MANAGEMENT OF SPONTANEOUS PNEUMOTHRAX - …thelungcenter.co.in/yahoo_site_admin/assets/docs/BTS_management_… · MANAGEMENT OF SPONTANEOUS ... IIa Well designed controlled study

BTS GUIDELINES FOR THEBTS GUIDELINES FOR THE MANAGEMENT OF MANAGEMENT OF

SPONTANEOUS SPONTANEOUS PNEUMOTHRAXPNEUMOTHRAX

20032003

GRADING OF PRIMARY GRADING OF PRIMARY LITERATURE(The Bibliographies)LITERATURE(The Bibliographies)

IaIa MetaMeta--analysis of randomised trialsanalysis of randomised trials

IbIb RandomisedRandomised controlled trialcontrolled trial

IIaIIa Well designed controlled study Well designed controlled study without without randomisationrandomisation

IIbIIb Another type of well designed Another type of well designed quasi quasi -- experimental studyexperimental study

IIIIII Well designed nonWell designed non--experimental experimental descriptive studies such as descriptive studies such as comparative studies,correlation comparative studies,correlation studies,andstudies,and casecase--control studies.control studies.

IV IV Opinion of expert committee reports or Opinion of expert committee reports or opinions and/or clinical experience of opinions and/or clinical experience of respected authorities. respected authorities.

Grading of Management Grading of Management

Recommendations(Recommendations(““Bullet PointsBullet Points””))

AA IaIa or or IbIb

B B IIa,IIb,IIIIIa,IIb,III

CC IVIV

INTRODUCTIONINTRODUCTION

Strong emphasis should be placed on the Strong emphasis should be placed on the relationship between the recurrence of relationship between the recurrence of pneumothorax and smoking in an effort to pneumothorax and smoking in an effort to encourage patients to stop smoking.encourage patients to stop smoking.

CLINICAL EVALUATION AND CLINICAL EVALUATION AND IMAGINGIMAGING

Expiratory chest radiographs are not Expiratory chest radiographs are not recommended for the routine diagnosis recommended for the routine diagnosis of of pneumothoraxpneumothorax.. [b][b]A lateral chest or lateral decubitus A lateral chest or lateral decubitus radiograph should be performed if the radiograph should be performed if the clinical suspicion of pneumothorax is clinical suspicion of pneumothorax is high,but a PA radiograph is normal.high,but a PA radiograph is normal. [b][b]

CT scanning is recommended when CT scanning is recommended when differentiating a pneumothorax from differentiating a pneumothorax from complex bullous lung disease,when complex bullous lung disease,when aberrant tube placement is suspected,aberrant tube placement is suspected,and when the plain chest radiograph is and when the plain chest radiograph is obscured by surgical emphysema.obscured by surgical emphysema. [c][c]

The clinical history is not a reliable The clinical history is not a reliable indicator of pneumothorax size.indicator of pneumothorax size. [c] [c]

SIZE OF PNEUMOTHORAXSIZE OF PNEUMOTHORAX

The previous classification of the size of a The previous classification of the size of a pneumothorax tends to underestimate its pneumothorax tends to underestimate its volume.In these new guidelines the size of volume.In these new guidelines the size of a pneumothorax is divided into a pneumothorax is divided into ““smallsmall””or or ““largelarge””depending on the presence of a depending on the presence of a visible rim of < 2cm or >2cm between the visible rim of < 2cm or >2cm between the lung margin and the chest wall.lung margin and the chest wall.

TREATMENT OPTIONS FOR TREATMENT OPTIONS FOR SPONTANEOUS SPONTANEOUS

PNEUMOTHORAXPNEUMOTHORAXOBSERVATIONOBSERVATION

Observation should be the treatment of Observation should be the treatment of choice for small closed choice for small closed pneumothoracespneumothoraceswithout significant breathlessness.without significant breathlessness. [b][b]

Patients with small (<2cm) primary Patients with small (<2cm) primary pneumothoracespneumothoraces not associated with not associated with breathlessness should be considered for breathlessness should be considered for discharge with early OPD review.These discharge with early OPD review.These patients should receive clear written patients should receive clear written advice to return in the event of worsening advice to return in the event of worsening breathlessness.breathlessness. [b] [b]

If a patient with a pneumothorax is If a patient with a pneumothorax is admitted overnight for observation,high admitted overnight for observation,high flow(10l/min) oxygen should be flow(10l/min) oxygen should be administered,with appropriate caution in administered,with appropriate caution in patients with COPD who may be sensitive patients with COPD who may be sensitive to higher concentrations of oxygen.to higher concentrations of oxygen.

