We know that critical procedures are rare in clinical practice but that when they do need to be done they need to be done right. Whether for relieving a haemo-pneumothorax or a large empyema it is incumbent upon us to know what to do when the need arises. With the exception of our South African colleagues, most of us may only ever insert a chest drain every other year. So let’s take a look at what you need to know with the help of this paper from the trauma team at the Royal Children’s Hospital in Melbourne.
Teague WJ, Amarakone KV, Quinn N. Rule of 4s: Safe and effective pleural decompression and chest drain insertion in severely injured children. Emergency Medicine Australasia. 2019 Apr 30.
Why do a chest drain?
When blood, pus or air fill the pleural space they disrupt the normal negative intrathoracic pressure leading to unopposed elastic recoil of the lung and thus collapse. When a chest drain is inserted blood, pus or air can drain to the outside world allowing re-expansion of the lung.
Although, as a whole, penetrating chest injuries are rare in children, the rising incidence of knife crime means that that the management of penetrating chest injuries is something that we are gaining more experience with. Blunt thoracic injuries are uncommon in children with 204 cases reported in Victoria over a 5 year period. These were overwhelmingly as a result of motor vehicle accidents.
In my part of the world, there has been an increase in the number of cases of massive empyema. These often seem to develop as a simple parapneumonic effusion (from Staph. pneumoniae), before developing interleaving septae and then becoming a loculated collection of lung custard. As the lung fills respiratory embarrassment becomes outright failure and cardiovascular instability. These children benefit from early drainage, prior to transfer if PICU is not available on-site, although whether this is best achieved via thoracocentesis or formal chest drain is still up for debate.
The pleural space is a virtual space until it becomes filled with either fluid or air. Whilst most pneumothoraces can be managed with either a conservative watch-and-wait approach, simple aspiration or insertion of a pigtail drain they do occasionally need insertion of a more formal intercostal drain.
How often do we do them?
When Nguyen and Craig looked at how often emergency paediatricians performed critical procedures across their network they found that only three were placed over the entire year. I’m sure our colleagues in South Africa have much more experience than I ever will ever get in this area of practice.
Rule of 4s
The paper describes an aide-memoire for the time-poor clinician – handily titled the “The Rule of 4s“.
- 4 steps in a good plan
- 4th (or 5th) intercostal space as the basis for a ‘good’ hole
- 4 x uncuffed ET tube size as a guide to a good sized chest tube
- 4cm mark for a good stop
As big fans of using infographics to get complex points across it is great to see Teague et al. take that on board. It is well worth taking the time to read through the whole article as it discusses some of the finer points of inserting an intrapleural drain.
How to secure them
Perhaps you have been taught that a purse-string is the way to go (it’s not) or perhaps you have spent some time in South Africa and have become a fan of the Jo’Burg knot as demonstrated by Neel Bhanderi.
One thing remains true – chest drains must be securely fastened before they get the chance to ‘fall’ out. That means sutures, an appropriate sandwich dressing and a mesentery of tape to take the strain in case someone pulls at the drainage tube.
What can possibly go wrong?
Sticking a needle in somebodies chest is not without risk. Even when I qualified from medical school the trocar method of inserting a drain was falling out of favour. Many a surgeon took them home to use in the garden rather than relegate them to the recycling bin.
Immediate complications include the following:-
- damage to underlying structures e.g. thoracic duct, lung, oesophagus, stomach (rare unless there is an undiagnosed diaphragmatic injury)
- bronchopleural fistula formation
- recurrent pneumothorax
- intercostal artery haemorrhage
- re-expansion pulmonary oedema
Delayed adverse events include:-
- Horner’s syndrome
What should you do if…
…it stops swinging?
If that spirit level like bubble stops swinging it may mean that the tube is kinked or compressed in some way. I’ve seen it happen as the tubing has been passed through the cot sides and been squashed as the side has been put down so be mindful.
…the drain stops bubbling?
Generally, this is a good thing as it means the air has drained out of the pleural space and the lung has re-expanded. You want to be more concerned when it continues to bubble and bubble and bubble as that would suggest a persistent air leak. If it seems to bubble more than a hookah pipe then you need to get out your trusty clamps to figure out where the leak is. If, when you clamp near the point of insertion, the bubbling stops then the problem must be either in the lung or at the insertion site (perhaps one of the eyelets has migrated outside?). If that fails to isolate the cause then you can work your way down to the collection chamber until the bubbling stops and you have found your leak/disconnect.
…it falls out?
If it’s just the connection between the drain and the tubing connecting to the underwater seal it is time to clamp the tube to prevent air going the wrong way, i.e. back into the chest, and causing a pneumothorax before fixing the problem.
If the whole drain falls out then cover up the hole with an occlusive dressing and decide if you actually need one in the first place. If another one is required it should go through a new incision.
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