PowerPoint presentation on Intercostal drainage (ICD) or Chest tube drainage. In this this presentation I have included different methods by which a chest tube can be inserted to drain fluid, pus, air from the Pleural cavity. please do mail me your feedback on this presentation at tinkujoseph2010@gmail.com.

1. INTERCOSTAL
DRAINAGE
DR.TINKU JOSEPH
ASSISTANT PROFESSOR
DEPT OF PULMONARY MEDICINE
DY PATIL MEDICAL COLLEGE
Contact (email)-: tinkujoseph2010@gmail.com

2. WHAT ARE THE ISSUES ?
 When to put a drain
 Site of insertion
 Choosing the drain
 Drainage system
 Clamping the chest drain
 Time & method of removal
 Trouble shooting

3. INDICATIONS
 Pneumothorax
 primary spontaneous ptx
 Secondary spontaneous ptx
 Tension ptx(after initial needle aspiration)
 Malignant pleural effusion
 Empyema and complicated parapneumonic pleural
effusion
 Traumatic haemo pneumothorax
 Postoperative,eg: after oesophageal, cardiac,
pulmonary,mediastinal or pleural surgery.
 Treatment with sclerosing agents or pleurodesis
 Post pneumonectomy bronchopleural fistula

4. CONTRAINDICATION
Lung adherent to the chest wall
Uncorrected coagulopathy

5. SITE OF INSERTION ?
 Exact site depends on the location of abnormality.
 5th ICS in mid axillary line is the site used most often.
 Earlier it was believed that air can be drained only
through anteriorly placed tube in 2nd ICS in mid-
clavicular line.A tube placed too medially can injure
internal mammary artery causing serious
haemorrhage.
 Experience has shown that a tube of proper
size,inserted through 5th ICS in mid axillary line can
drain effectively.

6. TRIANGLE OF SAFETY
 Area bordered by the
anterior border of latissmus
dorsi,the lateral border of the
pectoralis major, a line
superior to the horizontal
level of nipple,with its apex
towards axilla
 This is the usual site which
corresponds to the 5th or 6th
ICS in mid-axillary line

7. POSITION OF THE PATIENT
A chest tube can be inserted in supine,sitting
or lateral position.
Most preffered is supine position,in which
patient lies flat on the bed,slightly rotated to
the opposite side,with ipsilateral arm behind
her/his head.
Patients who are breathless may be asked to
sit upright in the bed,leaning over a cardiac
trolley with a pillow to place their arms

9.  If chest tube is inserted to drain blood,pus or
another fluid, the patient should be seated when
the tube is inserted to ensure that the diaphragm
is in the most dependent position and the fluid is
collected in the lower part of the chest
 When chest tube is placed for pneumothorax,the
patient should be in recumbent position if
anterior chest tube is placed, and should be in
decubitus position if an axillary tube is placed
 In case of loculated pathology it is good practice
to do an USG or CT guided ICD.

10. MATERIALS REQUIRED
 Sterile gloves and gown
 Skin antiseptic solution, e.g.
iodine or chlorhexidine in
alcohol
 Sterile drapes
 Gauze swabs
 A selection of syringes and
needles (21–25gauge)
 Local anaesthetic, e.g.
lignocaine (lidocaine) 1% or 2%
 Scalpel and blade
 Suture (e.g. “1” silk)
 Instrument for blunt dissection
(e.g. curvedclamp)

11.  Guidewire with dilators (if small tube being
used)
 Chest tube
 Connecting tubing
 Closed drainage system (including sterile
water if underwater seal being used)
 Dressing

13. GUIDEWIRE TUBE THORACOSTOMY
 Easiest way to insert a chest tube.
 Usually done under the guidance of either USG or CT.
 This procedure uses the Seldinger technique with guide
wires & dilators.
 Skin,periosteum and parietal pleura are anesthetized and
incision is made in skin
 18 gauge needle attached to a syringe is introduced into
the pleural space. Fluid or air is aspirated to confirm the
diagnosis.
 Syringe is removed and J wire is threaded through the
needle in desired direction into the pleural space
 Needle is then removed and smallest dilator is been
inserted with a rotating movement, it is advanced into
pleural space.