[b][b]Breathless patients should not be left Breathless patients should not be left without intervention regardless of the size without intervention regardless of the size of the pneumothorax on a chest of the pneumothorax on a chest radiograph.radiograph. [c][c]

SIMPLE ASPIRATIONSIMPLE ASPIRATIONSimple aspiration is recommended as first Simple aspiration is recommended as first line treatment for all primary line treatment for all primary pneumothoraces requiring intervention.pneumothoraces requiring intervention.

[a][a]Simple aspiration is less likely to succeed in Simple aspiration is less likely to succeed in secondary pneumothoraces and,in this secondary pneumothoraces and,in this situation,is only recommended as an initial situation,is only recommended as an initial treatment in small (<2cm) pneumothoraces treatment in small (<2cm) pneumothoraces in minimally breathless patients under the in minimally breathless patients under the age of 50years.age of 50years. [b][b]

Patients with secondary pneumothoraces Patients with secondary pneumothoraces

treated successfully with simple aspiration treated successfully with simple aspiration

should be admitted to hospital and should be admitted to hospital and

observed for at least 24 hours before observed for at least 24 hours before

discharge.discharge. [c][c]

REPEAT ASPIRATION AND CATHETER REPEAT ASPIRATION AND CATHETER ASPIRATION OF SIMPLE PNEUMOTHORAXASPIRATION OF SIMPLE PNEUMOTHORAX

Repeated aspiration is reasonable for primary Repeated aspiration is reasonable for primary pneumothorax when the first aspiration has pneumothorax when the first aspiration has been unsuccessful(i.e.patient still symptomatic) been unsuccessful(i.e.patient still symptomatic) and a volume of <2.5l has been aspirated on and a volume of <2.5l has been aspirated on the first attempt.the first attempt. [b][b]

Catheter aspiration kits with an integral Catheter aspiration kits with an integral one way valve system may reduce the one way valve system may reduce the need for repeat aspiration.need for repeat aspiration.

[c][c]Catheter aspiration of Catheter aspiration of pneumothoraxpneumothorax(CASP) can be used where the (CASP) can be used where the equipment and experience is available.equipment and experience is available.

[b][b]

INTERCOSTAL TUBE DRAINAGEINTERCOSTAL TUBE DRAINAGE

If simple aspiration or catheter aspiration If simple aspiration or catheter aspiration drainage of any pneumothorax is unsuccessful drainage of any pneumothorax is unsuccessful in controlling symptoms,then an intercostal tube in controlling symptoms,then an intercostal tube should be inserted.should be inserted. [b][b]

Intercostal tube drainage is recommended in Intercostal tube drainage is recommended in secondary pneumothorax except in patients secondary pneumothorax except in patients who are not breathless and have a very who are not breathless and have a very small(<1cm or apical) small(<1cm or apical) pneumothoraxpneumothorax.. [b][b]

A bubbling chest tube should never be A bubbling chest tube should never be clamped.clamped. [b][b]

If a chest tube for pneumothorax is If a chest tube for pneumothorax is clamped,this should be under the supervision of clamped,this should be under the supervision of a respiratory physician or thoracic surgeon,the a respiratory physician or thoracic surgeon,the patient should be managed in a specialist ward patient should be managed in a specialist ward with experienced nursing staff,and the patient with experienced nursing staff,and the patient should not leave the ward environment.should not leave the ward environment.

