Paediatric Chest Drains

 Although chest drain insertion may be rare in clinical practice, when it is done, it needs to be done right; this article provides some top tips on the what, why, and how of paediatric chest drain insertion.

Theodore is an 8-year-old boy involved in a motor vehicle collision.

He was intubated at the scene with a size 6cm cuffed endotracheal tube for reduced GCS.  He arrives at your resuscitation room in your emergency department via your pre-hospital emergency medicine team. 

On a primary survey, it is noted that he is becoming tachycardic and hypoxic, with tracheal deviation to the right side, a hyper-resonant chest to percussion on the left side of the chest, and reduced air entry on auscultation of the left side of the chest.

You correctly diagnosed a tension pneumothorax, proceeded with needle decompression, and then chose to continue with chest drain insertion once he is stabilised. 

What is a chest drain?

There is a potential space between the lining of the lungs (visceral pleura) and the lining which covers the chest wall, diaphragm, and mediastinum (parietal pleura). This space can become filled with air, blood, or pus, which can cause excessive pressure on the lungs and heart and impair their function.

Simply put, a chest drain is a tube inserted into the pleural space to remove air, blood, or pus. They come in various sizes and can be inserted in two different ways.

They are an open technique and the Seldinger technique.

An open technique with large bore drains is generally used in trauma where thick and viscous fluids, e.g. blood (haemothorax), could clog up a smaller tube.

The Seldinger technique uses smaller bore drains, typically to remove air from the pleural space (pneumothorax).

Historically, a third technique, the trocar method, was used. This is now long out of fashion due to the risk of complications.

In this blog post, we will cover both techniques, but the Seldinger technique has repeatedly been shown to have much lower serious complication rates and lead to lower pain scores than the open technique.  Nevertheless, the open technique is still the required technique in suspected haemothorax in trauma patients. 

Why do we insert chest drains?

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 the lung to reexpand.

Blood

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.

Air

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 a more formal intercostal drain.

Massive empyema

In Australia, 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.

How do we place a chest drain?

Whether we are relieving a haemopneumothorax or a large empyema, we must know what to do when the need arises.  

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.  This study looked at three EDs of a single Victorian Health network over 12 months with 54,633 paediatric presentations.  Only 53 “critical procedures” were performed, three of which were chest drains.  Except for our South African colleagues or those of us walking in busy inner city major trauma centres, most of us may find we are only inserting a chest drain every other year.

Regardless of the insertion technique, the chest drain is placed in the triangle of safety (a triangle formed by the border of the outside edges of the pectoralis major and latissimus dorsi muscles above the fifth rib) and inserted so that it avoids the bundle of nerves and blood vessels below each rib. In the video below, Dani Hall gives us her top tips on inserting a trauma chest tube.

Below, we have also provided a step-by-step guide on inserting a Seldinger chest drain:

1. Obtain chest tube set and tray.

2. Choose the appropriate chest tube size (4x ETT size).

3. Review CXR before the procedure.

4. Identify the insertion site via ultrasound (ensure the distance from the liver, kidneys, spleen, or heart).

5. Prepare chest tube insertion site with antiseptic solution and sterile drapes in standard fashion (sterile gown, gloves, head and face mask).

6. Consider a local anaesthetic (e.g., lignocaine; remember: 1% = 10mg/ml, maximum lignocaine dose 5 mg/kg without adrenaline).

7. Attach the introducer needle to the syringe and advance slowly and carefully the needle over the superior border of the rib into the pleural space. Fluid or air should be aspirated to verify intrapleural position.

8. When the appropriate drainage site and depth have been identified, de-attach the syringe and slowly introduce the guidewire’s J-tip: the guidewire should pass through and into the pleural space without any resistance!

9. Remove the needle, but leave the wire in situ.

10. While maintaining the wire position, dilate the tract using the supplied dilator (hold the dilator always at the tip, next to the skin, and rotate it carefully to prevent the wire from kinking).

11. Remove the dilator, keep the guidewire in situ, and advance the chest tube slowly into the pleural space (if there is any resistance, ensure the guidewire is still in situ and re-dilate the skin/pleural opening, if necessary).

12. Remove the guidewire, leaving the chest tube in situ.

13. Use sutures to secure the chest tube.

14. Attach 3-way tap and connect the tip of the chest tube via connector to a chest tube (use minimal suction – 10 cmH2O).

15. CXR to confirm position and success!

16. Always observe ventilation pressures and oxygen levels before, during and after the procedure.

How about an aide memoire; the rule of 4s

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.

Teague et al. created a reminder for the time-poor clinician titled “The Rule of 4s“. 

As discussed earlier in Nguyen and Craig’s paper, paediatric chest drain insertion is rare.  This, combined with the undoubtedly highly stressful environment that a paediatric trauma creates even when experienced clinicians are present, means a simple “rule of 4” can be an aide memoire for all grades of clinician:

• 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

We are big fans of infographics to convey complex points, so it is great to see Teague et al. take that on board. The whole article is well worth reading as it discusses some of the finer points of inserting an intrapleural drain.

Using the “Rule of 4s”, you consider the four steps; select a size 24Fr chest tube and insert the tube into the 4th intercostal space between the anterior and mid axillary lines on the left side of Theodore’s chest.  You advance the tube until the last side hole is 4cm inside his chest cavity.  You secure the chest drain and observe the drain to be swinging and bubbling. 

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.

As you insert Theodore’s chest drain, you observe an unexpected amount of fresh blood as you dissect through layers of tissue.  However, with time and some pressure, this bleeding stops.  You realise that you have mistakenly made your incision just below a rib and have likely caused an intercostal artery haemorrhage. 

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.

…if losses are >10 ml/kg/hr in a postoperative patient?

Notify the surgeons immediately. 

In the first two hours, losses may be up to 5 ml/kg/hr; thereafter, they should be less than 2 ml/kg/hr. If losses exceed these levels, check APTT, PT, fibrinogen, platelets, ACT, and TEG and transfuse accordingly.

If significant losses continue, notify the surgeons. 

…you are asked to remove the chest drain?

1. Keep the patient fasted: food/formula 6 hours, breast milk 4 hours, clear fluids 2 hours.

2. Continue monitoring the patient: ECG, SpO2, BP.

3. Ensure all emergency equipment is available.

4. Ensure appropriate analgesia is given (<6 months: 20mcg/kg morphine; >6months: 0.5mg/kg ketamine)

5. Remove the chest drain using an aseptic technique during expiration.

6. Repeat CXR 30 minutes after drain removal to exclude a pneumothorax.

Theodore is stepped down to the ward after three days of intensive care treatment. 

His chest drain is removed on day four of admission and a repeat CXR after removal shows no repeat pneumothorax: your chest drain was a success! 

Take home points

There are two ways to insert a chest drain: open and Seldinger – be familiar with both insertion techniques

Remember the “Rule of 4s” as a helpful aide-memoire.

Adequate fixation of chest drains is essential: sutures and dressings

Complications are common – be aware of immediate and delayed potential complications and know how to troubleshoot them

Chest drains are a HALO (high acuity, low occurrence) procedure: be prepared!

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 medicine, 5(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.