Small bore intercostal catheters ≥20 Fr

Includes straight pleural catheters or flexible pigtail catheters. (*New intercostal catheters >20Fr which may be inserted with Seldinger technique are available for use in a limited number of facilities. In this instance, operators should follow local facility protocols and specific manufacturer's instructions.)

• Due to the need to insert a needle into the pleural space blindly, it should only be inserted into the pleural space at a site known to be free of underlying lung or cardiac structures.
• Do not proceed without further imaging if air (pneumothorax) or fluid (pleural effusion) is not confirmed at the time of local anaesthetic infiltration.

Immediately prior to the procedure ensure

• Time Out check has been completed
• baseline observations including SpO2 are taken and recorded
• supplemental oxygen is administered
• the patient has received adequate analgesia
• SpO2 continuous monitoring is in place
• the small bore catheter kit is present.

Insertion site

Wherever available the choice of insertion site for a pleural drain should be made based on real time ultrasound guidance. This may be done immediately prior to the procedure at the bedside (as long as the patient's position during the chest drain insertion remains the same as during the ultrasound) or ultrasound may be performed during the procedure if the machine is appropriately set up before hand and a sterile sleeve is used for the ultrasound probe.

The marking of a site using thoracic ultrasound for subsequent remote aspiration or pleural drain insertion is not recommended.

Where real time ultrasound guidance is not used, the insertion site should only be:

• within the triangle of safety
• above the mid-clavicular line in the second intercostal space (pneumothorax only).

Sterile procedure

Perform hand hygiene: aseptic technique requires operator to use mask, sterile gown and gloves. Apply aseptic skin prep widely around the insertion site and allow three minutes to dry. Drape widely.

Local anaesthetic

• Infiltrate local anaesthetic widely around the insertion site and down to the pleural space.
• Injection of local anaesthetic into the pleura (also allowing confirmation of the presence of air/fluid) is advisable.
• Do not inject again into the tissues once pleural fluid has been aspirated into the local anaesthetic syringe.
• Allow at least five minutes for local anaesthetic to work.

Insertion procedure

(Note: some aspects of insertion will depend on the specific kit used.)

• Attach the needle to the syringe.
• Insert the needle firmly and confirm the position is within the pleural space by aspirating air (pneumonthorax) or fluid (effusion). Then proceed to pass the guidewire through so at least half the wire is in the pleural cavity. Avoid insertion of excess guidewire as this may increase the risk of kinking.
• Remove the assembly needle and pass an 8-14 Fr dilator over the wire to create a tract.
• Be aware that a standard dilator fully inserted can reach mediastinal structures and therefore the dilator should be inserted over the wire only so far as to allow its greatest diameter to have passed through the full chest wall. Chest wall width can and should be measured by real time bedside ultrasound or can be estimated at the time of instilling the local anaesthetic or the kit needle (using the depth of insertion at which fluid or air is aspirated).
• Remove the dilator (leaving the wire in situ) and pass the catheter over the wire into the pleural cavity. Ensure all drainage holes of the catheter are completely within the pleural cavity. Consider using the markers on the catheter to estimate how far the catheter will need to be inserted as this may avoid kinking of the catheter and the subsequent need for removal of sutures and withdrawal of the catheter.
• Remove the guidewire and close the stop cock to ensure that no air enters the pleural cavity.
• Secure the catheter to the skin with a suture and dress with water permeable transparent dressing so the insertion site is visible at all times.
• A suture to close the wound is not usually required for small bore pleural drain.
• When the tube is inserted to drain fluid, inclusion of a three-way tap is possible for some drain types which will facilitate sterile flushing of the catheter.
• Observe the five moments of hand hygiene.

Confirm drain position

A chest x-ray should be performed within one hour and reviewed by the inserting MO within four hours to confirm the tube position and successful drainage of air/fluid.

Document the procedure in patient's medical record and medication chart

• Sedation given and total volume local anaesthetic instilled.
• Depth of insertion and any complications.
• Type of tube inserted including serial number and bar code.
• Method of drain fixation and wound closure.
• Suture or locking mechanisms for removal / to be disabled before removal.