[c][c]If a patient with a clamped drain becomes If a patient with a clamped drain becomes breathless or develops subcutaneous breathless or develops subcutaneous emphysema,the drain must be immediately emphysema,the drain must be immediately unclamped and medical advice sought.unclamped and medical advice sought. [c][c]

COMPLICATIONS OF COMPLICATIONS OF INTERCOSTAL TUBE DRAINAGEINTERCOSTAL TUBE DRAINAGE

The complications of intercostal drainage The complications of intercostal drainage includes penetration of the major organs includes penetration of the major organs such as lung,heart,stomach,spleen & such as lung,heart,stomach,spleen & great vessels.great vessels.Pleural infection is another complication of Pleural infection is another complication of intercostal drainage.intercostal drainage.Surgical emphysema is a well known Surgical emphysema is a well known complication of intercostal tube drainage.complication of intercostal tube drainage.

SIZE OF TUBESIZE OF TUBE

There is no evidence that large tubes (20There is no evidence that large tubes (20--24F) 24F) any better than small tubes(10any better than small tubes(10--14F) in the 14F) in the management of pneumothoraces.The initialmanagement of pneumothoraces.The initialuse of large (20use of large (20--24F) intercostal tubes is not 24F) intercostal tubes is not recommended, although it may become recommended, although it may become necessary to replace a small chest tube with necessary to replace a small chest tube with a large one if there is a persistent air leak.[b]a large one if there is a persistent air leak.[b]

REFERRAL TO RESPIRATORY REFERRAL TO RESPIRATORY SPECIALISTSSPECIALISTS

Pneumothoraces which fail to respond Pneumothoraces which fail to respond within 48 hours to treatment should be within 48 hours to treatment should be referred to a respiratory physician.referred to a respiratory physician. [c][c]

CHEST DRAIN SUCTIONCHEST DRAIN SUCTION

Suction to an intercostal tube should not be Suction to an intercostal tube should not be applied directly after tube insertion,but can be applied directly after tube insertion,but can be added after 48hours for persistent air leak or added after 48hours for persistent air leak or failure of a pneumothorax to refailure of a pneumothorax to re--expand.expand. [b][b]

High volume,low pressure (High volume,low pressure (--10 to10 to--20cmH20cmH22 O) O) suction system are recommended.suction system are recommended. [c][c]

Patients requiring suction should only be Patients requiring suction should only be managed on lung units where there is managed on lung units where there is specialist medical and nursing experience.specialist medical and nursing experience.

[c][c]

CHEMICAL PLEURODESISCHEMICAL PLEURODESIS

Chemical pleurodesis can control difficult or Chemical pleurodesis can control difficult or recurrent recurrent pneumothoraxpneumothorax [a][a] but should only be but should only be attempted if the patient is either unwilling or attempted if the patient is either unwilling or unable to undergo surgery.unable to undergo surgery. [b][b]

Medical pleurodesis for pneumothorax should be Medical pleurodesis for pneumothorax should be performed by a respiratory specialist.performed by a respiratory specialist. [c][c]

Surgical chemical pleurodesis is best achieved Surgical chemical pleurodesis is best achieved with 5gm sterile talc,side effects such as ARDS with 5gm sterile talc,side effects such as ARDS and empyema are reported but rare.and empyema are reported but rare. [a][a]

REFFERAL TO THORACIC REFFERAL TO THORACIC SURGEONSSURGEONS

In case of persistent air leak or failure of the lung to In case of persistent air leak or failure of the lung to rere--expand,the managing respiratory specialist expand,the managing respiratory specialist should seek an early (3should seek an early (3--5days) thoracic surgical 5days) thoracic surgical opinion.opinion. [c][c]Open thoracotomy and pleurectomy remains the Open thoracotomy and pleurectomy remains the procedure with the lowest recurrence rate for procedure with the lowest recurrence rate for difficult or recurrent pneumothoraces.Minimally difficult or recurrent pneumothoraces.Minimally invasive procedures,thoracoscopy(VATS),pleural invasive procedures,thoracoscopy(VATS),pleural abrasion,and surgical talc pleurodesis are all abrasion,and surgical talc pleurodesis are all effective alternative strategies.effective alternative strategies.

DISCHARGE AND FOLLOW UPDISCHARGE AND FOLLOW UP

Patients discharged without intervention should Patients discharged without intervention should avoid air travel until a chest radiograph has avoid air travel until a chest radiograph has confirmed resolution of the confirmed resolution of the pneumothoraxpneumothorax..

[c][c]

Diving should be permanently avoided after a Diving should be permanently avoided after a pneumothorax,unless the patient has had pneumothorax,unless the patient has had bilateral surgical bilateral surgical pleurectomypleurectomy..

