Intercostal drainage tube insertion is an emergency as well as planned procedure. In emergency it is a one of the life saving procedures. That's why it is important to learn the anatomy and physiology behind insertion of ICD and what should be the ideal procedure and post procedure care.

1. One of the Emergency Life Saving Procedures

2. Topics to be discussed
• Anatomy
• Physiology
• ICD introduction
• Indications
• ICD insertion technique
• ICD care
• Complications

3. Anatomy
• Intercostal spaces lie between
adjacent ribs and are filled by
intercostal muscles.

4. Anatomy
• Intercostal neurovascular
bundle lie in the costal
groove along the inferior
margin of the superior
rib and pass in the plane
between the inner two
layers of muscles.
• So that ICD to be
inserted along the
superior surface of
inferior rib.

5. Anatomy
• Above to downward
relation is
 Vein
 Artery
 Nerve
• And nerve is unprotected
by groove in the rib.
• So that it is easy to give
intercostal nerve block
at this level.

6. Anatomy
• Diaphragm is balloon shaped.
• The right dome is higher than
the left, reaching as far as 6th
rib.
• If ICD is inserted below the 6th
rib there are higher chances of
abdominal visceral damage.

7. Anatomy
Level Pleura
(RIB no)
Lung
(RIB no)
Mid clavicular 8th 6th
Mid Axillary 10th 8th
Vertebral 12th 10th
Insertion of ICD should be above 6th
Rib = 5th intercostal space or above

8. Anatomy
• Triangle of safety – through
which ICD should be inserted
with minimal complications.

9. Physiology of respiration
• At the time of respiration
in normal lung, pressure
in pleural spaces is
always negative
compared to atmosphere
air pressure.  So it has
tendency to suck air
inside when there is
breach in barrier.
• ICD is iatrogenic case of
breach in barrier.

10. Physiology of respiration
• So we use water sealed bag
for drainage.
• ICD should be removed in
end inspiration or end
expiration  decreased
chances of pneumothorax

12. Physiology of respiration

13. Physiology of respiration

14. Intercostal Drainage Tube
• The concept of chest drainage was
first advocated by Hippocrates when
he described the treatment
of empyema by means of incision,
cautery, and insertion of metal tubes.
• However, the technique was not
widely used until the influenza
epidemic of 1917 to drain post-
pneumonic empyema, which was first
documented by Dr. C. Pope, on "Joel",
a 22-month-old infant.
• The use of chest tubes in
postoperative thoracic care was
reported in 1922, and they were
regularly used post-thoracotomy
in World War II.
• Though they were not routinely used
for emergency tube thoracostomy
following acute trauma until
the Korean War (1950).

15. Intercostal Drainage Tube
• Made from clear plastics like PVC and
soft silicone.
• Sizes measured by their external
diameter from 6 Fr to 40 Fr.
• Conventional chest tubes feature
multiple drainage fenestrations in the
section of the tube which resides
inside the patient.
• As well as distance markers along the
length of the tube.
• A radiopaque stripe which outlines
the first drainage hole.

16. Intercostal Drainage Tube
• The number of side holes is generally
6 on most chest tubes.

18. Indications for ICD insertion
• Pneumothorax
• Pleural effusion
 Chylothorax
 Empyema
 Hemothorax
 Hydrothorax
• Postoperative – Thoracotomy
• As a drain after removal of lung

19. Contraindication for ICD insertion
• Uncorrected coagulopathy
• Diaphragmatic hernia
• Severe pleural adhesion

20. Patient preparation
• Consent – Informed and Written
• Preparation of materials
• Positioning and marking the site
• Oxygen saturation monitoring

21. Preparation of materials
• Sterile gloves and gown
• Antiseptic solution
• Atropine Intramuscular and Analgesic
• Local anaesthetic solution
• Sterile gauze
• Scalpel no 11 and 23
• Curved and straight artery forceps

22. Preparation of materials
• Curved clamp
• Chest tube with connecting tube
• Drainage system ready with 100 cc
saline filled up to mark
• Suture silk no 1
• Dressing material
And obviously an assistant and nursing
staff.

