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CDHB

Intercostal Tubes

The insertion and management of intercostal tubes is a complex and specialized area which should only be undertaken by trained staff. Internal medicine patients requiring an intercostal tube should be referred to the Specialist Respiratory or Cardiothoracic surgical team for care in their respective wards.

The choice of the particular drain and drainage collection system should be discussed with the Consultant in charge before the procedure.

Indications for Intercostal Tubes

• Pneumothorax.
• Pleural effusion.
• Parapneumonic effusion/empyema.
• Haemopneumothorax.

Contraindications for Intercostal Tubes

• Coagulopathy.
• Possibility of bullous lung disease creating the impression of a pneumothorax - consider CT chest.
• Bronchial obstruction on the affected side.
• Chest wall infection.
• Loculated pleural effusion. A CT scan should be done first. An ultrasound scan is advised prior to the chest drain insertion.
• Known thickening of the visceral pleura seen on CT chest (discuss with Respiratory Physician).
• Previous pneumonectomy (discuss with Thoracic Surgeon or Respiratory Physician).

Care of chest tubes

Duty medical staff are often asked to assess patients with chest tubes for potential or actual problems. At Christchurch Hospital, the nursing staff from the Respiratory Ward have information and knowledge which may be helpful. If unsure, contact the Respiratory Physician on call.

A worsening pneumothorax or surgical emphysema in a patient with a chest tube in situ means that this is not performing adequately; it may be blocked, kinked, outside the pleural space, or simply too small.

• Assessment should include the following:
  • Check the insertion site, all tubes and connections for patency. Check if there is a 3-way tap - see above. If present, this should be removed and the chest tube connected directly to the underwater seal. Ensure the position of the drain is still correct.
  • Check for swinging, i.e., movement of the water column during deep breathing.

    Note: A tube on suction will not swing and any bubbling seen is due to the suction. However, if not on suction, any bubbling through the water seal chamber, especially on coughing, suggests a bronchopleural fistula.

  • Obtain a CXR if there is any concern about the patient. Ensure the chest tube is within the pleural space and not in the subcutaneous tissues. Consider a CT chest if still in doubt after the CXR.
  • Consider flushing the intercostal tube with 20-50 mL of sterile sodium chloride 0.9% under aseptic conditions.
  • Do not clamp chest tubes unless the patient can be closely monitored. Do not clamp tubes during patient transfers.
  • Never advance a chest tube after the insertion procedure itself although tubes may be withdrawn.

Emergencies

• Acute deterioration in the patient's condition:
  • Check all tube connections and underwater seal system.
  • Administer oxygen.
  • Bedside CXR.
  • Notify the Respiratory Physician on call.
• Development of surgical emphysema = subcutaneous air:
  • This suggests an insufficiently treated bronchopleural fistula.
  • After checking that the tube is not blocked or kinked and is in the right place, consider the use of low-pressure suction and urgent insertion of a larger tube (24 French or larger).
  • Call the Respiratory Physician if unsure.

Removal of chest drains

• See special protocol in Respiratory Services and Cardiothoracic Surgical Services.
• A CXR should usually be performed after removal of the drain and must be reviewed by the RMO. If the patient deteriorates after the drain removal, an urgent medical assessment is required and, if indicated, a further urgent bedside CXR.

Topic Code: 1684