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Practical Procedures
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Chest drain insertion

Underwater seals

  • Drapes
  • Suture kit
  • Dressing pack
  • Gauze pads
  • Scalpel
  • 1% or 2% lidocaine
  • 2/0 silk suture on curved needle
  • 10-ml syringe
  • 21-gauge (green) needles
  • 27-gauge (orange) needles
  • Sterile gloves
  • Cleaning agent (e.g., iodine or chlorhexidine)
  • Chest drain
  • Chest drain bag (for pleural effusion) or water-tight bottle containing some normal saline or sterile water (for pneumothorax)
  • An assistant

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  • Tell the patient what you are going to do.
  • Confirm the position of the pneumothorax/effusion clinically and also with a chest x-ray.
  • Sit the patient upright, legs over the side of bed, leaning over a high table so the arms are up, the back is straight, and you have access to the affected side of the chest. In an unwell patient, you might have to perform this with the patient sitting at a 45° angle.
  • Prepare the underwater seal – fill a bottle one-third full with sterile water. The end of the tube should be 2–3 cm into the water.
  • Choose the chest drain; tailor it to the patient by looking at how much rib space is available. Some chest physicians prefer larger drains, particularly for effusions and empyemas – as a guide, 24F is suitable for a pneumothorax; use 28–32F for effusions and empyemas.
  • Put on your gloves and prepare your cart so that all of the items are within easy reach.
  • Clean the patient's skin with chlorhexidine or iodine and perform pleural aspiration in the mid-axillary line at the 4th–5th intercostal space; aim above the rib.
  • When pleural fluid has been located, insert more local anesthetic: Be generous – use up to 15 ml in the area around the aspiration site. Some patients might find this uncomfortable, so you can give a small dose of diamorphine IV with 10 mg metoclopramide IV.
  • Make a 1–2 cm incision with the scalpel in line with the ribs, remaining just above the lower rib. When you are through the skin and into the subcutaneous fat, blunt-dissect down with forceps. Continue until you reach the pleura. This can be painful, so have remaining local anesthetic available and inject into pleura if necessary.
  • Take the introducer out of the chest drain, so only the tubing remains. After you have blunt-dissected the pleura and fluid or air begins to escape, insert the drain into the hole. It should enter the pleural cavity easily, but keep a finger over the end of the drain until it is connected to the bag or underwater seal.
  • Place a 1-mattress suture on either side of the drain and pull taut. Place another suture in the middle of incision around the drain. Tie the two side sutures, so the skin is pulled tight, then secure around the drain by coiling around several times. Leave the central suture free, to be tied when the drain is removed.
  • Place pads of gauze around drain and secure with dressing. Secure the proximal part of the drain to the patient with tape.
  • Ensure that the drain is draining/bubbling freely. Get a post-procedure chest x-ray to review the position.

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  Underwater seals

Underwater seals are used to drain air from the pleural cavity. They are always kept below the level of the chest. When the pressure of air in the pleural cavity rises, air is forced from the chest into the water, and it bubbles. Normal respiration causes some movement in air pressure and the water level oscillates accordingly – this is known as "swinging." If the fluid level does not swing, it means that the tube is

  • blocked – flushing it might help, or it might need to be replaced, or
  • kinked – the dressing needs to be removed and the tube reviewed, or
  • in the wrong place – it was inserted incorrectly or has fallen out; a chest x-ray will confirm.

If there is no bubbling, but the tube is still swinging, the pneumothorax has probably been corrected. If this is confirmed by chest x-ray, the drain can be removed after

24 hours.

If there is continuous bubbling and no or only partial resolution of the pneumothorax on chest x-ray, then there is a continuous leak, and a chest physician/thoracic surgeon should be contacted.

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