A chest drain may be inserted into the pleural cavity to clear it of blood or air, and except in an acute tension pneumothorax, should be preceded by a plain chest x-ray.
Any site between the fourth and seventh intercostal spaces, and between the mid-axillary and anterior axillary lines may be used. This avoids the risk of traumatising the great vessels or the heart. A common location is in the fifth intercostal space in the mid-axillary line but consult the x-ray beforehand if possible - intrapleural adhesions occur in about 15% of patients, and should be avoided as they obliterate the pleural space and result in the drain transfixing the lung.
Use a large Argyll chest drain - at least size 28 - anything smaller may occlude with blood clot.
In conscious patients, infiltrate the periosteum on the upper border of the rib at the chosen site with local anaesthetic - usually 10 to 15 ml lignocaine. Advance the needle above the rib and infiltrate the pleura.
Use a scalpel to incise the chest wall about 2 cm beneath the proposed site of insertion and complete the drain track through to the pleural cavity by blunt dissection with artery forceps. With one finger, explore the pleural cavity then slide the drain in - directed posteriorly and superiorly. Blood or air flash-fills the drain. Suture in position.
Connect the drain to an underwater seal. This applies negative pressure and ensures evacuation. A suction machine may be necessary if large volume suction is required. Ask the patient to cough - air bubbles in the water confirms that the drain is in position and is working.
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