Intercostal drainage tube

Intercostal drainage tube

1. INTERCOSTAL DRAINAGE TUBE Submitted By:- Nahid Roll No:- 17BPT024 BPT 4 th year Submitted To:- Dr. Jamal Ali Moiz

2. Introduction An intercostal drain (also known as a chest drain or pleural drain) is a flexible plastic tube that is inserted through the chest wall into the pleural space. It is used to drain pneumothoraces or effusions from the intrathoracic space. .

3. Principle of working The idea is to create a one-way mechanism that will let air/fluid out of the pleural space and prevent outside air/fluid from entering into the pleural space. This is accomplished by the use of an underwater seal. The distal end of the drainage tube is submerged in 2cm of H2O. Air is eliminated from the pleural space into the drainage chamber when intrapleural pressure is greater than +2cm H20. Thus, air moves from a higher to lower pressure along a pressure gradient. The drainage chamber has a vent to allow air to escape the chamber, and not build up within the chamber. Fluids will drain by gravity into the drainage chamber, and will not spill back into the pleural space if the bottle is always kept below the level of the patient's chest .

4. Preparation, patient positioning, and local anesthesia Explanation of the procedure, written informed consent from patient, except in emergency situations. A recent chest radiograph should be taken. F irst step involves positioning the patient according to the location chosen for drain insertion. Ideally, chest tubes should be inserted at the 4th–5th intercostal space anterior or mid-axillary line. T he patient is positioned supine, lying on the bed at 45°–60°, slightly rotated, and with the ipsilateral arm behind the neck or over the head. The British Thoracic Society (BTS) guidelines indicate that the insertion within the area known as the “safe triangle.”

5. The lateral decubitus position with the affected hemithorax upmost is also possible, but many times it is not tolerated by patients with massive pleural effusions. If the patient has a posterior loculated fluid collection (e.g., empyema), he/she will be in a seated position with the physician standing behind. Finally, in patients with pneumothorax, the second intercostal space in the mid-clavicular line (Monaldi position) has long been suggested as an alternative site A. Supine position with ipsilateral arm over head. B. Supported sitting C. Lateral decubitus position

6. Types of techniques SBCT are placed using the Seldinger technique, which a guide wire is inserted into the pleural space through an introducer needle. Then, the needle is removed and dilators are threaded over the wire using a slight twisting action. Afterwards, the chest tube is threaded over the guide wire and into the pleural space. LBCT (>24F) can be inserted by blunt dissection or the trocar technique. It requires an incision of the skin and subcutaneous tissue large enough to allow the introduction of a finger into the pleural space in order to avoid or break down pleuro-pulmonary adhesions and ensure proper chest tube positioning.

7. Procedure Bedside ultrasound (US) should be used to mark the entry point for all chest tubes in patients with pleural effusions in order to prevent incorrect placement and reduce risk of accidental organ injury associated with the procedure Chest tube insertion is a full aseptic technique; therefore, sterile gloves, gowns, surgical mask, and drapes should be used.  Close 3-way tap once position confirmed and suture drain in place This needs to be firm but not pinch the skin or occlude the drain Dress the drain so the insertion sight is visible Attach drain to chest drain tubing

8. Indications Pneumothorax Pleural effusions Hemothorax Chylothorax Thoracic, cardiac, or esophageal surgery Thoracoscopy Contraindications Coagulopathy P ulmonary adhesions from previous surgery, pulmonary disease, and/or trauma Diaphragmatic hernia

9. Complications Malposition of the chest tube Hemothorax Lung injury (laceration, bronchopleural fistula) Diaphragm injury Cardiac and great vessel injuries Esophageal injury Thoracic duct injury (chylothorax) Injury to abdominal organs (stomach, liver, spleen, bowel) Chest tube site infection Emphysema Tube occlusion Phrenic nerve palsy

