Intercostal Chest Drain Research Articles

Survey of major complications of intercostal chest drain insertion in the UK

BackgroundFollowing reports from the National Patient Safety Agency of deaths and serious harm from intercostal chest drains (ICD) we conducted a national survey among chest physicians of their experience of...

INTERCOSTAL CHEST DRAIN (ICD) INSERTION: METHODS AND PITFALLS AND OUTCOMES IN 52 PATIENTS WITH PLEURAL DISEASES

INTERCOSTAL CHEST DRAIN (ICD) INSERTION: METHODS AND PITFALLS AND OUTCOMES IN 52 PATIENTS WITH PLEURAL DISEASES

Routine placement of an intercostal chest drain during video-assisted thoracoscopic surgical lung biopsy unnecessarily prolongs in-hospital length of stay in selected patients☆☆☆

Video-assisted thoracoscopic surgical (VATS) lung biopsy is frequently used in the diagnosis of parenchymal lung disease. However, there is still debate over the need for routine use of an intercostal chest drain after this procedure. This study aimed to evaluate the necessity of positioning an intercostal chest drain as an integral part of VATS lung biopsy. Data from VATS lung biopsies performed over a 5-year period were retrospectively analysed. Patients in whom there was evidence of air leak intra-operatively following lung biopsy were excluded. Patients in whom no air leak was detected on testing were included in this study. A chest drain was inserted solely according to the surgeons' practice. This study included 175 patients. Of these, 82 patients had an intercostal chest drain positioned during the VATS procedure and 93 did not. There were no significant differences between the two groups in terms of mean (standard deviation (SD)), age (54.4 (14.9) vs 55.8 (13.5) years, p=0.58), gender (63% vs 59% males, p=0.56) or side of procedure (45% vs 56% right side, p=0.22). One patient in the 'no drain' group developed a clinically significant pneumothorax 24h after surgery and required a drain to be inserted. There was also no significant difference between the two groups in the incidence of radiologically detected pneumothorax immediately post-procedure (23% vs 20%, p=0.66) or on postoperative day 1 (26% vs 20%, p=0.63). There was no significant difference in the incidence of pneumothorax on follow-up (at 4-6 weeks) chest radiograph (10% vs 7%, p=0.61). In all cases, the pneumothoraces were small and not clinically significant. However, there was a significant difference in the median (inter-quartile range (IQR)) length of stay between the two groups (3 (2,4) vs 2 (1,3) days, respectively, p<0.001). The routine use of an intercostal chest drain after VATS lung biopsy unnecessarily increases the length of hospital stay without reduction in the incidence of pneumothorax.

Complications of tube thoracostomy for chest trauma.

To determine the insertional and positional complications encountered by the placement of intercostal chest drains (ICDs) for trauma and whether further training is warranted in operators inserting intercostal chest drains outside level 1 trauma unit settings. Over a period of 3 months, all patients with or without an ICD in situ in the front room trauma bay of Tygerberg Hospital were included in the study. Patients admitted directly via the trauma resuscitation unit were excluded. No long-term infective complications were included. A self-reporting system recorded complications, and additional data were obtained by searching the department's records and monthly statistics. A total of 3989 patients with trauma injuries were seen in the front room trauma bay during the study period; 273 (6.8%) patients with an ICD in situ or requiring an ICD were assessed in the trauma unit and admitted to the chest drain ward; 24 patients were identified with 26 complications relating to the insertion and positioning of the ICD; 22 (92%) of these had been referred with an ICD in situ. An overall complication rate of 9.5% was seen. Insertional complications numbered 7 (27%), with 19 (73%) positional complications. The most common errors were insertion at the incorrect anatomical site, and extrathoracic and too shallow placement (side portal of the drain lying outside the chest cavity). Operators at the referral hospitals have received insufficient training in the technique for insertion of ICDs for chest trauma and would benefit from more structured instruction and closer supervision of ICD insertion.

Secondary spontaneous pneumothorax: indication for intercostal chest drain insertion?

