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Insertion of intercostal drain, Seldinger technique: animated demonstration

How to insert an intercostal (chest) drain using the Seldinger technique. Video demonstrates: how to identify a safe site for insertion; use of an introducer needle, guidewire, dilators, and intercostal drain; how to confirm drain position; and postprocedure care.

Equipment needed

Sterile gloves
Sterile gown
Eye protection and mask
Sterile drapes
Ultrasound scanner, particularly if you will be aspirating fluid
Antiseptic
1% lidocaine local anesthetic
Syringe and needle for local anesthetic
Syringe and needle for guidewire introduction
Scalpel
Guidewire
Dilator(s)
Chest tube
Drainage bottle with water seal
Silk suture or purpose-made adhesive dressing to keep chest tube in position
Wound dressing.

Contraindications

Insertion of a large-bore chest tube using the open technique is more appropriate for patients with:

A traumatic pneumothorax
A haemothorax
Flail chest
Sucking chest wounds.

High-viscosity fluids require a wider bore of tube. Clinicians should take care to ensure the diagnosis is correct, and not to insert a drain into a large bulla or diaphragmatic hernia (which is a differential diagnosis for a pneumothorax).

Diagnostic imaging before insertion of the drain can aid decision-making. Current national guidelines strongly recommend that all insertions of chest drains for fluid should be under image guidance (ultrasound or computed tomography) except in an emergency.[36]British Thoracic Society. BTS Pleural disease guideline 2010. August 2010 [internet publication]. [This guideline has been archived by the British Thoracic Society. The BTS website states that guidelines that are more than 5 years old are marked as archived because their recommendations have not been checked to confirm continued validity at the date of archival. A BMJ Best Practice expert adviser has confirmed that these guidelines still reflect current practice in the UK.]

Avoid inserting chest drains that are non-urgent in patients taking anticoagulants until their international normalised ratio is below 1.5.[36]British Thoracic Society. BTS Pleural disease guideline 2010. August 2010 [internet publication]. [This guideline has been archived by the British Thoracic Society. The BTS website states that guidelines that are more than 5 years old are marked as archived because their recommendations have not been checked to confirm continued validity at the date of archival. A BMJ Best Practice expert adviser has confirmed that these guidelines still reflect current practice in the UK.]

Indications

Pneumothorax: spontaneous and iatrogenic. A large-bore drain may still be necessary if the air leak is very large[36]British Thoracic Society. BTS Pleural disease guideline 2010. August 2010 [internet publication]. [This guideline has been archived by the British Thoracic Society. The BTS website states that guidelines that are more than 5 years old are marked as archived because their recommendations have not been checked to confirm continued validity at the date of archival. A BMJ Best Practice expert adviser has confirmed that these guidelines still reflect current practice in the UK.]
Pleural effusions that are free flowing[36]British Thoracic Society. BTS Pleural disease guideline 2010. August 2010 [internet publication]. [This guideline has been archived by the British Thoracic Society. The BTS website states that guidelines that are more than 5 years old are marked as archived because their recommendations have not been checked to confirm continued validity at the date of archival. A BMJ Best Practice expert adviser has confirmed that these guidelines still reflect current practice in the UK.]
Empyema.[36]British Thoracic Society. BTS Pleural disease guideline 2010. August 2010 [internet publication]. [This guideline has been archived by the British Thoracic Society. The BTS website states that guidelines that are more than 5 years old are marked as archived because their recommendations have not been checked to confirm continued validity at the date of archival. A BMJ Best Practice expert adviser has confirmed that these guidelines still reflect current practice in the UK.]

Risk assessment

In May 2008, the UK’s National Patient Safety Agency (NPSA) issued a rapid response report entitled Risks of chest drain insertion,[37]highlighting significant complications directly related to the insertion of intercostal drains. The NPSA report recommended that only staff with the relevant competencies, and with adequate supervision, should insert intercostal drains.[37]The NPSA recommends that the clinician should reflect on the following:[37]

Do I need to do this?
Does it need to be done as an emergency: can it wait?
Have I had enough training to feel confident to do this?
Are senior staff to hand?
Am I familiar with this equipment?
Is ultrasound available, with trained staff to position it safely?

Complications

Potential complications of intercostal drain insertion are:[38]

Related to insertion:

Pain
Placement outside the pleural cavity - subcutaneous, intra-abdominal
Puncture of solid organ - liver, spleen, heart, lung, esophagus
Puncture of an intercostal artery
Insertion on incorrect side
Surgical emphysema.

Related to the position of the drain:

Pain
Failure of the drain (e.g., dislodged/kinked/blocked)
Re-expansion of pulmonary edema
Formation of a bronchopleural fistula
Pneumothorax.

Related to infection:

Wound infection
Empyema.

Haemothorax:

If the intercostal drain was inserted for a haemothorax and there is heavy bleeding, the patient will need a thoracotomy to control the bleeding vessel. Clinicians must consider a thoracotomy if there is more than 1500 mL immediate blood loss, or more than 200 mL/hour blood loss over 2 to 4 hours.[39]

Pneumothorax:

If there is a massive air leak through the drain in a patient with a pneumothorax, you should suspect a major injury to the bronchus, and a thoracotomy is indicated.