[c][c]

Primary Primary pneumothoraxpneumothorax patients treated patients treated successfully by simple aspiration should be successfully by simple aspiration should be observed to ensure clinical stability before observed to ensure clinical stability before discharge. Secondary discharge. Secondary pneumothoraxpneumothorax patients patients who are successfully treated with simple who are successfully treated with simple aspiration should be admitted for 24hrs aspiration should be admitted for 24hrs before discharge to ensure no recurrence.before discharge to ensure no recurrence.

[c][c]

PNEUMOTHORAX AND AIDSPNEUMOTHORAX AND AIDS

Early and aggressive treatment of Early and aggressive treatment of pneumothoraces in HIV patients, incorporating pneumothoraces in HIV patients, incorporating intercostal tube drainage and early surgical intercostal tube drainage and early surgical referral, is recommended.referral, is recommended. [b][b]

PNEUMOTHORAX AND CYSTIC PNEUMOTHORAX AND CYSTIC FIBROSISFIBROSIS

Early and aggressive treatment of Early and aggressive treatment of pneumothoraces in cystic fibrosis is pneumothoraces in cystic fibrosis is recommended.recommended. [c][c]

Surgical intervention should be considered Surgical intervention should be considered after the first episode, provided the patient after the first episode, provided the patient is fit for the procedure.is fit for the procedure. [c][c]

TENSION PNEUMOTHORAXTENSION PNEUMOTHORAX

If tension pneumothorax is present, a If tension pneumothorax is present, a cannula of adequate length should be cannula of adequate length should be promptly inserted into the second promptly inserted into the second intercostal space in the mid clavicular line intercostal space in the mid clavicular line and left in place until a functioning and left in place until a functioning intercostal tube can be positioned.intercostal tube can be positioned. [b][b]

IATROGENIC PNEUMOTHORAXIATROGENIC PNEUMOTHORAX

The incidence of iatrogenic pneumothorax is The incidence of iatrogenic pneumothorax is high,outnumbering spontaneous high,outnumbering spontaneous pneumothoracespneumothoraces..

Transthoracic needle aspiration(24%), Transthoracic needle aspiration(24%), subclavian vessel puncture(22%), subclavian vessel puncture(22%), thoracocentesis(22%)pleural biopsy(8%) and thoracocentesis(22%)pleural biopsy(8%) and mechanical ventilation (7%) are the five leading mechanical ventilation (7%) are the five leading causes.causes.

AUDIT POINTSAUDIT POINTS

Proportion of patients treated by (a)simple Proportion of patients treated by (a)simple observation,(b)aspiration,and(c)chestobservation,(b)aspiration,and(c)chest drains drains and their appropriateness(relative to the and their appropriateness(relative to the guidelines) and outcome(in terms of recurrence guidelines) and outcome(in terms of recurrence rates,complications,and lengths of stay in rates,complications,and lengths of stay in hospital) hospital)

Number of chest drains clamped and the Number of chest drains clamped and the reasons for this.reasons for this.

Referral rates to physicians and surgeons Referral rates to physicians and surgeons and the timing of such referrals.and the timing of such referrals.

Use of analgesics and local Use of analgesics and local anaestheticsanaesthetics..

Follow up rates.Follow up rates.

FUTURE POTENTIAL AREAS FUTURE POTENTIAL AREAS FOR RESEARCHFOR RESEARCH

Prospective randomised controlled trials Prospective randomised controlled trials comparing:comparing:

Simple observation versus aspiration+tube Simple observation versus aspiration+tube drainage for primary pneumothoraces larger drainage for primary pneumothoraces larger than 2cm on the chest radiograph;than 2cm on the chest radiograph;

Use of small catheter/Hemlichvalve kits versus Use of small catheter/Hemlichvalve kits versus intercostal tube drainage following failed intercostal tube drainage following failed aspiration in primary pneumothoraces;aspiration in primary pneumothoraces;

Small catheter aspiration(CASP) versus Small catheter aspiration(CASP) versus conventional aspiration or tube drainage;conventional aspiration or tube drainage;

VATS versus open thoracotomy for the difficult VATS versus open thoracotomy for the difficult pneumothorax.pneumothorax.

