Intercostal drainage

Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software

statisticsPhD(physiology)

Mahatma Gandhi medical college and research institute, puducherry, India

Definition • Insertion of a drainage tube into the pleural

cavity • Why ? • To drain • Air, • Fluid ,• Blood• – sometimes to inject drugs

Why we should drain such things ?

Lungs expand

This is what we do !!

Indications • Pneumo – any ventilated patient ,• recurrent pneumothorax,• tension ,large sec. pneumothorax, • surgeries, malignant effusions, • traumatic hemo pneumothorax, • Empyema, flail chest req. ventilation

White out or black out

• Beware of bulla or severe collapse

CONTRAINDICATIONS I

• Need for immediate thoracotomy

Where ?• A thoracentesis usually at bedside• chest drainage system system is hooked up to allow for

continuous drainage of either air, blood, or fluid. Often – as Emergency- well below chest level

• If goal is to remove air?- upper anterior chest, 2-4 intercostal space (catheter is inserted)

• If goal is to remove fluid/blood?-lower lateral chest 8-9 intercostal space (catheter inserted) ?? Previous

Its all “A”s

• AIR• ABOVE • ANTERIOR

Safe triangle- 1.latismus dorsi , 2.Pect. Major, 3.nipple line

Equipment• Under water sealed drain system (UWSD)• Tray

– use smaller size for draining air– larger size for draining blood/fluid

• Newborn 8-12 FG, Infant 12-16 FG • Child 16-24 FG, Adolescent 20-32 FG

Technique• sitting position at 45 degrees with arm of same side

placed above head• 3 or 4 ICS • Anterior – anterior to ant axillary line• Skin after LA – upper border of rib • "Blunt dissect" to reach pleura

Technique• Sweep with gloved finger• Hold the tip of the catheter with a curved artery

clamp and advance it into the pleural space, directing the catheter posteriorly and superiorly.

• All holes inside • Attach to underwater seal below chest level • Suture and anchor• w/f swinging water

•

Check and maintain • No big dressings • With inspiration water will rise up into the

chest tube, with expiration, water will fall. If the swing is less than 2 cm, the lung is not likely to be fully expanded and therefore suction may need to be increased

Maintenance – “tidaling”

• fluctuate gently up and down with each `inspiration/expiration

Tidaling stops – lungs reinflated

constant or vigorous “bubbling” occur please check for a “leak” something is wrong

TIPS• If no air or fluid comes, use gadgets except tension

pneumothorax • Flouro, Xray, USG • No force used• Small gauge catheter – ok , seldinger technique is

acceptable • Simple linear stitch

Never clamp ICD • Because somebody may forget to remove the clamp

and a tension pneumothorax may develop. • Two tubing clamps should be left at the patients

bedside to clamp the tube• in emergency , if the tubing became dislodged from

the chest tube bottle and air is at risk of entering the chest cavity.

Tips • large pleural effusion should be controlled to prevent

the potential complication of re-expansion pulmonary oedema

• No clamping prior to removal • small chest tubes and a Heimlich flutter valve – OP

management

Heimlich flutter valve

One is ok but fluid comes

Three bottle concept

Multifunction ICD -- adults and infants

When to remove• •In the presence of an air leak the drain should not be

removed unless another drain remains• •In general a period of 48 hours after the last bubble is safe.• •In the presence of fluid, remember that 100-200cc normally

drain from a pleural drain. Otherwise once the drainage is less than 150cc it may come out.

• •Exceptions include the presence of pus (empyema), lymph (chylothorax) or a residual cavity

Complications • Pain• Thoracic or abdominal visceral trauma• Tension pneumothorax• Inadequate - subcutaneous emphysema • Position change

Thank you all