Indications
To drain abnormal large-volume air or fluid collections in the pleural space
+ Hemothorax, chylothorax, empyema
- Pneumothorax, if:
- Large or progressive
- Patient is on mechanical ventilation
- Bronchopleural fistula
- Tension pneumothorax
+ To facilitate pleurodesis:
- i.e. obliteration of the pleural space by instilling talc or doxycycline to cause fibrosis and adherence of parietal and visceral pleura
- Indicated for recurrent pleural effusions (often malignant)
+ For long-term drainage of malignant effusions
Procedure
+ Tube size – varies according to indication; larger tube for more viscous drainage
+ Insertion site- typically 4th or 5th intercostal space in anterior axillary or mid-axillary line
+ Technique:
+ Technique:
- Local anaesthetic
- -2 em skin incision
- Kelly clamp for blunt dissection to the pleural space, taking care to pass over the top of the rib to avoid neurovascular bundle
- Tube is inserted and sutured in place
- Tube is attached to a pleural drainage system (suction/underwater seal, usually -20 mmH20)
- Post-insertion CXR to ensure proper tube placement (posterior apex of lung for pneumothorax, base oflung for fluid)
+ Removal:
- When drainage <100 cc/d, no air leak, and lung is fully expanded
- Consider clamping tube for 4-6 h then obtain CXR to ensure lung remains expanded
- Brisk removal after patient expires and holds breath
Complications
o Overall complications are rare (1-3%)
o Malposition (most common complication), especially by inexperienced operators:
- Tubes may dissect along the external chest wall, or may be placed below the diaphragm
o Bleeding (anticoagulation is a relative contraindication)
o Local infection, empyema
o Perforation oflung parenchyma
o Risk of re-expansion pulmonary edema when large volumes of air or fluid are drawn off quickly (> 1.0-1.5 L)