23. Step 1 – Position of patient
• Elevate the head of the bed 30 to 60
degrees
• Place (and restrain) the arm on the
affected side over the patient’s head.

24. Step 1 – Position of patient

25. Step 2 – Checklist
• Confirm that all needed material
are available nearby.
• Check that your assistant is free
for assistance.

26. Step 3 – Preparation of skin and LA
• Prepare the skin with povidone-iodine
or Chlorhexidine solution and allow to
dry.
• Drape the site with fenestrated sheet.
• Using the 10 ml syringe and 25 gauge
needle, raise a skin wheal at the
incision area (in the interspace one rib
below the interspace chosen for the
pleural insertion) with 1% solution of
Lidocaine.
• How to count ribs ?

27. Step 3 – Preparation of skin and LA
• Liberally infiltrate the
subcutaneous tissue and
intercostal muscles of the
interspace where pleural
entry will occur and down
to the parietal pleura.

28. Step 4 – Incision
• Make a 2 to 3 cm transverse incision
through the skin and the
subcutaneous tissues overlying the
interspace.
• Extend the incision by blunt dissection
through the fascia toward the
superior aspect of the rib above.
• After the superior border of the rib is
reached, close and turn the artery
forceps, and push it through the
parietal pleura with steady, firm, and
even pressure.

29. Step 4 – Incision
• Open the artery forceps widely, close
it, and then withdraw it.
• Be careful to prevent the tip of the
clamp from penetrating the lung.
• Insert an index finger to verify that
the pleural space, not the potential
space between the pleura and chest
wall, has been entered. Check for
unanticipated findings, such as pleural
adhesions, masses, or the diaphragm.

30. Step 5 – ICD insertion
• Grasp the chest tube so that the tip of
the tube protrudes beyond the jaws of
the clamp, and advance it through the
hole into the pleural space using your
finger as a guide.
• Direct the tip of the tube posteriorly
for fluid drainage or anteriorly and
superiorly for pneumothorax
evacuation.
• Advance it until the last side hole is
2.5 to 5 cm (1 to 2 inches) inside the
chest wall.

31. Step 5 – ICD insertion
• Attach the tube to the previously
assembled suction-drainage system

32. Step 6 – Confirm position
• Confirm the correct location of the
chest tube by the visualization of
column movement within the tube
with respiration or by drained pleural
fluid seen within the tube.
• Ask the patient to cough, and observe
whether bubbles form at the water-
seal level.
• If the tube has not been properly
inserted in the pleural space, no fluid
will drain, and the level in the water
column will not vary with respiration.

33. Step 6 – Confirm position
• Fix the tube to skin using silk no 1
suture.
• Proper dressing.
• Post procedure X-ray and note
position and kinking.

34. Step 7 – Documentation
• Note down the whole procedure
in patient file.
• Reporting of x-ray.
• Note down ICD care details.

35. Step 8 – Do and Explain ICD care
• Keep chest tube drainage below
chest level.
• Keep chest tube secured to
chest wall.
• Keep ICD bag filled with sterile
water up to marked line.
• Report if continuous bubbling
and continuous blood /
intestinal content in tube.
• Encourage the patient to cough.
• Chest physiotherapy.
• Pain management and
respiratory exercise.
• Daily auscultation and SpO2
monitoring.
• Check local site for
subcutaneous emphysema.
• Never clamp the ICD drain tube.

36. Chest tube placement – Steps summary
• Step 1 – Position of patient
• Step 2 – Checklist
• Step 3 – Preparation of skin and LA
• Step 4 – Incision
• Step 5 – ICD insertion
• Step 6 – Confirm position
• Step 7 – Documentation
• Step 8 – Explain ICD care