Use of suction with regard to its timing and Use of suction with regard to its timing and optimal mode.optimal mode.

Comparision of Comparision of ““clampingclamping”” and and ““nonnon--clampingclamping”” strategies after cessation of air leak.strategies after cessation of air leak.

PRIMARY PNEUMOTHORAXPRIMARY PNEUMOTHORAX

BREATHLESS AND/OR RIM OF AIR>2cmBREATHLESS AND/OR RIM OF AIR>2cmON CHEST RADIOGRAPH? NOON CHEST RADIOGRAPH? NO

YESYESASPIRATION YESASPIRATION YES

?SUCCESSFUL?SUCCESSFULNONO

CONSIDER REPEAT ASPIRATIONCONSIDER REPEAT ASPIRATIONNO YES NO YES

INTERCOSTAL DRAIN REMOVE 24HRSINTERCOSTAL DRAIN REMOVE 24HRS? SUCCESSFUL AFTER FULL RE? SUCCESSFUL AFTER FULL RE--

NO YES EXPLORATION/NO YES EXPLORATION/CESSATION OF AIR CESSATION OF AIR

LEAK WITHOUTLEAK WITHOUTCLAMPINGCLAMPING

REFERRAL TO CHESTREFERRAL TO CHESTPHYSICIAN WITHIN 48HRSPHYSICIAN WITHIN 48HRS?SUCTION CONSIDER ?SUCTION CONSIDER REFERRAL TO THORACIC DISCHARGEREFERRAL TO THORACIC DISCHARGESURGEON AFTER 5DAYSSURGEON AFTER 5DAYS

SECONDARY PNEUMOTHORAXSECONDARY PNEUMOTHORAX

BREATHLESS+AGE>50YRS + RIM OF BREATHLESS+AGE>50YRS + RIM OF AIR >2cm ON CHEST RADIOGRAPH AIR >2cm ON CHEST RADIOGRAPH YES NOYES NO

ASPIRATIONASPIRATIONINTERCOSTAL DRAIN ?SUCCESSFULINTERCOSTAL DRAIN ?SUCCESSFUL?SUCCESSFUL NO YES?SUCCESSFUL NO YESNO YES ADMIT TO NO YES ADMIT TO

HOSPITAL FOR HOSPITAL FOR 24HRS24HRS

REFERRAL TO CHEST REMOVE 24HRSREFERRAL TO CHEST REMOVE 24HRSPHYSICIAN AFTER 48HRS AFTER FULL PHYSICIAN AFTER 48HRS AFTER FULL ?SUCTION RE?SUCTION RE--EXPANSION/EXPANSION/?SUCCESSFUL YES CESSATION?SUCCESSFUL YES CESSATION

OF AIR LEAK OF AIR LEAK NO NO

EARLY DISCUSSION CONSIDEREARLY DISCUSSION CONSIDERWITH SURGEON AFTER DISCHARGEWITH SURGEON AFTER DISCHARGE

3DAYS3DAYS

BRITISH THORACIC BRITISH THORACIC GUIDELINES FOR THE GUIDELINES FOR THE

INSERTION OF A CHEST INSERTION OF A CHEST DRAINDRAIN--2003 2003

INDICATIONS FOR CHEST DRAIN INDICATIONS FOR CHEST DRAIN INSERTIONINSERTION

PNEUMOTHORAXPNEUMOTHORAXIn any ventilated patientIn any ventilated patientTension pneumothorax after initial needle Tension pneumothorax after initial needle reliefreliefPersistent or recurrent pneumothorax after Persistent or recurrent pneumothorax after simple aspirationsimple aspirationLarge secondary spontaneous Large secondary spontaneous pneumothorax in patients over 50years pneumothorax in patients over 50years

Malignant pleural effusionMalignant pleural effusion

Empyema and complicated parapneumonic Empyema and complicated parapneumonic pleural effusion.pleural effusion.

Traumatic haemopneumothorax.Traumatic haemopneumothorax.

Post operativePost operative--for example, for example, thoracotomy,oesophagectomy,cardiac surgery.thoracotomy,oesophagectomy,cardiac surgery.

