As far as I am aware, this topic has never come up in the CICM Fellowship written paper; however previously examined trainees report having to discuss ICCs in the viva sessions. Plus, there is this WCA thing which might become more relevant as the trainees joining post-2014 finally outnumber the old cohort. These days, pleural drain insertion is taken quite seriously, and not without reason. Next to arterial line insertion it is probably the most disaster-prone procedure in the ICU, and has the most potential for serious complications.
The purpose of this chapter is to unite the information which is otherwise contained in numerous widely spread-out sources. The main audience would probably be the supervisor of training who, upon arriving at work one morning, is greeted by an enthusiastic trainee brandishing the WCA form and demanding to undergo assessment. The supervisor, unprepared for this and possibly hung over, will be unlikely to agree unless a scripted resource is available for them where all the information necessary to answer the WCA questions is available. This chapter is that resource. All the important areas are covered.
In terms of published evidence, one could do worse than read the ACI Consensus Guideline for pleural drains in adults. Certainly, if you're working in NSW this is actually your practice policy document for chest drain insertion, and you will already be intimately familiar with it. A well-worn copy may be stuffed under your mattress. This document is heavily based upon the British Thoracic Society guidelines (Havelock et al, 2010); in fact whole blocks of text have been lifted from there by the unscrupulous plagiarists at NSW Department of Health. For indications and contraindications of pleural drain insertion, one should turn to the NEJM article by Shelly et al (2007) or the slightly dated by still excellent paper by Miller and Sahn (1987).
Shelly et al (2007, NEJM) offer an excellent list of indications, which is reproduced here with virtually no modification.
Elective (non-emergency) insertion
These are few:
There are actually few absolute contraindications to the placement of a pleural drain. According to Miller and Sahn (1987), there are none. Most people would probably disagree; for instance a nicely adherent post-pleurodesis lung would probably be a reason to seriously reconsider it. Alternatively, if you strongly suspect right ventricular rupture or something equally horrible, any attempt to insert a chest drain is really just a time-wasting exercise (a cardiac operating theatre should be readied instead).
Relative contraindications are numerous but all can be summarised as either "there is something in your way that is valuable or dangerous" or "the procedure is pointless". Example of valuable things in the way include abdominal viscera, for example in the case of a large diaphragmatic hernia. Examples of poinlessness include loculated effusions and hepatic hydrothorax, added to the list of relative contraindications by Runyon et al (1986) mainly because it caused "massive protein and electrolyte depletion and death of both patients" according to their case report.
An appropriate consent procedure would need to include the following important matters:
This information was collected from the QLD Department of Health website, where a comprehensive Intercostal Catheter Insertion Consent Form is available.
Additionally, basic pre-conditions for consent must be demonstrated:
In accepting consent from a patient, we operate under the presumption of competence: i.e. patient is over 18 and is “duly qualified: having sufficient, capacity, ability or authority” to give consent. This is tested by the following criteria:
. In short, the following are important features of your environment:
These could be considered "essential elements", but of course depending on where you are you may have more equipment and asisstence, or none whatsoever (eg. some sort of nightmarish pre-hospital battlefield scenario where you just have your trusty USMC KA-BAR and a bamboo reed). Furthermore, an "appropriate physical environment" for chest drain insertion is a fairly loose deascription of the situation, and any question like this could theoretically be correctly answered with a statement like "an ambient temperature of approximately 294 K, with a breathable oxygen-rich atmosphere pressurised to approximately 101 kPa".
Shelly et al (2007) also has an excellent table for sizing of chest tubes depending on their indication. A simplified version of this is included in the NSW Health ACI guideline (p.9). These tables are remixed and reinterpreted below. In short, the higher the flow you will require, the wider the catheter bore; also the more viscous the fluid you are draining, the wider the bore.
|Indication||Seldinger tube size||Blunt dissction technique tube size|
|Small pneumothorax||Fine bore pigtail||20Fr|
|Large pneumothorax||Standard pigtail (14Fr)
or straight 20Fr tube
|Transudative pleural effusion||Standard pigtail (14Fr)||20Fr|
|Empyema (i.e. thick and viscous)||-||24Fr|
The selection of tubes available ranged from 6-8Fr "fine bore" pigtails such as those favoured by interventional radiologists, through standard 14Fr pigtail catheters such as those available in commonly used kits (eg the Wayne set), to larger non-pigtailed sets still inserted via the Seldinger technique (eg. the Thal kit). The larger tubes require blunt dissection to insert.
Features of greatest relevance include the "triangle of safety" and knowing where the neurovascular bundle sits.