A patient with chronic obstructive pulmonary disease presented with a history of sudden onset breathlessness and the chest radiograph shown in fig 1. Current guidelines advocate insertion of an intercostal chest drain for …

Intra-pleural fibrinolytic therapy versus conservative management in the treatment of adult parapneumonic effusions and empyema

Pleural effusions and empyema may complicate lower respiratory tract infections. Treatment of these collections of pus includes surgical drainage and the use of intra-pleural fibrinolysis to break down fibrin bands that may cause loculation. To conduct a systematic review of the benefit of adding intrapleural fibrinolytic therapy to intercostal tube drainage in the treatment of complicated para pneumonic effusions and empyema to reduce mortality or the need for subsequent surgical debridement of the pleural space. We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Trial authors were contacted for further information and details regarding the possibility of unpublished trials was requested. The most recent search was conducted in November 2006. All studies in the review were Randomised Controlled Trials in adult patients with post-pneumonic empyema or complicated parapneumonic effusions who had not had prior surgical intervention or trauma. The intervention was an intrapleural fibrinolytic agent (streptokinase or urokinase) via an intercostal chest drain (ICD) versus control, or a comparison of the two agents. Two review authors independently extracted data . Study authors were contacted for further information. Seven studies met the eligibility criteria of the review, recruiting 761 participants. The only consistent end points in all trials were treatment failure, as gauged by the requirement for additional intervention including surgery or death. In studies where patients had either loculation and empyema, there was no significant difference in the risk of death with fibrinolytics (RR 1.08; 95% CI 0.69 to 1.68). When treatment failure was considered as surgical intervention, fibrinolytics reduced the risk of this outcome (RR 0.63; 95% CI 0.46 to 0.85), but there is discordance between earlier positive studies and the more recent negative study by Maskell. Intrapleural fibrinolytic therapy confers significant benefit in reducing the requirement for surgical intervention for patients in the early studies included in this review but not in the more recently published Maskell study. The reasons for this difference are uncertain. Separate subgroup analysis of proven loculated/septated effusions from the available data in our meta-analysis suggests a potential overall treatment benefit with fibrinolytics, but these results should be treated with caution as the data are incomplete and the benefit is not significant in the subgroup of high quality trials (Cochrane Grade A). Intrapleural fibrinolytics have not been shown to significantly increase adverse events, but the confidence interval is too wide to firmly exclude this possibility.

A study of the complications of small bore ‘Seldinger’ intercostal chest drains

Use of small bore chest drains (<14F), inserted via the Seldinger technique, has increased globally over the last few years. They are now used as first line interventions in most acute medical situations when thoracostomy is required. Limited data are available on the associated complications. In this study, the frequency of complications associated with 12F chest drains, inserted using the Seldinger technique, was quantified. A retrospective case note audit was performed of consecutive patients requiring pleural drainage over a 12-month period. One hundred consecutive small bore Seldinger (12F) chest drain insertions were evaluated. Few serious complications occurred. However, 21% of the chest drains were displaced ('fell out') and 9% of the drains became blocked. This contributed to high morbidity rates, with 13% of patients requiring repeat pleural procedures. The frequency of drain blockage in pleural effusion was reduced by administration of regular normal saline drain flushes (odds ratio for blockage in flushed drains compared with non-flushed drains 0.04, 95% CI: 0.01-0.37, P < 0.001). Regular chest drain flushes are advocated in order to reduce rates of drain blockage, and further studies are needed to determine optimal fixation strategies that may reduce associated patient morbidity.

Safety and Efficacy of Supracostal Access in Percutaneous Renal Surgery

During percutaneous renal surgery, subcostal access is preferred because it carries no risk of injury to either the lungs or pleura. However, in some situations, a supracostal approach may provide more direct access and achieve a more satisfactory result than the subcostal approach. In this prospective study, we evaluated the safety and efficacy of supracostal approaches in percutaneous renal surgery. Between 2004 and 2006, 30 patients underwent percutaneous renal surgery with a supracostal approach either as the sole or as a secondary access. The indications were staghorn stones, upper caliceal stones, upper ureteral stones, secondary ureteropelvic junction obstruction, disturbed lower caliceal anatomy, and high-lying kidneys. The puncture was above the eleventh rib in six procedures and above the twelfth rib in 24 procedures. All patients were examined for equal air entry on both sides of the chest, and all had chest radiography performed immediately after surgery to exclude pneumothorax or hydrothorax. Bleeding was assessed with evaluation of preoperative and postoperative hemoglobin, levels and vital signs; urine was also examined for gross hematuria. A routine nephrostogram was obtained for all patients. Supracostal was the sole access in 63.3% of patients and a secondary access in 36.7% of patients. Intraoperatively, bleeding occurred in one patient. Hydrothorax in another patient necessitated insertion of an intercostal chest drain. A renopleural fistula developed in another patient 2 days postoperatively that necessitated placement of a chest drain and Double J stent. Access in both patients with pleural complications had been above the eleventh rib. The mean drop in hemoglobin level was 0.79 +/- 0.72 g/dL. Our overall stone-free rate was 88.9%. Supracostal access above the twelfth rib is relatively safe; however, access above the eleventh rib should be limited to necessity because a higher incidence of pleural complications can be expected. A chest radiograph should be obtained immediately postoperatively for early detection of hydrothorax or pneumothorax.

