Insertion of a chest tube to drain pneumothorax

Abstract 

Intercostal chest tube drainage with an underwater seal is a simple and effective method to eliminate air in the pleural space. The patient is then positioned lying, shoulder elevated and undressed to the waist, with the arm abducted at 90°. The fourth intercostal space just anterior to the mid-axillary line is usually chosen. The surgical field is prepared with antiseptic solution, and lidocaine is injected to create a transverse wheal to demarcate the length and position of the skin incision. The tip of the scalpel blade is used to make an incision large enough to comfortably admit the index finger. Blunt dissection is undertaken using a Roberts clamp. Once the deep fascia is reached, the intercostal space becomes distinctive. Further lidocaine is used to create a field block by injecting multiple intercostal nerves. After leaving adequate time for the intercostal block to work, the Roberts clamp is then used with gentle but firm pressure spreading the intercostal muscles apart. When the Roberts clamp enters the pleural cavity, a gush of air is normally audible. The jaw of the Roberts clamp is opened to dilate the puncture site, and then followed by the index finger to dilate a tract into the pleural space. Once satisfied that there is no lung tissue adhering to the chest wall, a 28 French gauge drain is introduced into the pleural space without a trocar. Once the drain is sited, it is attached to an underwater seal, and the drain is then secured with a silk suture.

Keywords: chest drain, field block, pneumothorax

• * The ideal size of chest tube is influenced by both the size of the patient and the amount of air leak. Full lung expansion requires chest tube drainage to match the size of air leak. Air drains by a mixture of laminar and turbulent flow (depending on Reynold’s number). Because laminar and turbulent flow rates are proportional to the fourth and fifth powers of the radius, respectively (Hagen–Poiseuille and Fanning equations), it is important to select the largest tube that can comfortably fit within the intercostal space. For further information, see Anaesthesia and Intensive Care Medicine 2006; 7: 98.