"Triangle of safety" is bordered by:
There are caveats to this. In the following situations, one may wish to insert a chest drain somewhere else:
Indeed the ultrasound guidance of chest drain insertion is probably going to become the gold standard as it seems to reduce complication rate in comparison to the blind technique (Jayathissa et al, 2011).
The neurovascular bundle sits on the inferior surface of the ribs. One needs to aknowledge this as a part of knowing the insertion anatomy.
The NSW Guideline borrows from Havelok et al (2010):
In word form:
Another important part of the preparation is the "time out". This is important: you do not want to be known as the guy who punctured the wrong pleural cavity.
SpO2 monitoring is all NSW ACI recommend, beyond "baseline observations". This probaly depends on how you plan to sedate them (clearly, if a general anaesthetic is being planned this changes the requirements somewhat). Neither of the major review articles mention any specific guidelines for monitoring. The Royal Children's Hospital of Melbourne guideline suggests the following (more comprehensive) series of continuously monitored parameters:
If one were in an exam situation where one's safety as a practitioner were being assessed, one would want to err on the side of caution by asking for this level of monitoring.
In the British guidelines (Havelok et al, 2010) "thoracic ultrasound guidance is strongly recommended for all pleural procedures for pleural ﬂuid". The local guidelines seem to be significantly influenced by this set of guidelines, and also suggest that "real time bedside thoracic ultrasound guidance is gold standard for the insertion of non-emergency pleural drains for management of pleural fluid". These recommendations are based on the observation that the blind procedure has a 30-40% comlication and failure rate, as compared to virtually 0% for real-time ultrasound.
As for the use of it for pleural fluid - this is theoretically correct, but one can also use ultrasound to identify an area where there is definitely some pneumothorax, and so the use of ultrasound is not limited to fluid collections.
What might you expect to see on the sterile tray for pleural drain insertion?
One might expect that the range of equipment would vary depending on what exactly you are planning to insert. For instance, there may be a pigtail catheter with a series of dilators, or there may be a huge Kelly clamp and a scalpel. The photograph above depicts one of my more OCD-affected anaesthetic colleagues preparing for pigtail catheter placement, with equipment carefully laid out.
An important point to mention is that the eqipment trolley needs to be prepared immediately before the procedure. Duration of exposure to the room air is directly proportional to bacterial contamination of the equipment (Dalstrom et al, 2008). Therefore the correct answer to the question "what is the ideal amount of time between opening and using the sterile equipment" is in fact "zero minutes".
When asked "how long should you scrup for a procedure", the savvy trainee will reply "for five minutes, as consistent with NSW Health guidelines" as if this were a surgical procedure in the operating theatre.
The NSW ACI guideline does not specify a duration merely recommending that we "perform hand hygiene: aseptic technique requires operator to use mask, sterile gown and gloves". For those who want to read more, the WHO probably supplies the definitive international document for the rationale behind surgical scrub tecnique (Widmer et al, 2010); the local department policy for some reason appears to have been rescinded (but the old document is still interesting and can be viewed here).
Both the NSW ACI and the 2010 British guidelines recommend full aseptic technique:
How frequently is there a chest-drain-associated infection? Apparently, 0.2-2.4% (Havelock et al, 2010). This low rate is attributed to high levels of full aseptic technique implementation.
How might one prepare the site if chest drain insertion?
The college WCA document also mentions "drying time" which is porbably more relevant in the operating theatre where an incompletely dried 70% alcohol wash might burst into flames at the first touch of the diathermy probe. In summary:
All this can be explored in greater detail in the excellent book by Kamel et al (2011). In short:
The local guidelines merely say "drape widely". What could that mean? Without any published recommendations, one may rever to the basic principle that one will never be criticised for taking aseptic technique too seriously. Thus:
This would be determined by the level of pre-existing sedation (eg. deep sedation and paralysis vs. a wide awake patient) and by the technqiue (pigtail vs. large bore). Basic principles:
Generally speaking we all end up using lignocaine (1% or 2%), for which the safe dose without adrenaline is 3-4mg/kg. However, in case it is required, here is a helpful table from LITFL, listing some important characterisitics of local anaesthetics:
|Onset (min)||Duration (min)||Max dose (mg/kg)||Max mg (70kg person)|
|Lignocaine (1% or 2%)
|Lignocaine with adrenaline
(1% or 2%)
|Bupivicaine with adrenaline||5||180-420||3mg/kg||225mg|
|Prilocaine (0.5% or 1%)
|2||30-90||7mg/kg||500mg (<70kg)(50mL 1%)|
It should be pointed out that the NSW Health document recommends you wait for a full five minutes for the local anaestehtic to work.
