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Thoracocentesis and chest drain insertion

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    PIC Endorsed
  • See also

    Primary spontaneous pneumothorax
    Acute pain management
    Trauma    

    Key Points

    1. Tension pneumothorax is a clinical diagnosis and requires immediate intervention
    2. Patients undergoing thoracocentesis should receive analgesia both pre- and post-procedure. Nitrous oxide should not be used as it may enter the pleural space and rapidly increase the volume of the pneumothorax
    3. Chest X-ray should always be done post procedure

    Background

    • Fluid or air that accumulates in the pleural space will reduce lung expansion and lead to respiratory compromise and hypoxia 
    • Thoracocentesis should be performed urgently in cases of tension pneumothorax. It is also used in selected patients with primary spontaneous pneumothorax (see Primary spontaneous pneumothorax)
    • Insertion of an intercostal catheter (ICC) enables ongoing drainage of air or fluid from the pleural space and should be considered for patients with haemothorax, chylothorax, large pleural effusion or large pneumothorax 
    • Ventilated patients require an ICC, after an initial thoracocentesis alone

    Indications

    • Primary spontaneous pneumothorax
    • Tension pneumothorax  
    • Traumatic pneumothorax
    • Haemothorax
    • Pleural effusions

    Thoracocentesis should only be considered after consultation with a senior clinician in patients with:

    • spontaneous pneumothorax in patients with underlying lung disease
    • traumatic pneumothorax without tension
    • complex and/or loculated effusions

    Contraindications

    • Need for immediate thoracotomy
    • Relative contraindications include uncorrected clotting disorder, ventilation with positive end-expiratory pressure support, bullous lung disease or a single functional lung 

    Potential complications

    • Pain or chest wall numbness 
    • Wound infection and bleeding 
    • Subcutaneous emphysema 
    • Failure to drain collection, requires reattempt 
    • Trauma to viscera in the thorax or abdomen 
    • Tension pneumothorax 
    • New pneumothorax. There is a 10–20% chance of causing a pneumothorax if thoracocentesis is attempted and the child does not have a pneumothorax 

    Equipment

    • Antiseptic solution
    • 1% lignocaine + 1:10,000 adrenaline 5 mL ampoule
    • For non-urgent cases use topical anaesthetic (eg EMLAor  AnGel)
    • Small (eg 5 mL) and large (eg 20 mL or 50 mL) syringe with needles
    • 3 way tap
    • Waterproof transparent dressing x2 / tape
    • Large bore cannula (12, 14 or 16 gauge)
      • Central venous catheter (CVC) or pigtail catheter are alternatives

    For chest drain insertion, also:

    • Under water sealed drain system (UWSD)
    • Intercostal catheter(s): use smaller sizes for draining air and larger sizes for draining fluid
      • Guide sizes only
        • Newborn 8–12 FG
        • Infant   12–16 FG 
        • Child  16–24 FG 
        • Adolescent 20–32 FG
    • Spigot connector / tube adaptor — 2 sizes
    • Suction (confirm that it is at-hand and working)
    • Sterile gloves, gown, mask
    • Sterile towels x 2
    • 500 mL bottle of sterile water
    • Scalpel blade
    • Suture material - black silk or nylon with needle size 3.0 x 2
    • Waterproof transparent adhesive dressing x 2

    Analgesia, Anaesthesia, Sedation  

    Analgesia and local anaesthesia are mandatory except with tension pneumothorax which is immediately life threatening 

    • The use of sedation should always be discussed with a senior doctor, as it can potentially worsen the patient's clinical condition
    • Consider procedural sedation (see Acute pain management)
      • Nitrous oxide should not be used as it may enter the pleural space by diffusion and rapidly increase the volume of the pneumothorax
    • Use local anaesthesia
    • Use oral and/or parenteral analgesia both pre- and post-procedure 

    Procedure   

    1. Establish patient on continuous cardiac monitoring and pulse oximetry
    2. Unless contraindicated oxygen therapy should be administered during the procedure
    3. Position the patient
      • Place trauma patient in head-up, supine position
      • All other patients should be placed in a 45-degree sitting position with the arm that is on the same side as the collection, placed over the forehead
    4. Palpate landmarks
      • The 4th or 5th intercostal space just anterior to mid-axillary line 
        or
      • 2nd intercostal space at the upper border of the 3rd rib in the midclavicular line

