusion with effusion. Prophylactic placement of chest tubes in a patient with suspected chest trauma before transport to specialized trauma center

Contraindications
Infection over insertion site
Uncontrolled bleeding diathesis

Equipment
Dressing set
Chest drain of appropriate size Underwater seal and tubing Local anaesthetic (Lidocaine 1%)

Syringes ,green needle

Scalpel blade Suture material (Silk 0) Large curved blunt artery forceps

Antiseptics

Anatomy Chest Wall

The muscle of the lateral chest wall include the latissimus dorsi,serratus anterior and the intercostal muscles.
Sensation to the lateral chest wall is supplied by the long thoracic nerve and branches of the intercostal nerves Each rib is associated with a neurovascular bundle.This bundle lies just inferior to

the rib and is composed of an intercostal artery,vein and nerve.

Tube Insertion Site

The most common location for placement of a chest tube is mid to anterior

axillary line,usually in the fourth or fifth intercostal space. The fifth intercostal space is approximately at the level of nipple or the inferior scapula border in most patients,although the breast mass may lead to variance in females. The incision site should be lateral to the edge of the pectoralis major muscle and breast tissue.

Procedure
Explain procedure to patient and obtain verbal consent.
Position the patient in 45-60 degree position with the arm above the head and

out of field. Prep the patient and draped the area. Infiltrate the lidocaine using a green needle.The drain should normally be placed in the 5th intercostal space just anterior to mid axillary line. Using the scalpel blade make a 2cm transverse incision over the upper border of rib below to avoid neurovascular bundle.Incise through the subcutaneous tissue to the intercostal muscle. Split the muscle using a curved blunt artery forceps down to the level of pleura. There is usually a gush of air or fluid at this stage. By spreading the jaws of artery forceps ,the tract can be widened so that it is wide enough to admit the index finger. Remove the trocar from the drain.

 Insert the tube through the tract and gently push into the pleura cavity.
Its often useful to use the forceps to help guide the drain into position.Ensure

that the most proximal drainage hole is intra pleural. Position the drain approximately:apical for pneumothorax and basal to drain fluid. The tube is secured to the skin using the 0 silk suture and attached to the underwater seal.Check for movement of the water level within the tube with respiration. Place sutures to close the incision around the chest tube. Apply a sterile occlusive dressing. Request CXR to confirm position.

Chest x-ray showing incomplete expansion of lung after chest tube placement.

Complications
Infection Misplacement Intercostal nerve and vessel injury Haemothorax Perforation of liver/spleen/heart

Removal of chest tube

Position patient in sitting position and give analgesia. Remove all the dressings and cut the anchoring suture. Clean the area with antiseptics. Ask the patient to inspire and hold their breath as you swiftly remove the chest

drain.Suture chest tube site. Apply gauze dressing and leave for 48 hours. Obtain CXR after removal of the chest drain.

Thank You