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Paediatric Chest Drains


We know that critical procedures are rare in clinical practice but that when they do need to be done, they must be done right. Whether we are relieving a haemo-pneumothorax or a large empyema, it is incumbent upon us to know what to do when the need arises. Except for our South African colleagues, most of us may only ever insert a chest drain every other year. So let’s 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 insert 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.

Reasons for putting in a chest drain


Although, as a whole, penetrating chest injuries are rare in children, the rising incidence of knife crime means 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 five years. These were overwhelmingly as a result of motor vehicle accidents.

Massive empyema

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 causes cardiovascular instability. These children benefit from early drainage before transfer if PICU is unavailable on-site, although whether this is best achieved via thoracocentesis or formal chest drain is still debatable.


The pleural space is a virtual space until it becomes filled with fluid or air. While most pneumothoraces can be managed with a conservative watch-and-wait approach, simple aspiration, or the insertion of a pigtail drain, they do occasionally need the 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 will ever get in this area of practice.

Rule of 4s

The paper describes an aide-memoire for the time-poor clinician 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 reading through the whole article as it discusses some of the finer points of inserting an intrapleural drain.

Infographic for safe insertion of chest drains - the rule of fours

What is the best way to secure a chest drain?

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 can ‘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 are the complications of chest drain insertion?

Sticking a needle in somebody’s chest is not without risk. Even when I qualified from medical school, the trocar method of inserting a drain fell 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
  • chylothorax
  • re-expansion pulmonary oedema

Delayed adverse events include:-

  • infection
  • empyema
  • Horner’s syndrome

What should you do if…

…the chest drain stops swinging?

If that spirit-level-like bubble stops swinging, it may mean that the tube is kinked or compressed somehow. I’ve seen it happen as the tubing has been passed through the cot sides and squashed as the side has been put down, so be mindful.

…the drain stops bubbling?

Generally, this is good because 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, as that would suggest a persistent air leak. If it seems to bubble more than a hookah pipe, you need to get out your trusty clamps to figure out where the leak is.

If the bubbling stops when you clamp near the point of insertion, 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, you can work your way down to the collection chamber until the bubbling stops and you have found your leak/disconnect.

…the chest drain 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 from going the wrong way, i.e. back into the chest, and causing a pneumothorax before fixing the problem.

If the whole drain falls out, cover 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.

Selected References

Balfour-Lynn IM, Abrahamson E, Cohen G, Hartley J, King S, Parikh D, Spencer D, Thomson AH, Urquhart D. BTS guidelines for the management of pleural infection in children. Thorax. 2005 Feb 1;60(suppl 1):i1-21.

Brandt, M.L., Luks, F.I., Lacroix, J., Guay, J., Collin, P.P. and Dilorenzo, M., 1994. The paediatric chest tube. Clinical intensive care: international journal of critical & coronary care medicine5(3), pp.123-129.

Course CW, Hanks R, Doull I. Question 1 What is the best treatment option for empyema requiring drainage in children?. Archives of disease in childhood. 2017 Jun 1;102(6):588-90.

Kwiatt M, Tarbox A, Seamon MJ, Swaroop M, Cipolla J, Allen C, Hallenbeck S, Davido HT, Lindsey DE, Doraiswamy VA, Galwankar S. Thoracostomy tubes: a comprehensive review of complications and related topics. International journal of critical illness and injury science. 2014 Apr;4(2):143.

Laws D, Neville E, Duffy J. Pleural Diseases Group SoCCBTS. BTS guidelines for the insertion of a chest drain. Thorax. 2003;58(Suppl 2):i53-9.

Mehrabani D, Kopelman AE. Chest tube insertion: a simplified technique. Pediatrics. 1989 May 1;83(5):784-5.

Playfair GE. Case of empyema treated by aspiration and subsequently by drainage: recovery. Br Med J 1875;1:45.

Porcel JM. Chest tube drainage of the pleural space: A concise review for pulmonologists. Tuberculosis and respiratory diseases. 2018 Apr 1;81(2):106-15.

Samarasekera SP, Mikocka-Walus A, Butt W, Cameron P.  Epidemiology of major paediatric chest trauma.  J of Paediatrics and Child Health.  2009; 45: 676-680

Shoseyov D, Bibi H, Shatzberg G, Klar A, Akerman J, Hurvitz H, Maayan C. Short-term course and outcome of treatments of pleural empyema in pediatric patients: repeated ultrasound-guided needle thoracocentesis vs chest tube drainage. Chest. 2002 Mar 1;121(3):836-40.

Stather P, Cheshire H, Bogwandas H, Peek G. Pneumothorax post paediatric chest drain removal. The Thoracic and cardiovascular surgeon. 2011 Aug;59(05):302-4.

Strachan R, Jaffé A. Assessment of the burden of paediatric empyema in Australia. Journal of paediatrics and child health. 2009 Jul;45(7‐8):431-6.

Strutt J, Kharbanda A. Pediatric Chest Tubes And Pigtails: An Evidence-Based Approach To The Management Of Pleural Space Diseases. Pediatric emergency medicine practice. 2015 Nov;12(11):1-24.

Tovar JA, Vazquez JJ. Management of chest trauma in children. Paediatric respiratory reviews. 2013 Jun 1;14(2):86-91.

Walcott-Sapp S. A history of thoracic drainage: from ancient Greeks to wound sucking drummers to digital monitoring.



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1 thought on “Paediatric Chest Drains”

  1. Hi
    I am happy paediatric chest trauma is rare. If I advance the drain to 4 cm – then the last hole is 4 cm below skin surface – which may still may be outside of pleural space in an obese child. Shouldn’t the depth vary with thickness of subcutaneous tissue ? Is the rule of 4’s trying a bit too hard?