This document discusses intercostal drainage (thoracostomy), which is the drainage of fluid, air, blood, chyle, or other materials from the pleural space through an intercostal space. It describes the anatomy, indications, contraindications, patient preparation, procedure, types of chest tubes and drainage systems, complications, and recommendations for safe chest drain insertion. The key points are that intercostal drainage is used to drain various pathological accumulations from the pleural space, requires sterile technique and imaging guidance for safe insertion, and aims to drain fluid/air while preventing complications like re-expansion pulmonary edema.

1. INTERCOSTAL DRAINAGE
(THORACOSTOMY)
By Dr. B RAJA

2. ANATOMY

4. Definition
 Drainage of fluid/air/blood/chyle/from
the pleural space through intercostal
space

5. INDICATIONS
 Pneumothorax
 Hemothorax
 Empyema
 Malignant pleural effusion
 Pleurodesis (sclerotherapy)

6. CONTRAINDICATIONS
 Severe pleural adhesions
 Uncorrected/Refractory coagulopathy
 Diaphragmatic hernia

7. Patient preparation
 Explain the procedure
 Informed written consent
 Mark the site on patient’s chest
 Monitor O2 saturation and supplement
O2

8. SITE OF INSERTION
 5TH ICS in mid axillary line
 2nd ICS in mid clavicular line

9. Triangle of safety

10. Triangle of safety

11. POSITION OF THE PATIENT

12.  Sitting position : to drain blood, pus,
fluid
 Lateral decubitus position : for
pneumothorax
 Loculated pathology : USG/CT guided
ICD

13. REQUIRED MATERIALS
 Sterile gloves, gown
 Antiseptic solution (Iodine,
Cholhexidine,Alcohol)
 Sterile drapes
 Gauze swabs
 Syringes
 Local anesthetic (1% Lignocaine)
 Scalpel,Blade

14.  Suture (1-0 silk)
 Curved Clamp
 Guidewire with dilators
 Chest tube
 Connecting tube
 Closed drainage system ( with sterile
water)
 Dressing materials.

15. PLEURAL DRAINAGE
SYSTEM
Components
 Chest tube
 Connecting tubing
 Closed Drainage system
 Collection chamber
 Water seal chamber
 Suction control chamber

16. CHEST TUBE TYPES
 Thoracostomy Chest Tube
 Straight
 Right angled silicon/PVC
 Trocar chest tube
 Malecot Catheter
 Guidewire type chest drain

18. Guidewire Type Chest Drain

19. Chest tube insertion methods
 Operative tube thoracostomy
 Guidewire tube thoracostomy
 Trocar tube thoracostomy
 Single port thoracospic tube
thoracostomy

20. Operative tube thorocostomy

21. Guide wire tube thorocostomy

22. Trocar tube thorocostomy

23. Single port thoracospic tube
thoracostomy
 Hopkins rod lens telescope is loaded
into the most proximal port of chest
tube.
 Under direct visualisation the chest
tube is placed into the
costodiaphragmatic gutter

24. CHOOSING CHEST TUBE
PNEUMOTHORAX 8-14F
FOR PLEURODESIS 10-14F
EMPYEMA 24-28F
HEMOTHORAX 28-32F

25. Direction of tube
 Air : anterior and superior (towards apex)
 Fluid : posterior and inferior (towards
base)
Any tube position can be effective at
draining air or fluid
An effectively functioning chest tube
should not be repositioned solely
because of position in CXR

26. PHYSICS & PHYSIOLOGICAL
ASPECTS
 DISTAL END OF DRAINAGE TUBE 2cm
BELOW WATER
 COLLECTION CHAMBER ALWAYS
100cm BELOW THE CHEST
 LARGE DIAMETER COLLECTION
CHAMBER (20 cm Diameter)

27. One bottle chest drainage
system

28. Two bottle chest drainage
system

29. Three bottle chest drainage
system

30. Three bottle chest drainage
system
 Controlled amount of suction can be
applied
 Applying negative pressure to the
pleural space helps
◦ Re-expansion of underlying lung
◦ Better removal of air/fluid from pleural
space

33. Disposable chest drainage
unit

34. Disposable chest drainage
system
 Compact, sterile, disposable
 One piece disposable plastic box

35. MOBILE CHEST DRAINS
Facilitate early ambulation
Reduce hospital stay
 Heimlich valve
 Mini Chest drain

36. HEIMLICH VALVE
 Mechanical oneway valve
 Allow air to escape from chest and prevent
air from entering
 Adv: Does not require water to operate
 Not position sensitive
 Early ambulation of the patient
 Disadv:
 Less patient asessment information
 Cannot see changes in IPP

38. Securing chest drain

39. Securing chest drain
 Purse string
Converts a linear wound to a circular
one
More pain and unsightly scar
Should not be used

40. THAL QUICK CHEST TUBE
ADAPTER
 Proximal end attached with three way
stopcock through connecting tube
 Used for sclerotherapy (pleurodesis)

41. When to remove chest tube?
 Depends on indication
 Pneumothorax
 Bubbling ceased
 Lung fully expanded in CXR
 Get CXR12 o24 hrs after last air leak
 Pleural drainage
 Volume <100 ml in 24 hrs
 Serous fluid
 Lung re expanded and clinical status improved
 No fresh or altered blood coming out of chest
tube

42. Removing the chest tube
 Explain the procedure to patient
 During peak inspiration
 Remove the chest tube in one quick
movement
 If on MV : End expiration / diconnect
ventilator
 Two people :
 Instruct the patient and pull the tube
 Occlude the insertion site
 Tighten the suture and occlusive dressing
 CXR – 12 to 24 hrs after Removal to

43. Complications

44. Complications
Injury to
Neurovascular bundle
Lung parenchyma
Diaphragm, intraperitoneal structures
Heart and major vessels
Massive bleeding
Re-expansion pulmonary Edema
Empyema
Subcutaneous emphysema/hematoma

45. Recommendations for safe chest
drain insertion
 Triangle of safety , midaxillary line
 Imaging to be used to select site of
insertion
 Do not use substantial force
 CXR/CT should be available at the
time of insertion except in tension
pneumothorax

46. Patients on Mechanical
Ventilation
 Diconnect from the ventilator during
insertion of chest tube
◦ To avoid lung penetration

47. Repositioning chest drain
 Use imaging assistance
 Avoid pushing & Pulling
 Best is fresh insertion
 Avoid previous site, choose new one

48. Bubbling chest tube-
Differentials
 Not inserted far enough-one or more
holes ourside pleural space
 Air enters from atmosphere
 Leaks in system
 Bronchopleural fistula

49. AIR LEAKS
 Bubbling in water seal
 Collected in syringe-blood gas
analyzer
 Pco2>20 mmHg (Bronchopleural
fistula)
 Pco2<10 mmHg (Atmospheric air)

50. CLAMPING
 A bubbling chest tube should never be
clamped
 Drainage of a large pleural effusion
should be controlled – to avoid re-
expansion pulmonary edema.

51. Patient care
 Encourage deep breaths and cough
 Adequate pain relief
 Encourage movement
 Assess water level, tidalling
 Avoid milking and clamping
 Ensure collection unit below the level
of chest
 Suction can improve the speed of air
and fluid removal

52. Indication for Thorocotomy
 Rapid ICD exsanguination >1500 ml
 Hourly collection >300ml/hr for 2-4hrs.