The college WCA form makes a weird statement regaring the trainee being expected to prepare the equipment "with efficient movement and without compromising sterility", which concievable means that they do not position their sterile trolley in some profoundly stupid place where they have to reach across the patient to grab equipment. Nor is it adviseable to use the patient as a table for your equipment, even if they are well sedated and completely draped from head to toe. In short:
The main objective for the candidate being assessed is not to look like a buffoon while olooking for some critical piece of equipment halfway through the procedure, or having to walk back and forth across the room to get stuff.
These recommendations are common to both the NSW ACI and the 2010 British guidelines. Additionally, the British guidelines make statements regarding what exactly one is expected to see on ultrasound, and how one ought to react to seeing it. Briefly:
Shelley et al (2007) and Havelock et al (2010) recommend some steps; the best was selected for the summary below:
This image from Miller and Sahn (1987) correctly describes the position of the Kelly clamp in relation to the rib as it breaches the pleura (even though the image suggests that the proceduralist has gained entry to the patient's subcutaneous tissues through some sort of unusual skin flap)
For large-bore chest drain insertion, the recommendation to use blunt dissection is uncontroversial and unanimous (the alternative technique being the use of a trochar).
The ideal instrument should be:
The usual instrument is depicted below (image from Esteem Healthcare) , and seems to be interchangeably referred to as a Kelly artery forceps or a Spencer-Wells clamp.
Using this thing, "a path is made through the chest wall by opening the clamp to separate the muscle ﬁbres". There does not seem to be any specific guidelines for a particular technique.
For pigtail insertion, this consists of:
For large-bore ICCs, this consists of:
In addition to these, safety issues can be mentioned:
This can be assumed if fluid other than blood or bile comes out, or if there is a good air leak. More formally, the correct position of the drain can be confirmed in a variety of ways:
These are discussed in the chapter on underwater seal drains. In short:
The standard bottle drain system can be ornamented with clamps, valves and digital devices, with various advantages. For instance, it might be interesting or useful to be able to accurately quantify the leak, and have it graphed over time. Zisis et al (2015) wrote a good overview, for people who would dare to read more broadly about such things.
It is important to secure the drain. This is done by a variety of different techniques.
The correctness of the drain position is really determined by the fact that it has drained something. Ideally, it will have drained the thing you had intended to drain, rather than right ventricular blood. When this criterion is satisfied, the radiological drain tip position is academic.
Important radiological issues still remain:
The NSW ACI guideline makes a few more statements:
However, if a malposition of the drain is suspected (eg. you think you skewered the diaphragm or punctured the lung) a CT is the gold standard. On CXR, it would be impossible to tell when you are in the lung parenchyma, for example.
So you think you have it in the right position. What parameters will you use to decide that the drainage is adequate? Specifically this refers to excessive drainage.
Normally, the pleural cavity contains no more than 4-18ml of fluid, and this fluid turns over at approximately 0.2ml/kg/hr (i.e. a daily rate of around 336ml for a 70kg person). This represents the theoretical capacity of the pleural space to reabsorb fluid. Thus, if the daily drain output is less than this, the drain may be able to safely come out.
What does it mean when the underwater seal has stopped bubbling?
What does it mean when the drain has stopped "swinging" (oscillating)?
Harris et al (2016) have reported on the results of their survey of major complications in the UK. This list was added to the complications discussed by Kesiema et al (2011), which is in fact a comprehensive resource.
|Damage to local structures:
Other adverse events
Horner's syndrome is mentioned: it results from pressure of the tip of the chest tube on the sympathetic chain in the medial portion of the apex of the
Rather than complications of the tube insertion per se, these are complications of the drainage process itself
Because the complications are many and usually involving damage to internal organs, any sensible approach to their management includes calling the surgeons at some stage. Some select complications and their management options are listed below, again from Kesiema et al (2011)
|Reexpansion pulmonary oedema||
As with any procedure, the pleural drain should be documented somehow. Local guidelines recommend the following minimum details:
These "drain obs" should include the folloing minumum of data:
Additionally, the patient should have a minimum of 4-hourly observations recorded, consisting of:
In short, don't use them.
The British Thoracic Society guidelines only recommend 24 hours of good Gram-positive cover in the case of chest tubes inserted in the context of chest trauma. Apparently, a meta-analysis of 1241 chest drains had found significantly reduced rates of empyema (by two thirds).