14.  The first dilator is removed leaving the wire in place.
 Then the next size dilator is advanced over the guidewire
into the pleural space and removed.
 Finally chest tube containing the inserter is been threaded
over the guide wire.
 Once tube is in place inserter & guide wire are withdrawn.
 Tube is then clamped until it is attached to chest drainage
system.
 Tube is been anchored in place by means of purse string
suture.
 Incision is sutured without tension to avoid necrosis of skin
 Sterile dressing applied.

16. TROCAR TUBE THORACOSTOMY
 Initially requires a 2-4cm incision parallel to superior
border of the rib through the skin and subcutaneous
tissues after LA.
 Trocar is inserted between the ribs into the pleural
cavity,with flat edge cephalad to prevent damage to
intercostal vessels
 The hand not applying force should be placed next to the
chest wall to control depth of penetration
 Once trocar is in pleural space,stylet is removed and
chest tube with its distal end clamped is inserted into
the pleural space.
 Tocar is then removed.

17.  Alternate trocar method uses a chest tube with a
trocar positioned inside the tube
 DISADVANTAGES
 More chances for puncturing lung & other vital
organs.

19. OPERATING TUBE THORACOSTOMY
 Most commonly practiced
 Patient should be given anxiolytic 10-15mins before the
procedure and liberal doses of LA be used.
 3-4cm incision is made in the skin parallel to the chosen
intercostal space. The incision should be made down to
the fascia overlying the intercostal muscle.
 Once fascia has been incised the muscle fibers are
spread with a blunt tipped hemostat
 Incision is then made in the intercostal fascia just above
the superior border of the inferior rib over which tube
will pass
 Parietal pleura is then penetrated using blunt tipped
hemostat

20.  Hole in the parietal pleura is then enlarged with
operators index finger
 Operator should then palpate adjacent pleural space to
detect any adhesions.
 Chest tube with its distal end clamped is then introduced
with help of a hemostat into the pleural space
 Tube is sutured in place(mattress sutures) as per BTS
guidelines
 Site is cleaned and sterile dressing applied

24.  ADVANTAGES
 Safer then other methods
 Adhesions between lung & chest wall can be
removed.
 DISADVANTAGES
 Insertion of tube ectopically

25. SINGLE PORT THORACOSCOPY
Hopkins rod –lens telescope is loaded into the
most proximal port of chest tube. Under direct
visualization the chest tube is placed into the
costodiaphragmatic gutter and scope is been
removed & tube fixed.

26. HOPKINS ROD - LENS TELESCOPE

27. CHOOSING THE CHEST DRAIN.
SIZE MATTERS ??
MALIGNANT EFFUSION FOR
PLEURODESIS
SMALL BORE TUBES 10-14F
HEMOTHORAX 28-32F
PNEUMOTHORAX 8-14F(SUCCESS RATE OF 84-97%)
EMPYEMAS 24-28F

28. PLEURAL DRAINAGE SYSTEMS
• ONE WAY(HEIMLICH)VALVE
 this drainage system is by far the simplest
 Chest tube is attached to a one way flutter valve
assembly, which is constructed so that the flexible
tubing is occluded whenever the pressure inside the
tubing is less than atmospheric pressure & is patent
whenever the pressure inside the tubing is above the
atm pressure
 When pleural pressure and pressure in the tube are
negative flutter valve is closed and no air enters
pleural space.
 When pleural pressure becomes positive the tube is
patent and air or fluid can egress from pleural space.

30. ADVANTAGE
 It is a simple & renders freedom of the patient from a
bulky drainage apparatus
 Patients can be sent home with the flutter valve in place

31. ONE BOTTLE COLLECTION SYSTEM
 Consists of one bottle that serves as both a
collection container and a water seal.
 Chest tube is connected to a rigid straw
inserted through a stopper into a sterile
bottle
 Enough sterile solution is instilled into the
bottle so that tip of the rigid straw is
approximately 2cms below the surface of
saline solution.
 Bottles stopper must have a vent to prevent
pressure from building up when air or fluid
coming from pleural space enters the
bottle.

32. When pleural pressure is positive,the pressure in
the rigid straw becomes positive,and if the
pressure inside the rigid straw is greater than the
depth to which straw is inserted into the saline
solution,air(or liquid)will enter the bottle and will
be vented to the atmosphere(or collect in the
bottle).
If the pleural pressure is negative,fluid will be
drawn from the bottle into the rigid straw and no
extra air will enter the system.
Thus water in the bottle seals the pleural space
from air or fluid from outside the body

33. • ADVANTAGES:
• Easy to carry & works well for uncomplicated
pneumothorax
• DISADVANTAGES:
• If large amounts of fluid is draining from patients pleural
space level of fluid will rise in one bottle system and
therefore pressure will have to be higher & higher in the
rigid straw to allow additional air or fluid to exit from
pleural space
• If the bottle is inadverently placed above level of the
patients chest,fluid can flow back into the pleural cavity.