PRE DRAINAGE RISK PRE DRAINAGE RISK ASSESSMENTASSESSMENT

Risk of haemorrahage: where possible,any Risk of haemorrahage: where possible,any coagulopathy or platelet defect should be coagulopathy or platelet defect should be corrected prior to the chest tube insertion corrected prior to the chest tube insertion but routine measurement of the platlet but routine measurement of the platlet count and prothrombin time are only count and prothrombin time are only recommended in patients with known risk recommended in patients with known risk factors.factors. [c][c]

The differential diagnosis between a The differential diagnosis between a pneumothorax and bullous disease requires pneumothorax and bullous disease requires careful radiological assessment.Similarly it is careful radiological assessment.Similarly it is important to differentiate between the presence important to differentiate between the presence of collapse and a pleural effusion when the of collapse and a pleural effusion when the chest radiograph shows a unilateral chest radiograph shows a unilateral ““whiteoutwhiteout””..

Lung densely adherent to the chest wall Lung densely adherent to the chest wall throughout the hemithorax is an absolute throughout the hemithorax is an absolute contraindication to chest drain insertion.contraindication to chest drain insertion. [c][c]

The drainage of a post The drainage of a post pneumonectomypneumonectomy space should only be carried out by or space should only be carried out by or after consultation with a cardiothoracic after consultation with a cardiothoracic surgeon.surgeon. [c][c]

EQUIPMENTEQUIPMENT

Sterile gloves,gown,sterile drapes,gauge Sterile gloves,gown,sterile drapes,gauge swabs.swabs.Syringes,needles(21Syringes,needles(21--25gauge),scalpel 25gauge),scalpel and blade,instrument for blunt dissection.and blade,instrument for blunt dissection.Skin antiseptic solution e.g.iodine or Skin antiseptic solution e.g.iodine or chlorhexidine in alcohol.chlorhexidine in alcohol.Local anaesthetics,e.g.lignocaine 1%or2%Local anaesthetics,e.g.lignocaine 1%or2%Suture(e.g. Suture(e.g. ““11”” silk)silk)

Guidewire with dilators (if small tube being Guidewire with dilators (if small tube being used).used).

Chest tube.Chest tube.

Connecting tubing.Connecting tubing.

Closed drainage system(including sterile Closed drainage system(including sterile water if underwater seal being used)water if underwater seal being used)

Dressing.Dressing.

CONSENT AND CONSENT AND PREMEDICATIONPREMEDICATION

Prior to commencing chest tube insertion Prior to commencing chest tube insertion the procedure should be explained fully to the procedure should be explained fully to the patient.the patient. [c][c]Unless there are contraindications to its Unless there are contraindications to its use,premedication(benzodiazepin or use,premedication(benzodiazepin or opiod) should be given to reduce patient opiod) should be given to reduce patient distress.distress. [b][b]

PATIENT POSITIONPATIENT POSITION

The preferred position for drain insertion is The preferred position for drain insertion is on the bed,slightly rotated,with arm on the on the bed,slightly rotated,with arm on the side of the lesion behind the patientside of the lesion behind the patient’’s head s head to expose the axillary area.to expose the axillary area.

An alternative way is to sit upright leaning An alternative way is to sit upright leaning over an adjacent table with a pillow or in over an adjacent table with a pillow or in the lateral decubitous position.the lateral decubitous position.

CONFORMING SITE OF DRAIN CONFORMING SITE OF DRAIN INSERTIONINSERTION

A chest tube should not be inserted without further A chest tube should not be inserted without further image guidance if free air or fluid cannot be image guidance if free air or fluid cannot be aspirated with a needle at the time of aspirated with a needle at the time of anaesthesiaanaesthesia..