How do you know that it is time for it to come out?
It would be possible to digress exensively here on the management of "site infection, catheter displacement or erosion including, broncho-pleural fistula, empyema" but it is probably more important that the candidate is able to recall a handful of these, and offer at least one non-idiotic management option.
Occasionally, one might be tempted to introduce fibrinolytic agents into an empyema cavity in order to destroy the locules and promote drainage. There are a few indications for this therapy:
The advantages of this method:
As per the local (NSW ACI) guidelines, the following is expected of a practitioner who is competent in the insertion of chest drains:
Complications may be audited:
LITFL have an excellent summary of the relevant details, entitled "Own the Chest Tube!" It takes the form of an audiovisual multimedia extravaganza.
Trauma.org have a somewhat more sober, less FOAMy page dedicated to the topic.
Finally, the most dry and academic information can be found in the formal literature.
Bailey, R. C. "Complications of tube thoracostomy in trauma." Journal of accident & emergency medicine 17.2 (2000): 111-114.
Gilbert, T. B., B. J. McGrath, and M. Soberman. "Chest tubes: indications, placement, management, and complications." Journal of intensive care medicine 8.2 (1992): 73-86.
UpToDate has a good article on this for the paying customer.
Miller, K. Scott, and Steven A. Sahn. "Chest tubes." Chest 91.2 (1987): 258-264.
Dev, Shelly P., et al. "Chest-tube insertion." New England Journal of Medicine357.15 (2007): e15.
Runyon, Bruce A., Marc Greenblatt, and Richard HC Ming. "Hepatic hydrothorax is a relative contraindication to chest tube insertion." American Journal of Gastroenterology 81.7 (1986).
Jayathissa, Sisira, and Stephen Dee. "How safe is the'safe triangle'?." The New Zealand Medical Journal (Online) 124.1343 (2011).
Tang, Augustine, Theodore J. Velissaris, and David F. Weeden. "An evidence‐based approach to drainage of the pleural cavity: evaluation of best practice." Journal of evaluation in clinical practice 8.3 (2002): 333-340.
Havelock, Tom, et al. "Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010." Thorax 65.Suppl 2 (2010): i61-i76.
Dalstrom, David J., et al. "Time-dependent contamination of opened sterile operating-room trays." JBJS 90.5 (2008): 1022-1025.
Widmer, A. F., et al. "Surgical hand preparation: state-of-the-art." Journal of Hospital Infection 74.2 (2010): 112-122.
Kamel, Christopher, et al. "Preoperative skin antiseptic preparations and application techniques for preventing surgical site infections: A systematic review of the clinical evidence and guidelines." (2011).
Yasuda, Tatsuya, et al. "Optimal Timing of Preoperative Skin Preparation with Povidone-Iodine for Spine Surgery: A Prospective, Randomized Controlled Study." Asian spine journal 9.3 (2015): 423-426.
Jenkins, Jamie A., et al. "Sonographic identification of tube thoracostomy study (SITTS): confirmation of intrathoracic placement." Western Journal of Emergency Medicine 13.4 (2012): 305.
Zisis, Charalambos, et al. "Chest drainage systems in use." Annals of translational medicine 3.3 (2015).
Kocijancic, Igor, and Ksenija Vidmar. "Small Pleural Effusion Versus Physiologic Pleural Fluid." American Journal of Roentgenology 200.4 (2013): W400-W400.
Harris, Ann, B. Ronan O'driscoll, and Peter M. Turkington. "Survey of major complications of intercostal chest drain insertion in the UK." Postgraduate medical journal 86.1012 (2010): 68-72.
Kesieme, Emeka B., et al. "Tube thoracostomy: complications and its management." Pulmonary medicine 2012 (2011).
Huang, Dayu, et al. "Intrapleural Fibrinolytic Therapy for Residual Coagulated Hemothorax After Lung Surgery." World journal of surgery 40.5 (2016): 1121-1128.
Janda, Surinder, and John Swiston. "Intrapleural fibrinolytic therapy for treatment of adult parapneumonic effusions and empyemas: a systematic review and meta-analysis." CHEST Journal 142.2 (2012): 401-411.
Robinson, Lary A., et al. "Intrapleural fibrinolytic treatment of multiloculated thoracic empyemas." The Annals of thoracic surgery 57.4 (1994): 803-814.
Abu-Daff, Saleh, et al. "Intrapleural fibrinolytic therapy (IPFT) in loculated pleural effusions—analysis of predictors for failure of therapy and bleeding: a cohort study." BMJ open 3.2 (2013): e001887.