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Intercostal drainage

Intercostal drainage . Dr. S. Parthasarathy MD., DA., DNB, MD ( Acu ), Dip. Diab . DCA, Dip. Software statistics PhD(physiology) Mahatma Gandhi medical college and research institute, puducherry , India . Definition . Insertion of a drainage tube into the pleural cavity Why ?

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Intercostal drainage

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  1. Intercostal drainage Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD(physiology) Mahatma Gandhi medical college and research institute, puducherry, India

  2. Definition • Insertion of a drainage tube into the pleural cavity • Why ? • To drain • Air, • Fluid , • Blood • – sometimes to inject drugs

  3. Why we should drain such things ? Lungs expand

  4. This is what we do !!

  5. Indications • Pneumo – any ventilated patient , • recurrent pneumothorax, • tension ,large sec. pneumothorax, • surgeries, malignant effusions, • traumatic hemopneumothorax, • Empyema, flail chest req. ventilation

  6. White out or black out • Beware of bulla or severe collapse

  7. CONTRAINDICATIONS I • Need for immediate thoracotomy

  8. Where ? • A thoracentesis usually at bedside • chest drainage system system is hooked up to allow for continuous drainage of either air, blood, or fluid. Often – as Emergency- well below chest level • If goal is to remove air?- upper anterior chest, 2-4 intercostal space (catheter is inserted) • If goal is to remove fluid/blood?-lower lateral chest 8-9 intercostal space (catheter inserted) ?? Previous

  9. Its all “A”s • AIR • ABOVE • ANTERIOR

  10. Safe triangle- 1.latismus dorsi , 2.Pect. Major, 3.nipple line

  11. Equipment • Under water sealed drain system (UWSD) • Tray • use smaller size for draining air • larger size for draining blood/fluid • Newborn 8-12 FG, Infant   12-16 FG  • Child  16-24 FG, Adolescent 20-32 FG

  12. Technique • sitting position at 45 degrees with arm of same side placed above head • 3 or 4 ICS • Anterior – anterior to ant axillary line • Skin after LA – upper border of rib • "Blunt dissect" to reach pleura

  13. Technique • Sweep with gloved finger • Hold the tip of the catheter with a curved artery clamp and advance it into the pleural space, directing the catheter posteriorly and superiorly. • All holes inside • Attach to underwater seal below chest level • Suture and anchor • w/f swinging water

  14. Check and maintain • No big dressings • With inspiration water will rise up into the chest tube, with expiration, water will fall. If the swing is less than 2 cm, the lung is not likely to be fully expanded and therefore suction may need to be increased

  15. Maintenance • “tidaling” • fluctuate gently up and down with each ` inspiration/expiration Tidaling stops – lungs reinflated constant or vigorous “bubbling” occur please check for a “leak” something is wrong

  16. TIPS • If no air or fluid comes, use gadgets except tension pneumothorax • Flouro, Xray, USG • No force used • Small gauge catheter – ok , seldinger technique is acceptable • Simple linear stitch

  17. Never clamp ICD • Because somebody may forget to remove the clamp and a tension pneumothorax may develop. • Two tubing clamps should be left at the patients bedside to clamp the tube • in emergency , if the tubing became dislodged from the chest tube bottle and air is at risk of entering the chest cavity.

  18. Tips • large pleural effusion should be controlled to prevent the potential complication of re-expansion pulmonary oedema • No clamping prior to removal • small chest tubes and a Heimlich flutter valve – OP management

  19. Heimlich flutter valve

  20. One is ok but fluid comes

  21. Three bottle concept

  22. Multifunction ICD -- adults and infants

  23. When to remove • •In the presence of an air leak the drain should not be removed unless another drain remains • •In general a period of 48 hours after the last bubble is safe. • •In the presence of fluid, remember that 100-200cc normally drain from a pleural drain. Otherwise once the drainage is less than 150cc it may come out. • •Exceptions include the presence of pus (empyema), lymph (chylothorax) or a residual cavity

  24. Complications • Pain • Thoracic or abdominal visceral trauma • Tension pneumothorax • Inadequate - subcutaneous emphysema • Position change

  25. Thank you all

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