    5. Thoracocentesis & Chest Drain
    6. Antiseptically prepare the area. Asepsis is required if a chest drain is inserted 
    7. Ensure local anaesthetic is infiltrated from subcutaneous tissue down to pleura  
    8. Attach a 5 mL syringe to the catheter device (cannula or CVC or pigtail) 
    9. Insert the cannula vertically into the chest wall, just above the rib below, aspirating continuously 
    10. In tension pneumothorax, often you will hear a pop or feel a change in resistance 
    11. Withdraw the needle while gently advancing the cannula downwards into position. If inserting a chest drain, proceed to step 14 
    12. Secure the cannula with tape and a waterproof transparent dressing 
    13. Attach 3 way tap and 20 mL / 50 mL syringe 
    14. Drain until no further drainage to a maximum of 30 mL/kg of liquid (max 2.5 L) 
    15. Do not remove the aspiration device until a decision is made that the patient will not require further drainage   

      For chest drain insertion, also:
    16. If appropriate, use the Seldinger technique
    17. Select the appropriate size intercostal catheter and remove stylet 
    18. Incise the skin parallel to the upper border of the rib below the chosen intercostal space. Incise down to the fascia 
    19. "Blunt dissect" (eg using an artery forcep) down to the pleura, enter the pleural space, and then widen the hole by opening the forceps 
    20. In older children, sweep the pleural space with a gloved finger to widen the hole and push the lung away from the hole (beware of rib fractures in an injured child) 
    21. Hold the tip of the catheter with a curved artery clamp and advance it into the pleural space, directing the catheter posteriorly and superiorly 
    22. Advance so that all apertures of the tube are in the chest and not visible
    23. Attach the tube to UWSD below the patient's chest level
    24. Anchor the drain and suture the wound. Tape in place with a waterproof transparent dressing sandwich and anchor the tube to the patient's side 
    25. Connect to the UWSD 
    26. Watch for "swinging" of water in the connected tube 
    27. Auscultate the chest for the quality of air-entry and observe chest expansion 

    Post procedure care and discharge instructions

    Reassess ABC 

    • Prescribe further analgesia
    • Organise appropriate patient disposition
    • After thoracocentesis, perform a chest X-ray
    • After removal of an ICC, cover the area with a large waterproof transparent dressing. In children this is sufficient for closure rather than a formal purse string suture
    • If there are concerns of bleeding from the site, infection or breathing difficulties worsen, that patient must seek urgent medical review

    Consider consultation with local paediatric team when

    • Patient has an underlying lung disease, complex effusion or sustained trauma
    • Cause of the collection is unknown
    • Adequate analgesia and anaesthesia to ensure compliance with the procedure cannot be assured
    • Oxygen saturation levels are abnormally low in room-air

    Consider transfer when

    • Staff/equipment required are unavailable to safely perform the procedure provided there is no tension pneumothorax
    • Patient requires ventilation
    • Patient has sustained trauma or there is a suspicion of thoracic injury, open pneumothorax or massive pneumothorax

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Parent information sheet

    Chest drain

    Additional notes

    • Chest drains require close observations including documentation of the amount and type of fluid drained, colour, consistency and the presence of oscillation and/or air bubbling
    • If there is significant large volume or an unexpected change seek urgent senior advice
    • When a patient is mobilised, drain clamps must be carried in case of accidental disconnection of the chest drain from the UWS for urgent clamping

     

    Last Updated December 2019

  • Reference List

    1.  Allen CJ, Valle EJ, Thorson CM, et al. Pediatric emergency department thoracotomy: A large case series and systematic review. J of Pediatric Surgery. 2015; 50: 177-181. 
    2. Ferner RE, Mackenzie AA, Aronson JK. The adverse effects of nitrous oxide. Adverse drug reaction bulletin. 2014; 285: 1099-1102. 
    3. Miyazaki T, Yamasaki N, Tsuchiya T, Matsumoto K, Hatachi CO, Nagayasu T. The assessment of chest tube insertion to intercostal nerve damage in thoracic surgery. American Thoracic surgery. 2013; 22: 35.
    4. Sullivan B. Nursing management of patients with a chest drain. British Journal of Nursing. 2008; 6: 17. 
    5. Strutt J, Kharbanda A. Pediatric Chest Tubes And Pigtails: An Evidence-Based Approach To The Management Of Pleural Space Diseases. Pediatric Emergency Medicine Practice. 2015; 12: 1-24.