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1. INTERCOSTAL TUBE DRAINAGE

2. TUBE THORACOSTOMY It is the method of draining fluid/blood/air collected in the pleural cavity safely, so as to allow the underlying lung to expand.

3. ANATOMY

4. INDICATIONS Haemothorax , hydrothorax, chylothorax Pneumothorax; Haemopneumothorax Empyema thoracis Traumatic lung contusion After thoracotomy, to drain pleural cavity

5. Instrument Tube - Chest or intercostal tube or drain Chest tube is made up of clear plastics or PVC; It has multiple fenestrations on the side which resides inside the thoracic cavity. It has got a radio-opaque strip. Silastic channel styled chest drains ( Blake drains ) which drain through capillary action and suction; it is less painful.

6. Site of Insertion

7. Triangle of safety : The safe zone as-bounded by Anteriorly - lateral border of pectoralis major , Superiorly - a horizontal line inferior to the axilla, Laterally - anterior border of latissimus dorsi Inferiorly – Horizontal line superior to the nipple Tube is inserted into the 5 th intercostal space slightly anterior to the midaxillary line. In pneumothorax – 4 th intercostal space In haemothorax or empyema – 6 th intercostal space. In this point muscle bulk is less and so easy to pass the intercostal tube.

8. Procedure Position : Patient is kept in supine (with head end up if possible 45°) position. Arm should be abducted and externally rotated Palm of the hand is kept over the patient’s head . Cleaning and draping is done. Local anaesthesia xylocaine 1% or 2% is injected at the site of insertion of the tube in the space under the skin, muscle and to parietal pleura. Horizontal skin incision is made, 4 cm in length

9. Site is just above the rib , i.e., in the lower part of the intercostal space so as to avoid injury to neurovascular bundle which are located in the groove in the lower part of the rib close to the upper part of the intercostal space. F ascia and intercostal muscles are opened and separated A dequacy - confirmed using finger tip Structures pierced Tube is gently forced across the parietal pleurae which gives a ‘ given way ’ feel.

10. Fenestrated end of the selected chest tube No. 28 in adult No. 18 in children No. 12 in infants No. 10 in neonates Held firmly using long curved haemostat ( Kelly's clamp ) Outer end is clamped which will be released later.

11. Drainage canister is used to collect the blood, air, fluid through a water seal apparatus. Triple chamber canisters are often used for better function; 1st chamber collects the fluid content. 2 nd chamber acts as water seal which allows the air escape acting as one way valve; it also indicates the air leak from pleura or lung. 3rd chamber is the suction control chamber; height of water column in this regulates the negative pressure so controls the suction system. Only water seal and water column regulator system is ‘ wet ’ type water seal with mechanical regulator is ‘ wet-dry type ; system without water seal but uses mechanical check valve and mechanical regulator is called as ‘ dry ’ system.

12. Air or blood or fluid will pass through the tube; tube is connected to under water seal apparatus which should be filled with sterile normal saline up to the mark in the canister. ICT is sutured to the skin using nonabsorbable polyethylene suture , often additional suture bites are taken around and kept untied which will be tied immediately firmly after removal of the ICT (central vertical mattress suture-sealing suture). Airtight plaster dressing is placed around to keep the ICT in position. Check chest X-ray should be taken immediately to assess the position of the ICT. Movement of the air column during respiration should be checked; quantity of fluid or blood collecting also should be observed. O 2 supplementation is often needed; patient should be monitored throughout. Canister or bag should be kept 100cm below the patient level. Trocar ICT or guide wire directed ICT placement is also used in few centres but they are not popular.

13. Postoperative Care ICT care is crucial. Movement of the column, quantity of fluid collected should be observed. Mechanical manipulation (tapping, milking) gently may be done to correct kinking, clot inside or to facilitate free flow of fluid but they are painful. Closed chest tube clearing device using sterile magnetically wired loops can prevent clogging and blocking of the tube so as to prevent formation of retained blood syndrome ( haemothorax , pleural effusion, tamponade , atrial fibrillation).

14. Postoperative care Lung expansion should be checked at regular intervals. Usually ICT is placed for 3-5 days for pneumothorax until lung expands adequately which should be confirmed by chest X-ray, F or haemothorax for 4-7 days . For bronchopleural f istula ICT should be kept for longer period. Respiratory physiotherapy using spirometer or football balloon and breathing exercise should be done.

15. ICT Removal It is done once chest X-ray confirms that lung gas has expanded properly . Pleural fluid drain becomes serous and < 25 mL/day f or 3 consecutive days, water column movement becomes < 1 cm . It is removed under all aseptic precaution Suture is removed Patient is asked to take deep inspiration ; often outer end of the tube may be connected to low volume suction. At the summit of deep inspiration, tube is pulled out, wound is cleaned quickly and if sealing suture is present it should be tied firmly, sealed plaster dressing is placed to avoid re-entry of air into the pleural cavity .

16. Contraindications Traumatic diaphragmatic hernia Refractory coagulopathy
Pleural adhesions
Emphysematous bullae

17. Complications Clogging of the ICT (40%) is the main complication. It can cause retained blood syndrome, tension pneumothorax, effusion, haemothorax . Injury to intercostal nerve and vessels , diaphragm, liver, spleen, aorta and heart can occur. Improper placement of the tube. Re-expansion pulmonary o edema - if large quantity of fluid or pus drained in effusion or empyema, it may cause sudden onset cough, breathlessness and respiratory arrest (potentially fatal). In such situation gradual decompression is better.

18. Complications Subcutaneous haematoma S eroma S ubcutaneous emphysema Displacement, pain I ntercostal neuralgia D yspnoea, cough I nfection

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