Chest Drain

• Insertion
  • Via triangle of safety - pec major | lat dorsi | 5th ICS (above)
• Indications
  • Haemothorax
  • Pneumothorax
    • Tension, > 3cm, Any resp distress
    • Any size undergoing transfer, GA or positive pressure ventilation (say this for the exam but in reality not all patient receving PPV need a chest drain but instead close monitoring)

• Mechanism of effect of an Under Water Seal Chest Drain
  • A system that allows drainage of the pleural space using an airtight system to maintain subatmospheric intrapleural pressure; the underwater seal acts a one-way valve
  • Expiration and coughing pushes air out via drain and causes bubbling
  • Chest drain creates a siphon effect for fluid and air
  • Fluid drained via gravity (keep canister below level of insertion)
  • Air drained through water seal valve reservoir which prevents back flow into the pleural space
• Equipment
  • 3 chambers - fluid, air and suction
    • 1 -  fluid trap or collection bottle, can be independently emptied and allows accurate record of drainage amount
    • 2 - underwater seal drain, maintained at a predetermined level whilst still allowing for drainage of pleural fluid (if bubbling continuously → bronchopleural fistula)
    • 3 - manometer or pressure-regulating bottle allows suction to be attached and should bubble continuously

• Complications
  • Bleeding - Intercostal vessels → HTX
  • Pain - Intercostal nerve
  • Traumatic organ injury - lung, great vessels, oesophagus, colon, spleen, liver
  • Infection
  • Malposition/kinking/blocking
  • Recurrence or tension
• Pathophysiology
  • HTX and fluid drained by gravity dependence - chest drain below patient
  • PTX drained via UWSD
  • Normally intrapleural pressure is negative
  • Chest injury causes loss of negative intrapleural pressure - lung collapse
  • Chest drain drains air as intrapleural pressure is higher
  • Air bubbles and can’t return due to UWSD
  • Vented out as well to maintain pressure gradient

Procedure

• Positioning and site selection
  • Position patient sitting upright or semi-recumbent at 45°, with arm on affected side raised behind the head
  • Identify the “safe triangle”:
    • Anterior border of latissimus dorsi
    • Lateral border of pectoralis major
    • Line superior to the nipple (5th intercostal space)
  • Mark the insertion point just anterior to the mid-axillary line, 4th or 5th intercostal space
• Asepsis and anaesthesia
  • Clean skin widely and drape
  • Infiltrate local anaesthetic into skin, subcutaneous tissue, intercostal muscles, and pleura
  • Aspirate to confirm entry into pleural space (air or fluid return)
• Incision and blunt dissection
  • Make a 2–3 cm horizontal incision
  • Use curved haemostat or artery forceps to bluntly dissect through tissues
    • Over the rib below the interspace (to avoid neurovascular bundle)
  • Pierce parietal pleura with controlled force—may feel a “give” or air/fluid egress
• Finger sweep
  • Insert gloved finger into pleural space to confirm entry and exclude adhesions or organs
• Chest tube insertion
  • Direct tube posteriorly and superiorly for air, or posteriorly and inferiorly for fluid
  • Advance until last side hole is well inside the pleural space (typically 12–18 cm)
  • Connect to underwater seal drainage system
• Secure and dress
  • Anchor tube with heavy silk suture (e.g., stay and purse-string technique)
  • Apply occlusive sterile dressing
• Post-insertion checks
  • Confirm bubbling (for pneumothorax) or fluid drainage
  • Check for swinging with respiration
  • Obtain a chest X-ray to confirm position and re-expansion of lung
• Postoperative care
  • Monitor output volume and quality
  • Daily review for air leak, signs of infection, or malfunction
  • Clamp trial (if indicated) before removal
  • Remove when no air leak and fluid output is minimal