Pleural effusion:

Drainage of a large pleural effusion should be controlled to prevent the potential complication of re-expansion pulmonary edema. In the first hour after insertion, a maximum of 1.5 L should be drained;[36]British Thoracic Society. BTS Pleural disease guideline 2010. August 2010 [internet publication]. [This guideline has been archived by the British Thoracic Society. The BTS website states that guidelines that are more than 5 years old are marked as archived because their recommendations have not been checked to confirm continued validity at the date of archival. A BMJ Best Practice expert adviser has confirmed that these guidelines still reflect current practice in the UK.]then apply a clamp for approximately 30 minutes before draining again.

Aftercare

The drain is connected to an underwater seal drainage system to prevent re-accumulation of fluid or air in the pleural cavity.

Check chest radiograph:

Request a chest radiograph to check the position of the chest drain, exclude complications such as pneumothorax or surgical emphysema, and assess the success of the procedure in the volume of fluid drainage or resolution of a pneumothorax.[36]British Thoracic Society. BTS Pleural disease guideline 2010. August 2010 [internet publication]. [This guideline has been archived by the British Thoracic Society. The BTS website states that guidelines that are more than 5 years old are marked as archived because their recommendations have not been checked to confirm continued validity at the date of archival. A BMJ Best Practice expert adviser has confirmed that these guidelines still reflect current practice in the UK.]

Monitoring:

Re-examine the patient and their drain after insertion and closely monitor them thereafter. After initial confirmation that the patient’s clinical condition is stable or has improved, and that the drain is draining, bubbling (if a pneumothorax), and swinging, intercostal drain observations should start and be recorded regularly.

These should include:

Observations of the wound site
Volume/color of fluid drained
Swinging/bubbling activity
Routine vital signs, including respiratory rate and oxygen saturations.

Daily reassessment should be documented, preferably on a dedicated chest drain chart.[36]British Thoracic Society. BTS Pleural disease guideline 2010. August 2010 [internet publication]. [This guideline has been archived by the British Thoracic Society. The BTS website states that guidelines that are more than 5 years old are marked as archived because their recommendations have not been checked to confirm continued validity at the date of archival. A BMJ Best Practice expert adviser has confirmed that these guidelines still reflect current practice in the UK.]Patients should be located on a floor with nursing staff who are experienced in managing patients with chest drains.

Potential problems:

Persistent bubbling: if the underwater seal drain continues to bubble there may be a persistent air leak.
Persistent drainage of blood or fluid.
Further fluid or blood collection: indicates an ongoing intrathoracic problem.
Blockage: if the chest drain ceases swinging with inspiration, the tube may be blocked or no longer in a suitable position and should be checked. Never advance a chest drain catheter into the pleural cavity once the sterile field has been removed, due to the risk of infection.
In cases where the patient is having respiratory difficulty after removal of a chest drain, an urgent chest x-ray is indicated to ensure the original cause for the drain has not recurred.
Do not raise the drain above the patient’s chest height as this can cause the tube contents to reflux back into the pleural cavity.
The drain should never be clamped in patients with a pneumothorax, unless specifically instructed by an attending respiratory physician. A chest drain for pleural effusion may be clamped initially if more than 1.5 L of fluid is within the pleural cavity, but this is not usually required after the initial drainage period.

Removal:

Timing of removal depends on the indication for the drain in the first place. A chest radiograph showing resolution of the problem is reassuring when deciding to remove the drain. Post-surgical drains could be removed after 24 to 48 hours, depending on drainage; however, a drain for a pneumothorax may be required for longer.

Removal requires the coordinated removal of the drain and closure of the skin with the placement of a dressing so that air cannot get into the pleural cavity.

The chest tube should be removed either while the patient performs the Valsalva manoeuvre, or during expiration with a brisk firm movement while an assistant applies a dressing.[36]British Thoracic Society. BTS Pleural disease guideline 2010. August 2010 [internet publication]. [This guideline has been archived by the British Thoracic Society. The BTS website states that guidelines that are more than 5 years old are marked as archived because their recommendations have not been checked to confirm continued validity at the date of archival. A BMJ Best Practice expert adviser has confirmed that these guidelines still reflect current practice in the UK.]If there is further drainage of fluid (in a pleural effusion) from the chest drain site, it may be necessary to place a suture.

A chest x-ray should be requested after the drain has been removed to ensure there were no complications when removing the drain (e.g., air entering the pleural cavity).

Do not clamp the chest drain in patients with a pneumothorax. There is no evidence to suggest that clamping a chest drain before its removal increases success or prevents recurrence of a pneumothorax, and it may be hazardous. A bubbling drain should never be clamped.[36]British Thoracic Society. BTS Pleural disease guideline 2010. August 2010 [internet publication]. [This guideline has been archived by the British Thoracic Society. The BTS website states that guidelines that are more than 5 years old are marked as archived because their recommendations have not been checked to confirm continued validity at the date of archival. A BMJ Best Practice expert adviser has confirmed that these guidelines still reflect current practice in the UK.]