1. Preparation

• Give oxygen as required and secure iv access.
• Verbal or written consent to be obtained.
• Atropine (600 micrograms) should be handy as profound vagal stimulation, with resulting bradycardia, can occur during pleural manipulation.
• Premedicate anxious patients with midazolam 1mg to 5mg iv or diazepam 5mg to 10mg sublingually (ordinary tablets dissolve) unless the patient is in respiratory failure.
• Flumazenil (300-600micrograms) should be immediately available to reverse over-sedation.
• Morphine 2.5 to 10mg s/c is an effective alternative premedication, the lower dose being appropriate in the frail and elderly.
• Look at the CXR and mark intubation site with pen on patient's chest: 4th or 5th ICS just anterior to the mid-axillary line for pneumothorax, site directed by signs/ultrasound for effusion. (A reference mark in the mirror image position on the opposite side is useful if the original mark is washed off during skin preparation, but must not lead to confusion
  about which side the tube is needed!)
• Position the patient supine (20-30 degrees head up) with the patient's ipsilateral arm behind head
• Wash hands and put on a sterile gown and gloves. This is a messy, sterile procedure and a gown protects your patient and your clothes!
• Clean the lateral chest wall with antiseptic, and drape it leaving free access to the planned drain site. Absorbent pads below the drain site are useful as fluid is often spilled during the procedure.

2. Selection of a suitable drain

• In general, small diameter drains (eg. 12 French) are preferred for simple pneumothorax, as they are more comfortable to insert and manage.
• If it is anticipated that talc pleurodesis will be needed after drainage, it is essential to use a larger diameter drain, (e.g. 16 French or larger) otherwise it will not be possible to drain off excess fluid and talc, which may cause a florid inflammatory reaction. Equally if a haemothorax or empyema is suspected a larger drain may be required.
• Small drains are generally of the Seldinger (Portex or Cook) variety, large drains may be
  conventional Argyle or Seldinger (Cook).

3. Optimum positioning of a chest drain

• For pneumothorax try to advance the drain upwards towards the pleural apex during insertion.
• For effusion, basally placed drains are best. If effusions are complex or loculated, use chest ultrasound to guide positioning.
• Always insert drains a generous distance into the chest – position may be adjusted later by partial withdrawal but NOT by advancing the drain.
• Many drain related problems occur when drains are insufficiently advanced (or insufficiently secured) and drain side holes come to rest in the chest wall or subcutaneous tissues.

4. Procedure for conventional (Argyle) drain

• Prepare the water seal bottle with sterile water.
• Infiltrate the skin down to parietal pleura with 1% lidocaine 10-20ml, using a blue then subsequently a green needle aspirating intermittently (look for air or fluid in syringe to confirm that the pleural space has been entered). Maximum safe dose of lidocaine is 200mg = 20ml of 1% in total.
• A small transverse incision into skin and subcutaneous fat is made over the rib below the intercostal space selected for insertion of the tube.
• Two 2/0 silk stitches should be placed across the incision with the stitch ends left loose to close the wound after drain removal. (purse string sutures are to be avoided)
• Using blunt dissection (spreading forceps within the incision), form a track for the tube through the intercostal muscles to the level of the pleura. The size of the track is very important. Too small and excessive force will be needed for drain insertion, too large invites leakage of air and fluid around the drain.

5. Securing your drain

It is vitally important that the drain is secured appropriately and that the weight of the tubing is not pulling on the drain.

6. Patient education

It is imperative that you educate the patient in care of their drain, as I am sure they will not wish to have this procedure done multiply. Details contained in care of chest drain document.

7. Underwater seal

When attaching circuit ensure that it is complete and joins are tight. If using 3 way tap in circuit ensure the tap is closed to the ‘open’ port.

Trouble shooting chest drain problems are included in a separate document.