34. TWO BOTTLE COLLECTION SYSTEM
 Preferred when substantial amounts of fluid is draining
from pleural space
 With this system, bottle adjacent to the patient acts as a
collection bottle for drainage, and second bottle
provides the water seal and the air vent.
 Degree of water seal does not increase as the drainage
accumulates.

35. SUCTION & THREE BOTTLE COLLECTION
SYSTEMS
Applying negative pressure to the pleural space
helps in facilitating reexpansion of the underlying
lung or to expedite removal of air or fluid from
pleural space
Suction at a fixed level, usually -15 to -20cm
H2o,can be applied to the vent on a one or two
bottle collection system with an Emerson pump
In this system, suction is poorly controlled.

36.  Controlled amount of
suction can be applied to a
three bottle collection
system.
 A vent on suction control
bottle is connected to a
vent on the water seal
bottle.
 Suction control bottle has a
rigid straw. Suction is
connected to a second
vent on the suction control
bottle.

37.  When suction is applied to
suction control bottle, air enters
this bottle through it rigid straw if
the pressure in the bottle is more
negative than the depth to which
straw is submerged.
 Amount of negative pressure in
the system is equal to the depth
to which rigid straw in the
suction control bottle is
submerged below the surface as
long as bubbles are entering
suction control bottle through its
rigid straw.

38.  Air enters the suction control bottle
from the atmosphere while its rigid
straw is submerged at 20cm
H2o.Thwe pressure in the suction
control bottle is -20cm H20.
 Same pressure exists in water seal
bottle,since these two bottles are in
direct communication.The pressure in
drainage bottle is less negative than in
other bottles
 In this case depth of water seal is
2cm,so pressure in the drainage
collection bottle and pleural space is -
-18cm H20.
 Amount of negative pressure in the
system can be adjusted by changing
the position of rigid straw or depth of
water in suction bottle.

39. INTRINSIC NEGATIVE PRESSURE IN CHEST TUBES
 If the distance from patients chest to the
top of collection apparatus is 50cms and
tube is filled with liquid, there will be a
negative pressure of 50cm H2o in the
pleural space if no suction applied
 Actual negative pressure applied to the
pleural space from the entire system is
the net vertical distance that the liquid
occupies the tube(A-B)minus the level of
fluid in the water seal(C) plus negative
pressure applied through
suction(D).negative pressure in chest is
A-B-C+D
 If there is no liquid in the tube, actual
applied pressure will be suction pressure
minus the depth of the water seal.

40. PLEUR EVAC UNIT
 The drainage system
is disposable,molded
plastic unit with
three chambers
duplicating the
classic three bottle
system

43. CHOICE OF DRAINAGE SYSTEM
 Cost
 Indication of the chest drain
 Type of patient
 Water seal should be easily visualized
 Tube should be functional when no suction is applied
 Volume of collection chamber should be adequate and
markings should be such that drainage is easily
quantitated.
 Pop up valve to provide safety if pressure builds up in
the system.

44. INJECTION OF MATERIALS THROUGH
CHEST TUBES
 Injection of a fibrinolytic or DNAase in a patient with a
loculated complicated parapneumonic effusion
 Tetracycline derivative or a different sclerosing agent
through the chest tube in patients with malignant
pleural effusion
 This is usually done by taking chest tube apart and
injecting material through a Toomey syringe.
 This procedure compromises the sterility of the system
and increases chances of pneumothorax.

45. THAL QUICK CHEST TUBE ADAPTER
 This unit consists of two adapters
separated by flexible tubing with a
clamp.
 On the proximal end there is a
sideport with a short segment of
connecting tubing to which
attached a three way stopcock.
 When one wishes to inject
anything through the chest
tube,the tube is clamped and
material is injected through the
three way stop cock
 Indicated when a sclerosing or
fibrinolytic agent is been injected.

