Chest Drain (Thoracentesis)

Needle Aspiration

1/3 of needle aspirations fail and these will require conversion to a chest drain. In clinical practice physicians can sometimes suggest going straight to chest drains if they clinically feel there is a high chance of failure. 

This is inserted below the armpit: in the triangle of safety, mid auxillary line, 2nd intercostal space.

Acute management: emergency needle decompression: large wide bore (e.g. grey) cannula into the mid clavicular line, 2nd intercostal space (recently changed from the triangle of safety). If a tension is suspected, this must be done immediately. 

Chest Drain

This is also inserted in the armpit: in the triangle of safety, mid auxillary line, 2nd intercostal space. A healthy chest drain should be swinging and bubbling. Bubbling shows that air is moving out of the chest into the drain. The drain swings with the pressure changes associated with the breathing of the individual. 

If the drain has stopped bubbling but it is swinging, this suggests the pneumothorax has resolved and this is confirmed on CXR. If the drain is not swinging then either:

1. The pneumothorax has resolved

2. The drain is blocked (by i.e. infection) 

3. The drain has migrated out of the pleural space

A repeat CXR is required to investigate the position of the drain and size of the pneumothorax.

Pleurodesis

This procedure is for recurrent pneumothoraces. It uses a mild irritant to bind the two pleura together, closing the pleural space and preventing future pneumothoraces.

Chest drain

Indications

• Pneumothorax

• Pleural effusion (hydrothorax)

  • • • Diagnostic- ?transudate ?exudate ?malignant cells

• Empyema (pus in pleural cavity)

• Haemothorax

Cxind

Platelets

INR

Patient refuses

Pleural fluid results

Lights criteria- for exudate 

• Protein- pleural fluid/ serum ratio > 0.5, 

• LDH- pleural fluid/ serum > 0.6, 

• Pleural LDH > 2/3 upper limit of normal

Otherwise transudate

pH < 7.2 suggests exudate. 

Lymphatic: increased chylomicrons +++

Causes of transudate pleural effusion

Causes of exudative pleural effusion

• Empyema

• Malignancy

• Inflammatory: rheumatoid arthritis, 

Chest aspirate

Indication

• Pneumothorax

Primary spontaneous > 2cm 

Emergency Needle Decompression

Procedure

Large bore cannula 

Inserted in 2nd intercostal space, inferior portion of intercostal space 

Alternative: triangle of safety- lat dorsi, pec maj, 5th intercostal space 

Indications

• Clinical diagnosis of emergency tension pneumothorax

• Preventative measure in deteriorating pneumothorax

Contraindications

• Consent refused with capacity

• Alternative is death

Post Drain Care

Swinging: changes with pressure during inspiration/ expiration, in correct place

Not swinging causes

• Drained all of the air, still in pleural space

• Drain is blocked

• Drain is in the wrong place

Bubbling:

• Draining air 

• Not bubbling: finished draining as much air as it can 

Subcut emphysema

Occurs when air is leaking into the subcut, often from the pneumothorax

Risk of compressing the trachea, therefore a chest drain should be reinserted

Removal of chest drain

Repeat CXR shows adequate resolution of pneumothorax/ or pleural effusion

Once not draining for 12-24hrs

Suction- variation in clinical practice here

Discharge planning

If repeat CXR 4hrs after removal of chest drain is ok (& no other issues) usually safe for discharge

Pleurodesis

Stick pleura together with talc, after pneumothorax drained