[c][c]

Imaging should be used to select the appropriate Imaging should be used to select the appropriate site for chest tube placement.site for chest tube placement. [b][b]

A chest radiograph must be available at the time A chest radiograph must be available at the time of drain insertion in the case of tension of drain insertion in the case of tension pneumothoraxpneumothorax.. [c][c]

DRAIN INSERTION SITEDRAIN INSERTION SITEThe most common position for chest tube The most common position for chest tube insertion is in the mid axillary line,through the insertion is in the mid axillary line,through the ““safe trianglesafe triangle””.This is the triangle bordered by .This is the triangle bordered by the anterior border of the latissmus dorsi,the the anterior border of the latissmus dorsi,the lateral border of the pectoralis major muscle,a lateral border of the pectoralis major muscle,a line superior to the horizontal level of the line superior to the horizontal level of the nipple,and an apex below the axilla.This position nipple,and an apex below the axilla.This position minimises risk to underlying structures such as minimises risk to underlying structures such as the internal mammary artery and damage to the internal mammary artery and damage to muscle and breast tissue resulting in unsightly muscle and breast tissue resulting in unsightly scarring. scarring.

DRAIN SIZEDRAIN SIZE

Small bore drains are recommended as Small bore drains are recommended as they are more comfortable than larger they are more comfortable than larger bore tubes bore tubes [b][b] but there is no evidence that but there is no evidence that either is therapeutically superior.either is therapeutically superior.

Large bore drains are recommended for Large bore drains are recommended for drainage of acute haemothorax to monitor drainage of acute haemothorax to monitor further blood loss.further blood loss. [c][c]

ASEPTIC TECHNIQUEASEPTIC TECHNIQUE

Aseptic technique should be employed Aseptic technique should be employed during catheter insertion.during catheter insertion. [c][c]

Prophylactic antibiotics should be given in Prophylactic antibiotics should be given in trauma cases.trauma cases. [a][a]

ANAESTHESIAANAESTHESIA

Local anaesthesia should be infilterated Local anaesthesia should be infilterated prior to insertion of the drain.prior to insertion of the drain. [c][c]

INSERTION OF CHEST TUBEINSERTION OF CHEST TUBE

Chest drain insertion should be performed Chest drain insertion should be performed without substantial force.without substantial force. [c][c]Small bore tube(8Small bore tube(8--14F)14F)

•• Insertion of a small bore drain under image Insertion of a small bore drain under image guidance with a guidewire does not require blunt guidance with a guidewire does not require blunt dissection.dissection.Medium bore tube(16Medium bore tube(16--24F)24F)

•• Medium sized chest drains may be inserted by a Medium sized chest drains may be inserted by a Seldinger technique or by blunt dissection.Seldinger technique or by blunt dissection.

Large bore tube (>24F)Large bore tube (>24F)

•• Blunt dissection into the pleural space must be Blunt dissection into the pleural space must be performed before insertion of a large bore chest performed before insertion of a large bore chest tube drain.tube drain. [c][c]

•• IncisionIncisionThe incision for insertion of the chest drain The incision for insertion of the chest drain should be similar to the diameter of the tube should be similar to the diameter of the tube being inserted.being inserted. [c][c]

Position of tube tipPosition of tube tip•• The position of the tip of the chest tube The position of the tip of the chest tube

should ideally be aimed apically for a should ideally be aimed apically for a pneumothorax or basally for pneumothorax or basally for fluid.However, any tube position can be fluid.However, any tube position can be effective at draining air or fluid and an effective at draining air or fluid and an effectively functioning drain should not be effectively functioning drain should not be repositioned solely because of the repositioned solely because of the radiographic position.radiographic position.

Securing the drainSecuring the drain•• Large and medium bore chest tube Large and medium bore chest tube

incisions should be closed by a suture incisions should be closed by a suture appropriate for a linear incision.appropriate for a linear incision.

[c][c]

•• ““Purse stringPurse string”” sutures must not be used.sutures must not be used. [c][c]

MANAGEMENT OF DRAINAGE MANAGEMENT OF DRAINAGE SYSTEMSYSTEM

Clamping Drain.Clamping Drain.A bubbling drain should never be clamped.A bubbling drain should never be clamped.