Fat embolism syndrome : A diagnostic dilemma

Fat embolism syndrome (FES) is a constellation of clinical manifestations following fracture of long bones. In retrospective review, incidence of FES was less than 1% [1]. Fat embolism syndrome is a clinical diagnosis. This condition is often misdiagnosed and fatal if the treatment is delayed. We present two cases of fat embolism syndrome to highlight problems of missed diagnosis. Case 1 A 19 year old male sustained bilateral closed tibial and fibular fracture. Plaster of Paris (POP) slab was applied over both lower limbs and surgery planned. While awaiting fixation of fractures patient developed high grade fever from second day. Surgery was deferred to investigate fever. No specific cause for fever could be found and empirical treatment for malaria administered. Four days after the injury, patient suddenly developed tachypnea (breath rate 55/minute), tachycardia (pulse 145/minute), and altered sensorium. Oxygen saturation on pulse oximetry (SpO2) was 60% with high flow oxygen by facemask. He was intubated and mechanically ventilated with 100 % oxygen using anaesthesia circuit and later placed on ventilator in control mode with positive end expiratory pressure (PEEP). As oxygen saturation did not improve, PEEP was gradually increased to 20 cm of H2O. The high level PEEP resulted in pneumothorax for which an intercostal chest drain was inserted and patient was shifted to a tertiary care hospital. On arrival to the intensive care unit quick clinical evaluation revealed marked pallor, pulse 140/minute, blood pressure of 130/70 mm Hg, SpO2 90%, breath rate and neurological status could not be ascertained as patient was under effect of muscle relaxants. Patient was placed on Seimens Servo i ventilator in synchronized intermittent mandatory ventilation (SIMV) mode with PEEP. Initial ventilator settings were tidal volume 350 ml, mandatory breath rate 16/minute, fraction of inspired oxygen (FiO2) 0.7 and PEEP 10 cm H2O. With these settings peak inspiratory pressure of 23 cm H2O, plateau pressure of 20 cm H2O, mean airway pressure of 12 cm H2O and dynamic compliance of 30 ml/cm H2O was recorded. There were no petechial or subconjuctival haemorrhages. Chest auscultation revealed bilateral extensive crepitations and bronchial breath sounds. Fundoscopy revealed multiple haemorrhages along the vessel in entire field of both eyes. Doppler study of lower limb showed no evidence of venous thrombosis. Investigations revealed haemoglobin (Hb) 6.8 gm %, chest radiograph showed bilateral non homogenous opacities with predominant basal distribution (Fig. 1). Arterial blood gas (ABG) showed pH of 7.25, partial pressure of oxygen in arterial blood (PaO2) 55 mm Hg, partial pressure of carbon dioxide in arterial blood (PaCO2) 35 mmHg, bicarbonate (HCO3) 18 mmol/L and PaO2/FiO2 ratio of 78. Other investigations were within normal limits. Right internal jugular vein was cannulated and central venous pressure (CVP) of 12 cm of saline was recorded. Frank blood was noted on endotracheal suction. Fig. 1 Chest radiograph (antero-posterior view) shows bilateral non homogenous opacities in a predominantly basal distribution On the basis of clinical background, chest radiograph and arterial blood gas analysis report, the case was diagnosed as fat embolism syndrome with acute respiratory distress syndrome (ARDS). Patient was kept sedated, muscle relaxants discontinued and mechanical ventilation continued. Tachycardia and tachypnea settled down after eight hours of ventilation and patient started responding to simple verbal commands. The case was discussed with orthopaedic surgeon for fixation of fractures on fifth day. A consensus decision was taken to wait for some time. Next day while on ventilator, patient suddenly desaturated (SpO2 70%), became restless and developed tachypnea (breath rate 60/minute) and tachycardia (heart rate 150/minute). There were no specific changes on electrocardiogram and transthoracic echocardiography did not show any evidence of right ventricular strain. Patient improved within one hour with readjustment of ventilator settings. This episode was thought to be fresh episode of fat embolism. In view of recurring fat embolism, it was decided to fix fractures early. On sixth day bilateral open reduction and dynamic compression plating of both fractures was done under general anesthesia. Intraoperative course was uneventful. Postoperatively, ventilation, adequate analgesia, and antibiotics were continued. On seventh day patient improved and he was placed on oxygen mask. After eight hours of extubation patient again developed tachycardia, tachypnea, diaphoresis, and mild desaturation (SpO2 90%). This time noninvasive ventilation was used to tide over the crisis. After six hours of mask ventilation SpO2 improved to 97%. Thereafter he made an uneventful recovery.

