Before embarking on this procedure, be sure to set up your tray with the necessary equipment.

Supply supplementary oxygen by mask or nasal prongs if the patient is distressed.

Constantly speak to the patient in a gentle and reassuring manner, explaining the steps as the procedure progresses.

Positioning:

Raise the head of the bed 45 degrees and elevate the patient's arm gently over his/her head. Have the arm held in place by an assistant if necessary.

Raising the arm facilitates access to the drain insertion site and helps to widen the intercostal spaces for easier dissection.

Landmark:

Counting from the angle of Louis at the upper sternum (2nd intercostal space), identify the 5th intercostal space and follow this space to the lateral aspect of the chest.

Place a mark anterior to the midaxillary line, using a marking pen.

Cleaning and draping:

This is a strictly aseptic procedure. Wash your hands, don sterile gloves, and take universal precautions.

Warn the patient that a cold solution is going to be used to clean the chest.

Using a sponge-holding forceps with mounted swabs/sponges, clean the pre-marked area with antiseptic solution. Start centrally and work outwards in circles towards the periphery until an area of roughly 15 cm x 15 cm has been cleaned.

Discard used swabs well away from the sterile tray area.

Drape the patient to expose an area roughly 10 cm x 10 cm.

Draw up local anesthetic from the vial held by an assistant, maintaining sterility and using a blunt needle to avoid accidental injury.

Warn the patient that a needle is going to be inserted and infiltrate local anesthetic into the skin and subcutaneous tissues at the pre-marked landmark.

Advance the needle, guiding it just over the top of the lowermost rib of the chosen ribspace (so as to avoid the neurovascular bundle which lies in the costal groove of the uppermost rib). Infiltrate generous amounts of local anesthetic at multiple levels to ensure delivery to all layers of the chest wall.

Be sure to aspirate before injecting each time.

When you enter the pleural cavity, you will aspirate the pleural contents (eg, air, fluid, or blood).

Allow 2 to 3 minutes for the local anesthetic to take effect and test the skin by asking the patient to give feedback while the skin is pinched. Proceed only once full local anesthesia is in effect.

Make an incision through the skin and subcutaneous tissue along the superior border of the lowermost rib of the chosen intercostal space (ie, the superior aspect of the intercostal space is avoided).

Make the incision long enough to allow for the full width of the drain; thus, in an adult, the incision should be approximately 1 cm in length.

Carry the incision down to the surface of the intercostal muscles.

Using a curved artery forceps, perform blunt dissection through the intercostal muscles and into the pleural cavity.

Perform this dissection by a series of movements consisting of a gentle forward push followed by splaying of the arms of the forceps; this results in separation of the tissues as the forceps advances. Keep the curve of the instrument pointing inferiorly, to facilitate easy dissection over the top of the inferior rib minimizing the risk of injury to the neurovascular bundle.

Perform this dissection with two hands. Use the right hand to perform the dissection as described above and the left hand to hold and control the advancing forceps. This avoids the instrument suddenly plunging into the chest once the parietal pleura is breached.

A "pop" or a "give" can be felt when the forceps penetrate the parietal pleura. This is usually followed by either a gush of air or drainage of the fluid contents (if present) of the pleural cavity. Do not advance the forceps any deeper into the chest; this minimizes the risk of injury to the lung or the heart.

With its arms in the tract that has been created in the chest wall, open the forceps gently but forcefully to ensure a wide enough passage for the chest drain. Perform this action swiftly and remove the forceps.

It may be necessary to occlude the tract with a finger to prevent gross spillage while using the free hand to perform the next steps.

Insert a little finger into the pleural cavity and sweep it through 180 degrees in each direction. This is done to rule out adhesions between the lung and the chest wall (eg, in a patient who has had previous pneumonia or tuberculosis).

If an adhesion is encountered, it may be possible to gently release it using your inserted finger. Alternatively, you may be able to ascertain a safe path for the drain to be passed through without injuring the lung. However, if dense adhesions are encountered, it may be necessary to select an alternative drain site.

If in doubt about any adhesions encountered, call for senior assistance.

Mount the chest drain on a curved artery forceps (ie, insert one leg of the forceps into the drain lumen, via one of the holes near its tip).

Using a drain clamp, cross clamp the drain at the opposite end. This will prevent a gush of pleural contents onto you when the drain enters the pleural cavity.

Pass the drain tip through the incision into the chest, using the mounted artery forceps to guide the drain. Once the drain tip is well into the chest, remove the artery forceps and advance the drain.

Ask your assistant to hold the drain in place and insert a simple suture on each side of the drain entry site, bringing the wound edges together and "snugging" the wound around the drain. Each suture is tied around the drain several times to avoid dislodgement.

Some clinicians prefer to use a purse string suture or horizontal mattress suture, so that it may be used for wound closure after drain removal. This is not essential.

Connect the intercostal drain to the drainage bottle's tubing and remove the drain clamp.

If you are inserting the drain for a hemothorax or pleural effusion, you will notice the blood or fluid pass through the drain into the drainage bottle, and the fluid level within the bottle rise accordingly. Use the markings on the drainage bottle to take a reading of the volume of fluid drained.

 If you are inserting the drain for a pneumothorax, you will see bubbling in the water of the drainage bottle when the patient coughs or exhales.

Clean the drain insertion site and apply a gauze dressing around the drain.

Apply an adhesive dressing over the gauze in such a way as to supply additional drain anchorage (eg, Elastoplast cut into partial strips and applied to the chest wall and drain).

Postprocedure considerations