• Drainage of pneumothorax
• see Spontaneous pneumothorax guideline for when to place chest drain
• Therapeutic drainage of fluid from pleural space

• All relative. Discuss with consultant or radiologist performing procedure
• Impaired blood clotting
• Post-pneumonectomy space. Discuss with cardiothoracic surgeon

Equipment

• Chest drain pack - 12 French Gauge (FG) to 28 FG
• Sterile gloves
• Lidocaine 1-2% 10 mL with another 10 mL on standby in case needed
• Underwater seal drainage bottle and tubing
• Skin antiseptic solution. Use 2% alcoholic chlorhexidine gluconate solution
• if allergic, use povidone-iodine solution

• If not competent in procedure, organise supervision by a clinician experienced in the procedure

Consent

• Explain procedure and reassure patient
• Obtain and record written consent - see Consent guideline
• Complete WHO surgical procedure checklist

Premedication

• Consider premedication
• oral morphine solution (e.g. Oramorph^®) 5mg 1 hr before procedure OR
• IV morphine 2.5mg given immediately before procedure
• If respiratory depression occurs, give naloxone 100-200 microgram IV
• if no response, then naloxone 100 microgram IV for up to 2 doses at 1 min intervals every 1 min, continue titrating up to maximum of 2 mg until adequate response achieved

Non-surgical chest trauma

• If pneumothorax caused by non-surgical chest trauma, give anti-microbial cover

Penicillin Allergy

• True penicillin allergy is rare
• Ask the patient and record what happened when they were given penicillin
• If any doubt about whether patient is truly allergic to penicillin, seek advice from a microbiologist or consultant in infectious diseases

Antimicrobial doses

• Co-amoxiclav 1.2 g IV over 3-4min or 625 mg oral 8-hrly for total course of 5 days
• If allergic to penicillin, give levofloxacin 500 mg IV 12-hrly over ≥60 min plus metronidazole 500 mg IV 8-hrly over 20 min or 400 mg oral 8-hrly
  • contact respiratory team for further advice

Site of insertion and position of patient

• Site must be just above rib
• Check correct site on most recent chest X-ray
• Mark site (ultrasound guidance for pleural effusion)

For simple pneumothorax

• Usual site fourth or fifth intercostal space (ICS), mid-axillary line
• within ‘safe triangle’, bordered by anterior border of latissimus dorsi, lateral border of the pectoralis major, a line superior to the horizontal level of the nipple and apex below axilla
• Support patient with head of bed elevated to about 30°, arm behind head

Aseptic technique and local anaesthesia

• Wash hands and wear sterile gloves, mask and gown
• Clean patient’s skin over a wide area with skin antiseptic
• Check all equipment fits adequately
• Palpate intercostal space, infiltrate with 10-20 mL of lidocaine to parietal pleura and periosteum of lower rib, and:
• once fluid/air can be aspirated, infiltrate into pleural space

Insertion of drain

Seldinger technique

• Preferred as avoids need for blunt dissection
• Use a needle and syringe to localise position by identification of air or fluid
• Pass guidewire down hub of needle, remove needle and enlarge track with a dilator
• never use a trocar to dissect tissues during chest drain insertion
• Pass drain into thoracic cavity along the wire
• Tie securing suture - one loop through skin and at least four ties on tube
• Loop tube and secure with adhesive plaster
• if there is a poor seal around drain, insert further vertical suture near drain and tie to partially close incision

• Adequate analgesia for pleuritic pain
• paracetamol alone is unlikely to be adequate
• if well hydrated and eGFR ≥30 mL/min, ibuprofen 400 mg oral 8-hrly
• in dehydrated patient or if eGFR <30 mL/min, to prevent renal damage, prefer morphine sulphate 10 mg oral 4-hrly. Ibuprofen may be substituted once adequate fluid replacement achieved if eGFR ≥30 mL/min
• Repeat chest X-ray within 2 hr
• For care of intercostal tube and underwater seal, see Spontaneous pneumothorax guideline

Pleural effusion

• Remove only 1-1.5 L of fluid at any one time due to danger of re-expansion pulmonary oedema
• wait 2hrs before again removing up to 1-1.5L

• Confirm bubbling from pneumothorax (see Spontaneous pneumothorax guideline) or drainage of fluid has stopped for at least 24 hr
• If malignant pleural effusion, attempt talc pleurodesis before removal, to reduce rate of recurrence. See Medical pleurodesis guideline

Procedure

• Cut drain-securing suture
• Withdraw tube while patient holds breath in expiration
• Close wound with sutures
• sutures will be required if large wound or if ≥18F drain has been used