Thoracic Drainage

Indications:

• Pneumothorax (width 1 QF), recurrent pneumothorax, hemothorax, chylothorax, pleural empyema, post-operative after thoracoscopy/thoracotomy.

Contraindications:

• Coagulopathies (INR 1.5 or Quick 50%, PTT 50 s, platelets <50,000/µl). Contraindications depend on urgency.

Complications:

• Injury to intercostal vessels, internal thoracic artery (anterior approach), pneumothorax, lung injury, injury to the heart, abdominal organs (lateral approach), misplacement of the drain (especially subcutaneous), infections.

Materials:

• Thoracic drainage tube (28 – 32 Ch), motor suction system (suction: 10 – 20 cmH2O), 20-40 ml 1% lidocaine, disposable scalpel, sterile instrument set (surgical tweezers, curved sharp-blunt scissors, artery clamp, needle holder, collection tray, drapes, swabs, compresses), sterile gloves, disinfectant solution, sutures.

Access Routes:

Anterior Access (“Monaldi Access”):

• 2nd or 3rd intercostal space, midclavicular line.
• Used for pneumothorax.
• Note: Avoid in women due to cosmetic concerns.

Lateral Access (“Bülau Access”):

• 4th to 6th intercostal space, anterior axillary line.
• Preferred access for pleural effusion (while lying), hemothorax, and pneumothorax in women.
• For pleural effusion in a sitting patient: Prefer posterior axillary line.

Procedure:

1. Preparation: Administer an antitussive, possibly mark the puncture site using ultrasound, disinfect the skin, wear sterile gloves, and drape.
2. Local Anesthesia: Administer anesthesia across two intercostal spaces.
3. Incision: Make a transverse skin incision 1 intercostal space above or below the planned site.
4. Blunt Dissection: Perform blunt dissection between intercostal muscles, and penetrate the pleura bluntly. Identify the correct access using your finger.
5. Tube Insertion: Insert the drainage tube (helped by artery forceps) in the desired direction, up to the marked site.
6. Suture Fixation: Secure the tube with a Donati stitch near the tube’s entry point, then connect to suction (closed system with 10 – 20 cm water column).
7. Sterile Dressing: Apply sterile dressing.
8. X-ray: Confirm tube placement and rule out pneumothorax.

Important Notes:

• Using a trocar for tube placement can lead to complications (e.g., organ perforation), and should only be used in exceptional situations.
• Infection Prevention: Always work sterilely.
• Avoid Lung Injury: Instruct the patient to exhale during the procedure and avoid inhalation. For ventilated patients, ensure to interrupt positive pressure to reduce lung expansion and minimize the risk of lung injury.
• Vessel/Organ Injury: Always dissect along the upper edge of the ribs. Do not dissect medially in the midclavicular line (risk of internal thoracic artery injury). Avoid the area above the nipple line in the lateral approach (risk of brachial plexus and large vessels).

Duration of Drainage:

• Suction is continued until lung re-expansion is complete and air leak or secretion ceases.
• Once re-expansion is confirmed, clamp the drain and leave it clamped for 12 hours. Perform an X-ray. If fully re-expanded, the drain can be removed (see below). A second X-ray is performed 24 hours after removal.

Drain Removal:

• Remove the fixation sutures and pull the drainage tube swiftly. Ask the patient to perform a Valsalva maneuver (hold the nose and close the mouth tightly) just before and during the removal.
• Follow up with an X-ray.

Pleurodesis:

Indications:

• Palliative therapy for recurrent malignant pleural effusion or recurrent pneumothorax (when surgery or thoracoscopy is not possible or is refused).

Procedure:

1. Insert a thoracic drain or pleural catheter with continuous suction (pressure around 20 cmH2O) until the effusion is completely drained.
2. Clamp the drain. Administer an analgesic (e.g., Dolantin 1/2 to 1 amp. IV).
3. Administer a local anesthetic (150 mg lidocaine, diluted with 50 ml NaCl 0.9%) through the drainage tube.
4. Change patient positions every 5 minutes (supine, right side, left side, and prone).
5. Instill tetracycline (500 mg in 50 ml NaCl 0.9%) via the drainage tube. Flush with 10 ml NaCl 0.9%.
6. Change the patient’s position every 30 minutes.
7. Continue suction drainage. Repeat the medication installation if daily fluid output exceeds 100 ml/24h. If output is 50 ml/24h, remove the drain (usually after 5-7 days).

Alternative Methods:

• Pleurodesis can also be performed using talc (3-5 g talc in 100 ml NaCl 0.9%) or cytostatics like Mitoxantrone or Bleomycin.