Intercostal Drainage

Indications

• Significant pneumothorax (>25% of lung volume on the affected side)
• Lesser degrees of pneumothorax when associated with respiratory distress and underlying respiratory disease or major trauma
• Pneumothorax in a patient requiring mechanical ventilation
• Recurrent or bilateral pneumothoraxes
• Drainage of an empyema, hemothorax or malignant pleural effusion.

Precaution

• Premedication using oral or intravenous diazepam is recommended
• Always examine the patient and chest X-ray to confirm the presence of pneumothorax
• Following trauma, rupture of the left hemidiaphragm with gastric dilatation may simulate a left pneumothorax (if in doubt, pass a nasogastric tube to confirm or exclude this possibility).

Technique

The optimal site for the intercostal drain is in the fifth or sixth interspace in the midaxillary line (above the level of xiphisternum to avoid injury to abdominal organs) or in the midclavicular line in the second intercostal space. The former location causes the least discomfort, allows for better mobility and the scar is cosmetically more acceptable (Fig).

• For the anterior approach, seat the patient comfortably on a bed or couch
• For the axillary approach, ask the patient to straddle a chair with the outstretched arms supported on a pillow
• Under strict aseptic precautions, infiltrate the skin with 1% lignocaine plain down to and including parietal pleura; then block the intercostals nerve above and below this point with local anesthetic
• Make a 2 cm scalpel incision in the skin and underlying tissues in line with upper border of rib
• Sinus forceps is carefully introduced through the incision and then introduce PVC stiff tubes with side holes or
• Malecot catheter (22FG) into the pleural space
• Remove the introducer of Malecot catheter and pull the catheter back gently until its flange contacts the chest wall
• Connect the catheter to an underwater seal bottle containing sterile saline to a depth of 5 cm or alternatively to a Heimlich flutter valve
• Wrap the ends of purse-string suture around the catheter over a swab to secure the catheter to skin. In this way, the suture is available to close the wound when the catheter is removed
• Confirm satisfactory positioning with a repeat X-ray
• On re-expansion, the underwater seal fluid will cease to oscillate with changes in intrapleural pressure allowing the drain to be clipped off
• Repeat the X-ray and remove the drain 48 hours after the underwater seal has ceased to oscillate provided the pneumothorax has not recurred
• Cleanse the wound with antiseptic solution and close the wound using purse-string suture
• Repeat the chest X-ray
• Patency of the tube should be confirmed frequently.

Site

• A tension pneumothorax demands urgent decompression by using a large bore needle, preferably 14G needle and cannula in the second intercostal space in the midclavicular line on the appropriate side. Then insert an intercostal drain as above.
• In the presence of hydro or hemopneumothorax insert a lower intercostal drain to ensure complete evacuation of intrapleural fluid.
• If the pneumothorax is recurrent, an attempt should be made to obliterate the pleural space. Request the help of a senior person/thoracic surgeon.
• If the pneumothorax fails to resolve despite patent intercostal drainage, it suggests the presence of either a bronchopleural fistula or a bullous emphysema without a pneumothorax or a blocked airway due to growth or foreign body.

Complications

• Ask the patient to breathe out and hold breath in expiration or perform a Valsalva’s maneuver. This reduces the riskof a pneumothorax due to air entering through the side holes as the drain is removed.
• Have an assistant pull out of the drain in one quick movement while you compress the tract.
• Close the wound using purse-string suture