[c][c]Drainage of a large pleural effusion should Drainage of a large pleural effusion should be controlled to prevent the potential be controlled to prevent the potential complication of recomplication of re--expansion pulmonary expansion pulmonary edema.edema. [c][c]In case of pneumothorax,clamping of the In case of pneumothorax,clamping of the chest tube should usually be avoided.chest tube should usually be avoided. [b][b]

If a chest tube for pneumothorax is If a chest tube for pneumothorax is clamped,this should be under the clamped,this should be under the supervision of a respiratory physician or supervision of a respiratory physician or thoracic surgeon,the patient should be thoracic surgeon,the patient should be managed in a specialist ward with managed in a specialist ward with experienced nursing staff, and the patient experienced nursing staff, and the patient should not leave the ward environment. should not leave the ward environment. [c][c]

If a patient with a clamped drain becomes If a patient with a clamped drain becomes breathless or develops subcutaneous breathless or develops subcutaneous emphysema,theemphysema,the drain must be drain must be immediately unclamped and medical immediately unclamped and medical advice sought.advice sought. [c][c]

Closed system drainageClosed system drainage

All chest tubes should be connected to a All chest tubes should be connected to a single flow drainage system e.g.,under single flow drainage system e.g.,under water seal bottle or flutter valve.water seal bottle or flutter valve. [c][c]

Use of a flutter valve system allows earlier Use of a flutter valve system allows earlier mobilisation and the potential for earlier mobilisation and the potential for earlier discharge of patients with chest drains.discharge of patients with chest drains.

SuctionSuctionWhen chest drain suction is required,a When chest drain suction is required,a high volume/low pressure should be used.high volume/low pressure should be used.

[c][c]When suction is required,the patient must When suction is required,the patient must be nursed by appropriately trained staff. be nursed by appropriately trained staff. [c][c]Ward instructionsWard instructionsPatients with chest tubes should be Patients with chest tubes should be managed on specialist wards by staff who managed on specialist wards by staff who are trained in chest drain management.are trained in chest drain management.

A chest radiograph should be performed A chest radiograph should be performed after insertion of a chest drain.after insertion of a chest drain. [c][c]

Removal of the chest tubeRemoval of the chest tubeIn case of pneumothorax, the chest tube In case of pneumothorax, the chest tube should not be clamped at the time of its should not be clamped at the time of its removal.removal. [b][b]

AUDIT POINTSAUDIT POINTS

The presence and use of an appropriate nursing The presence and use of an appropriate nursing chest drain observation chart should be noted.chest drain observation chart should be noted.The frequency of chest drain complications The frequency of chest drain complications should be recorded.should be recorded.The use of premedication and analgesics and The use of premedication and analgesics and patient pain scores relating to chest drain patient pain scores relating to chest drain insertion should be recorded.insertion should be recorded.The duration of chest tube drainage should be The duration of chest tube drainage should be recorded. recorded.

PATIENT REQUIRING ASSISTED PATIENT REQUIRING ASSISTED VENTILATIONVENTILATION

During the insertion of a chest tube in a During the insertion of a chest tube in a patient on a high pressure patient on a high pressure ventilator,especially with positive end ventilator,especially with positive end expiratory pressure(PEEP),it is essential expiratory pressure(PEEP),it is essential to disconnect from the ventilator at the to disconnect from the ventilator at the time of insertion to avoid the potentially time of insertion to avoid the potentially serious complication of lung serious complication of lung penetration,although as long as blunt penetration,although as long as blunt dissection is carried out and no sharp dissection is carried out and no sharp instruments are used,this risk is reduced.instruments are used,this risk is reduced.

INDICATION TO INSERT CHEST DRAININDICATION TO INSERT CHEST DRAIN

CONSENTCONSENT

PREMEDICATIONPREMEDICATION

CONFIRMATION OF SITE OF INSERTION CONFIRMATION OF SITE OF INSERTION CLINICALLY AND ON RADIOGRAPHYCLINICALLY AND ON RADIOGRAPHY

POSITIONING OF PATIENTPOSITIONING OF PATIENT

SIZE OF CHEST DRAINSIZE OF CHEST DRAIN

ASEPTIC TECHNIQUEASEPTIC TECHNIQUELOCAL ANAESTHESIALOCAL ANAESTHESIA

BLUNT DISSECTION IF REQUIREDBLUNT DISSECTION IF REQUIRED

SECURING DRAIN AND SUTURESECURING DRAIN AND SUTURE

UNDERWATER SEALUNDERWATER SEALCLAMPING INSTRUCTIONSCLAMPING INSTRUCTIONS

DECISION RE SUCTIONDECISION RE SUCTION

REMOVAL OF DRAINREMOVAL OF DRAIN

All the best..All the best..