Intercostal drainage

1. Intercostal drainage Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD(physiology) Mahatma Gandhi medical college and research institute, puducherry, India

2. Definition • Insertion of a drainage tube into the pleural cavity • Why ? • To drain • Air, • Fluid , • Blood • – sometimes to inject drugs

3. Why we should drain such things ? Lungs expand

4. This is what we do !!

5. Indications • Pneumo – any ventilated patient , • recurrent pneumothorax, • tension ,large sec. pneumothorax, • surgeries, malignant effusions, • traumatic hemopneumothorax, • Empyema, flail chest req. ventilation

6. White out or black out • Beware of bulla or severe collapse

7. CONTRAINDICATIONS I • Need for immediate thoracotomy

8. Where ? • A thoracentesis usually at bedside • chest drainage system system is hooked up to allow for continuous drainage of either air, blood, or fluid. Often – as Emergency- well below chest level • If goal is to remove air?- upper anterior chest, 2-4 intercostal space (catheter is inserted) • If goal is to remove fluid/blood?-lower lateral chest 8-9 intercostal space (catheter inserted) ?? Previous

9. Its all “A”s • AIR • ABOVE • ANTERIOR

10. Safe triangle- 1.latismus dorsi , 2.Pect. Major, 3.nipple line

11. Equipment • Under water sealed drain system (UWSD) • Tray • use smaller size for draining air • larger size for draining blood/fluid • Newborn 8-12 FG, Infant   12-16 FG  • Child  16-24 FG, Adolescent 20-32 FG

12. Technique • sitting position at 45 degrees with arm of same side placed above head • 3 or 4 ICS • Anterior – anterior to ant axillary line • Skin after LA – upper border of rib • "Blunt dissect" to reach pleura

13. Technique • Sweep with gloved finger • Hold the tip of the catheter with a curved artery clamp and advance it into the pleural space, directing the catheter posteriorly and superiorly. • All holes inside • Attach to underwater seal below chest level • Suture and anchor • w/f swinging water

14. Check and maintain • No big dressings • With inspiration water will rise up into the chest tube, with expiration, water will fall. If the swing is less than 2 cm, the lung is not likely to be fully expanded and therefore suction may need to be increased

15. Maintenance • “tidaling” • fluctuate gently up and down with each ` inspiration/expiration Tidaling stops – lungs reinflated constant or vigorous “bubbling” occur please check for a “leak” something is wrong

16. TIPS • If no air or fluid comes, use gadgets except tension pneumothorax • Flouro, Xray, USG • No force used • Small gauge catheter – ok , seldinger technique is acceptable • Simple linear stitch

17. Never clamp ICD • Because somebody may forget to remove the clamp and a tension pneumothorax may develop. • Two tubing clamps should be left at the patients bedside to clamp the tube • in emergency , if the tubing became dislodged from the chest tube bottle and air is at risk of entering the chest cavity.

18. Tips • large pleural effusion should be controlled to prevent the potential complication of re-expansion pulmonary oedema • No clamping prior to removal • small chest tubes and a Heimlich flutter valve – OP management

19. Heimlich flutter valve

20. One is ok but fluid comes

21. Three bottle concept

22. Multifunction ICD -- adults and infants

23. When to remove • •In the presence of an air leak the drain should not be removed unless another drain remains • •In general a period of 48 hours after the last bubble is safe. • •In the presence of fluid, remember that 100-200cc normally drain from a pleural drain. Otherwise once the drainage is less than 150cc it may come out. • •Exceptions include the presence of pus (empyema), lymph (chylothorax) or a residual cavity

24. Complications • Pain • Thoracic or abdominal visceral trauma • Tension pneumothorax • Inadequate - subcutaneous emphysema • Position change

25. Thank you all