Is an Intercostal Chest Drain Necessary After Video-Assisted Thoracoscopic (VATS) Lung Biopsy?

Video-assisted thoracoscopic surgical lung biopsy is a frequently performed procedure as an integral part of the diagnostic armamentarium for parenchymal lung disease. However, there is no evidence in the literature concerning the need for an intercostal chest drain after the procedure. A prospective randomized control trial was set up to assess the need for intercostal chest drainage after video-assisted thoracoscopic surgical lung biopsy. Patients who did not have any air leak after the procedure (lung tested while patient was still under anesthetic) was randomized to either having a chest drain or not. The study was powered at 0.9 using an alpha of 0.01. Thirty patients were recruited in each group. There were no significant differences between the two groups in terms of patients' age (mean age, 59 versus 54 years), sex, history of steroid use, immediate postoperative pain scores, and wound complications. No significant pneumothoraces occurred in either group. However in the immediate postoperative phase, 28% and 15% of patients with and without chest drains, respectively, had a small (clinically not significant) pneumothorax (size <10%) on their chest radiograph. Moreover, there was significantly increased in-hospital stay in the chest drain group (median, 3 days versus 1 day; p < 0.001). At 6 weeks' follow-up, all patients had fully expanded lungs bilaterally. There is no need for an intercostal chest drain in patients undergoing video-assisted thoracoscopic surgical lung biopsy if no air leak is identified at the time of surgery. Patients without a drain are discharged home within 24 hours postoperatively, raising the possibility of this procedure being an outpatient procedure.

Sudden hypoxia during anesthesia in a patient with Kartagener's syndrome

We report a case of anesthesia in an adolescent with recurrent left pneumothorax, Kartagener's syndrome, and severe learning disability with behavioral difficulties. After induction of anesthesia, he rapidly developed severe desaturation as measured on pulse oximetry. Placement of an intercostal chest drain did not remedy the situation and he was found to have blocked the left main bronchus with viscous secretions. Subsequent suctioning relieved the obstruction. Despite successful postoperative thoracic epidural analgesia and minitracheostomy for bronchial toilet, he developed bronchopneumonia that resolved with antibiotics. We discuss anesthesia for patients with Kartagener's syndrome and for patients with pneumothorax.

Management options for hydrothorax complicating peritoneal dialysis.

Hydrothorax as a result of pleuroperitoneal communication occurs in approximately 2% of continuous ambulatory peritoneal dialysis (CAPD) patients. Although our understanding of its mechanisms is incomplete, it is apparent that the key to successful therapy is obliteration of a transdiaphragmatic route of dialysate leakage (pleuroperitoneal communication), possibly coupled with reduction of intra-abdominal pressure. This review corroborated the findings from 10 major population-based case series in which 60 of the 104 cases (58%) were able to resume long-term peritoneal dialysis (PD). Temporary interruption of PD alone was successful in half of them. As compared to this conservative approach, as well as chemical pleurodesis via intercostal chest drain, video-assisted thoracoscopic intervention (including direct pleurodesis and diaphragmatic repair) has shown a promising role. Efficacy of thoracoscopic treatment has been confirmed by several case series from various centers and the demonstration of a success rate in excess of 90%. With accumulating experience using the thoracoscopic technique, it remains to be seen whether this mode of treatment will obviate the traditional closed pleurodesis.

Oesophageal atresia: a simplified approach to early management.

Management following the repair of oesophageal atresia (OA) with tracheooesophageal fistula (TOF) in the past included the routine use of an intercostal chest drain, a gastrostomy, or a transanastomotic tube (TAT) for enteral nutrition and a routine contrast swallow (CS) before oral feeds. There has been a trend towards simplification of the management, but this is not universal. The aim of this study was to evaluate the safety of a simplified management regime in infants undergoing primary repair of OA in a retrospective case note review of infants undergoing surgery for OA with TOF under the care of one consultant over a 12-year period. Intercostal chest drains, TATs, and CSs were not routinely used. Early enteral feeding was initiated and oral feeding was allowed in babies of adequate birth weight (BW) and gestation. A CS was only performed when there were specific anastomotic concerns. Parameters recorded included demographic details, time to first enteral feed by tube or mouth, time to full oral feeds, and complications. Forty patients were studied; 17 were managed without (group 1) and 23 with (group 2) a TAT. Sex distribution, gestational age, and BW were comparable in the two groups. In group 1, the time to the establishment of full oral feeds was 2-8 days (average 3.9). Four infants developed strictures; 2 were managed with dilatation alone and 2 required surgery. In group 2, the time to the establishment of full enteral feeds was 2-12 days (average 5.9). Four patients developed strictures; 2 underwent an anti-reflux procedure and a 3rd resection of a cartilaginous remnant. There was 1 death in a patient with intractable cardiac failure. The majority of infants with OA and TOF can thus be safely managed without routine chest drainage or CS. A sizeable minority do not require a TAT. Early introduction of oral feeds in the non-TAT group is not associated with an increased complication rate.