46. SECURING THE DRAIN
 Mattress suture
 1 zero mersilk
 Complicated “purse string” sutures must not
be used as they convert a linear wound into a
circular one that is painful for the patient and
may leave an unsightly scar.A suture is not
usually required for small gauge chest tubes.

48. CHEST DRAIN DRESSING
 Large amounts of tape and padding to dress the
site are unnecessary and concerns have been
expressed that they may restrict chest wall
movementor increase moisture collection.
 A transparent dressing allows the wound site to
be inspected by nursing staff for leakage or
infection.
 An omental tag of tape has been described
which allows the tube to lie a little away from
the chest wall to prevent tube kinking and
tension at the insertion site.

49. • Omental tag to support
the tube while allowing
it to lie a little away
from the chest wall.

51. CLAMPING
 A bubbling chest tube should never be
clamped.
 Drainage of a large pleural effusion should
be controlled to prevent the potential
complication of re-expansion pulmonary
oedema.
 In cases of pneumothorax, clamping of the
chest tube should usually be avoided.

52. BUBBLING CHEST TUBE-DIFFRETIALS
• If tube is not inserted far enough into pleural
space – one or more of holes in chest tube will
be outside pleural space
• Air enters from atmosphere
• In debilitated patients – with poor tissue turgor –
negative pleural pressure will cause air to enter
pleural space around chest tube at insertion site
• Leaks in the system.

53. HOW TO DIFFERENTIATE- AIR LEAKS
• Measuring the level of pco2 in the air coming
from chest tube
• Collected in syringe – blood gas analyzer
• Pco2 >20mmHg (Bronchopleural fistula)
• Pco2 <10mmHg (Atmospheric air)

54.  If a chest tube for pneumothorax is
clamped, this should be under the
supervision of a respiratory physician or
thoracic surgeon, the patient should be
managed in a specialist ward with
experienced nursing staff, and the
patient should not leave the ward
environment.
 If a patient with a clamped drain
becomes breathless or develops
subcutaneous emphysema, the drain
must be immediately unclamped and
medical advice sought.

55. COMPLICATIONS
 Injury to the neurovascular bundle in the ICS
 Injury to lung parenchyma
 Injury to diaphragm and consequent injury to
intraperitoneal structures may occur
 Injury to heart and other vessels
 Massive bleeding
 Re expansion pulmonary oedema due to rapid
evacuation of fluid from the pleural cavity
 Empyema
 Skin excoriation and inflammation
 Subcutaneous emphysema & subcutaneous haematoma

57. REMOVAL OF THE DRAIN
 Original indication
 Clinical progress
 Daily drainage should be <100ml.
 There should be no air leak
 No fresh or altered blood should be draining
from chest tube
 Radiological status-lung should be fully
expanded.
 End expiration/valsalva

58. REPOSITIONING CHEST DRAINS
 Use imaging assistance
 Avoid pushing & pulling drains
 Best is a fresh insertion
 Avoid a previous site, choose a new one

59. Procedure for chest tube removal
 Gather supplies and explain procedure to patient
 The clinician will remove the dressing and sutures
 During peak exhalation, the clinician will remove the
chest tube in one quick movement
 Immediately apply a sterile gauze dressing containing
petroleum to prevent air from entering pleural space
 Monitor patient’s respiratory status
 Arrange for chest X-ray to confirm lung reexpansion
 Monitor patient’s respiratory status and SpO2 for 1-2
hours after removal

60. PATIENTS REQUIRING ASSISTED
VENTILATION
 During the insertion of a chest tube in a patient on a high
pressure ventilator (especially with positive end
expiratory pressure (PEEP), it is essential to disconnect
from the ventilator at the time of insertion to avoid the
potentially serious complication of lung
penetration, although as long as blunt dissection is
carried out and no sharp instruments are used, this risk is
reduced.

62. TAKE HOME
MESSAGE

63. RECOMMENDATIONS FOR SAFE PRACTICE OF CHEST
DRAIN INSERTION
1. Site: safe triangle in the midaxillary line
2. Imaging to be used to select appropriate site of
insertion
3. USG guided insertion can ensure safety placement
4. Do not use substantial force
5. Small bore drains to be placed under imaging guidance
with a guide wire(dissection not required)
6. Blunt dissection for large tube bore
7. CXR available at time of insertion except in case of
tension pneumothorax
BTS GUIDELINESS

65. For more details and
feedback mail @
tinkujoseph2010@gmail.com
drtinkujoseph@gmail.com