Intercostal Chest Drain (Thoracostomy Tube)

Historically, the treatment for a large pneumothorax was insertion of a large drain (e.g. 28FG) through an incision in the chest wall.

During the last decade there has been a move towards inserting smaller drains percutaneously. Small drains (e.g. 8-14FG) have been shown to be associated with fewer complications (particularly subcutaneous emphysema) without prolonging time to resolution [17].

Small drains may be associated with a higher failure rate when draining very large pneumothoraces but currently this evidence is limited. In obese patients, the Seldinger technique may not be technically possible as the needle may be too short to traverse the chest wall. Whichever technique is used, insertion in the ‘safe triangle’ attempts to avoid injury to the long thoracic nerve and lateral thoracic artery, which sit in the mid-axillary line.

Safe triangle

The triangle is formed by the anterior border of latissimus dorsi posteriorly, the lateral aspect of pectoralis major anteriorly, and the 6th rib inferiorly forming an apex below the axilla. In young, thin males the nipple will lie in the 5th intercostal space. Insertion of the drain just above the underlying rib minimises the risk of injury to the intercostal bundle.

Seldinger technique

• Inform the patient about the planned procedure and obtain written consent
• Position the patient reclined at approximately 45 degrees with their hand placed behind their head
• Identify the insertion point (just anterior to the mid-axillary line in the 5th intercostal space) and mark the with a pen
• Put on a gown and sterile gloves, clean the area with anti-septic solution and apply drapes
• Using an aseptic technique, infiltrate 1% lidocaine (maximum 0.3mls/kg of 1% lidocaine) subcutaneously and down to the pleura
• Insert the needle from the drain kit (attached to the provided syringe) slowly through the chest wall, just above the underlying rib, in a horizontal plane
• Stop advancing the aspiration needle when aspiration of air confirms correct placement
• Thread the guidewire through the needle
• Remove the aspiration needle
• Gently dilate the track with the dilators provided (sometimes a small nick needs to be made in the skin with a scalpel to facilitate this)
• Feed the drain over the guide wire (usually to about 12 cm in adults)
• Remove the guidewire and the tube obturator
• Fogging of the tube suggests correct placement
• Connect the tube to an underwater drainage system (below the level of the patient). An assistant should hold the drain at this stage to prevent the drain coming out before suturing
• Bubbling on patient coughing and a fluid swing confirms drain placement
• Secure with a stay suture (BTS guidance)
• Place a clear dressing over the insertion site
• Secure the drain to the chest wall with an ‘omental tag‘ (BTS guidance)
• Repeat the chest radiograph

During the procedure, holding the dilators close to the chest wall should prevent excessive force of insertion or ‘a sudden give’. These are solid objects and on the left side the apex of the heart lie close to the insertion point. The BTS cautions that the dilator should not be inserted more than 1 cm deep to the skin.

Example commercial kit