10. Physiotherapy management As a part of physiotherapy objective assessment it is important to examine the intercostal drainage. Aspects of intercostal drainage examination:- Swinging- During inspiration a more negative intrapleural pressure causes the fluid to rise up in tube of drainage chamber. Similarly, during expiration a less negative intrapleural pressure causes the fluid to move down the tube. Bubbling- Presence of bubbles in underwater sealed chamber indicates an air leak. Drainage- Amount and color of drained fluid should be observed. Pain

11. Pain Management TENS:- TENS around the incision site with alternating low and high frequency current for 20-30 minutes for 2-3 times a day. Cryotherapy:- Ice pack application over incision. Ice pack during huffing/coughing and deep breathing exercises. Positioning Proper and early positioning enhances proper ventilation, less strain on incision and less strain on the affected area and breathing muscles. Early upright sitting Lateral side lying with operated lung on top position

12. Wound support Support the patient’s intercostal drain sites with firm but gentle pressure, taking care not to press directly on the drain site. This reduces pain and allows the patient to breathe in deeply and/or to cough with little discomfort.  One method involves the physiotherapist standing on the contralateral side, with one hand placed on the anterior chest wall to stabilize the incision from the front, and the other hand placed on the posterior chest wall to stabilize the incision from behind, while at the same time the physiotherapist’s forearms stabilize the entire chest.

13. The patient can support by placing the hand of the un-operated side across the front of the thorax as far as possible, resting firmly over the incision and drain sites, while the other hand reinforces the back of incision. Assisted huffing/coughing is taught to the patient while supporting the wounds. Deep Breathing Exercises Deep breathing exercises improves ventilation and oxygenation, prevent basal atelectasis, re-inflate collapsed lung regions, and reverse minimal postoperative atelectasis R ecommended protocol is 5 deep breaths with a 3-second end-inspiratory hold per every waking hour.

14. Mobilization Mobilization on the first postoperative day can begin by having the patient sit on the edge of bed or in a chair out of bed, and then taking short steps to walk around the bed. All patient's connections should be checked before mobilization and/or ambulation, and care should be taken not to pull any of the patient’s drains, or tubes. Ambulation should start low and go slow; that is, to start with sessions that are short (i.e., 3–5 minutes), more frequent (i.e., 2–3 times/day), and relatively non-intense. T he patient must receive appropriate analgesia prior to ambulation because chest drains can cause severe pain, limiting the patient’s ability to ambulate and to cooperate with the physiotherapy.

15. S ymptoms of tachypnea, dyspnea, increased use of the accessory muscles, orthopnoea, a restless or increased heart rate, or cyanosis may indicate malfunctioning of the drain system.  Care should also be taken that the patient keeps the drainage system upright and below the level of the patient’s chest by least 0.5 m during all mobilization activities.  Mobilization activities for patients who are connected to wall suction include bed-side marching on the spot or doing steps up on a fixed single step. If tube gets disconnected a sk patient to exhale and press gauze against the wound at end exhalation and call for medical help.

16. Exercises Active -assisted or active ROM exercises for the shoulder (e.g., arm elevation) within pain limits can be starterted. The scapula on the operated side can be mobilized gently through its full range of protraction, retraction, elevation, and depression, while the patient is in the side-lying position. These exercises need to be performed 3–4 times daily. S houlder abduction and external rotation are initially avoided to prevent increased stress on the incision. Non-resistance leg exercises (i.e., quadriceps and ankle exercises) can be started on the first postoperative day to minimize circulatory stasis.

17. References Anitha N, Kamath SG, Khymdeit E, Prabhu M. Intercostal drainage tube or intracardiac drainage tube?.  Ann Card Anaesth . 2016;19(3):545-548. doi:10.4103/0971-9784.185561 Ahmad AM. Essentials of Physiotherapy after Thoracic Surgery: What Physiotherapists Need to Know. A Narrative Review.  Korean J Thorac Cardiovasc Surg . 2018;51(5):293-307. Porcel JM. Chest Tube Drainage of the Pleural Space: A Concise Review for Pulmonologists.  Tuberc Respir Dis (Seoul) . 2018;81(2):106-115. Merkle A, Cindass R. Care Of A Chest Tube. [Updated 2020 Nov 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;Jan 2020