- Is there a risk of leaving the suture in place for later skin closure? Will it become colonised and increase risk of infection when tied on drain removal? Should fresh suture be used at time of drain removal?
- BTS guidelines suggest a horizontal mattress suture around the tube that is loosely tied with a simple knot. After tube removal the knot is untied and the sutured tightened to close the wound, and further suturing is not needed.
- Local trauma and haemorrhage (e.g. intercostal vessel injury)
- Nerve injury (e.g. long thoracic)
- Malplacement, either extrathoracic (obvious on CXR), or intra-thoracic but extrapleural (not obvious on CXR, but extremely painful)
- Subcutaneous emphysema
- Trauma to heart, liver, lung or spleen (e.g. use of trocar, or re-insertion through a recent drain site—never do either of these)
- Infection and empyema
- Re-expansion pulmonary oedema.
- Malposition (as described)
- Air leaks – from skin site, from subcutaneous tube port, from tubing/ drainage system
- Blocked drainage – elevation of drainage bottles with retrograde flow into chest, clots in tubes, kinked tubes
- Find another use for the trocar that is supplied with the chest drain kit!Keep the underwater sealed chest drain below the level of the heart at all times.
- Regularly check that the fluid in the drain is ‘swinging’ with normal respiration. If the fluid level fails to swing at all, initially the chest tube is kinked, blocked or in the wrong place
- How far to insert the tube? Place tip of tube at level of clavicle and check distance to insertion site. A clamp may be place on the tube as a marker.
- The parietal pleura can be tough and penetrating it is painful. Further local anaesthetic may be required. If unable to penetrate with digital pressure a Kelly clamp may be used. Measure the expected depth and hold the clamp at this point to prevent excessive insertion depth, as reasonable pressure may be required.
- Avoid a gaping hole in the parietal pleura as this may lead to subcutaneous emphysema, but it must be big enough to admit the tube and a finger.
- The dissected track and pleural opening is easily lost in the obese patient – leave a finger in the pleural space once the parietal pleura has been penetrated, until the tube is inserted.
- If the tube does not pass freely it is either travelling subcutaneously or you have not made a large enough hole.
- Rotate the tube 360 degrees to reduce the likelihood of kinking.
- If the drain is not obviously swinging or bubbling ask the patient to cough.
- sutures must be tied tightly enough to indent the chest tube slightly to avoid slippage