Paediatric Chest Drains

Cite this article as:
Andrew Tagg. Paediatric Chest Drains, Don't Forget the Bubbles, 2019. Available at:

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.

Chest drains

Cite this article as:
Marc Anders. Chest drains, Don't Forget the Bubbles, 2013. Available at:

If losses >10 ml/kg/hr in a postoperative patient, notify surgeon immediately.

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

If significant losses continue, notify surgeons.

Insertion of chest drains:

Preparation and equipment:

1. Chest tube set and tray.

2. Choose appropriate size.

3. CXR before procedure.

4. Identify insertion site via ultrasound (ensure distance from 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 local anaesthetic (i.e. lignocaine; remember: 1% = 10mg/ml, maximum lignocaine dose 5 mg/kg without adrenaline).

7. Attach introducer needle to syringe and advance slowly and carefully 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 has been identified, de-attach syringe and slowly introduce the J-tip of the guidewire: the guidewire should pass through and into the pleural space without any resistance!

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

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

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

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

13. Use sutures or steri-strips 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. Observe ventilation pressures and FiO2 always before, during and after the procedure.

Removal of chest drains:

Preparation and equipment:

1. Keep patient fastened. Food/formula 6 hours, breast milk 4 hours, clear fluids 2 hours.

2. Continue monitoring: ECG, SpO2, BP.

3. All emergency equipment available.

4. Appropriate analgesia.

Age < 6 month > 6 month
Morphine 20 mcg/kg
Ketamine 0.5 mg/kg
if dysphoric response with Ketamine, consider
midazolam 0.1 mg/kg, can be repeated once


5. Remove drain in aseptic technique during expiration.

6. Repeat CXR 30 mins after drain removal to exclude pneumothorax.

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