Tension pneumothorax in the presence of bilateral intercostal chest drains

A 34-year-old woman was admitted to the Accident and Emergency Department in respiratory distress following a horse riding accident. She had been competing in a steeplechase event when the horse fell attempting a jump. The horse rolled on to her chest, and whilst regaining its feet, fell again crushing her chest a second time. On arrival she was conscious and maintaining her own airway, but was in respiratory distress with paradoxical chest movements and left sided surgical emphysema. Her arterial blood gases on a 100% Oz reservoir mask on arrival were: pH 7.220, PO, 7.1, PCO, 6.94, Base excess 6.0, Sa 0, 70%. Her systolic blood pressure was initially 100 mmHg, but fell to 69 mmHg. Fluid resuscitation was commenced, together with Venflon cannulation of the pleural spaces. A chest radiograph revealed multiple rib fractures bilaterally (Figure 1) with no visible pneumothorax. Bilateral intercostal chest drains were inserted along ATLS protocols, and 1100 ml and 150 ml of frank blood were drained from the left and right tubes, respectively. The drains were both noted to be bubbling through the underwater seals. She was then intubated and was ventilated with intermittent positive pressure ventilation (IPPV). A repeat radiograph was performed to check the position of the drains. Whilst in X-ray, her ventilation pressures increased and O2 saturation began to decline, her trachea was deviated to the right with reduced air entry on the left. A diagnosis of a left tension pneumothorax was made (F@uY~ 2). A Venflon was inserted in the left second intercostal space, mid-clavicular line to decompress the chest. This resulted in an improvement in both her ventilation pressures and her arterial blood gases: pH 7.340, PO, 28.1, PCO, 4.80, Base excess -4.8 on 100% 0,. A second left intercostal drain was then sited. A third radiograph (Figure 3) was taken showing that her mediastinum was no longer displaced and the lung reinflated. Her pulmonary function remained satisfactory. Her right drain and apical left drain were removed on day 7, and the remaining left drain on day 10. After 10 days in intensive care she was fit to return to the ward and made an excellent recovery.

Horner's syndrome caused by an intercostal chest drain.

Horner's syndrome occurred in a young woman as a complication of the treatment of a traumatic pneumothorax with an intercostal drain. The nerve damage probably occurred when the lung had fully re-expanded, pressing the tip of the intercostal drain, lying at the apex of the pleural cavity, on to the sympathetic chain.

Accidental pharyngeal rupture from explosion of a bottle into the mouth

CASE REPORT A 16year-old boy came to hospital with dysphagia and pharyngeal haemorrhage 4 hours after a bottle of home-made cider had exploded into his mouth as he tried to remove the cap with his teeth. After the explosion he noticed pain in the right side of his back and increasing shortness of breath. The plastic bottle remained intact and the bottle top was retrieved intact from his mouth. On examination the patient was pallid, with a temperature of 39”C, a pulse rate of 140lmin and a blood pressure of 120/60mmHg. His uvula was oedematous and abraded and his left tonsil was severely contused and partially separated from its bed. Nevertheless, his airway was intact. Surgical emphysema extended from the right supraclavicular fossa to the anterior triangle of the neck and front of the right side of his chest wall. He had a right-sided pneumothorax, confirmed by radiograph. The patient was given intravenous fluids and cefuroxime. A right apical intercostal chest drain was inserted immediately, and 40 per cent oxygen was given by mask. Oral intake was restricted. The patient became increasingly breathless as the size of the extrapleural pneumothorax increased. The apical intrapleural chest drain was removed and replaced by an extrapleural chest drain. A basal intrapleural drain was inserted and this drained about 200ml of bloodstained fluid. It was thought likely that the pneumothorax was due to rupture of a main airway as there was a dramatic increase in the drainage of air on inspiration. However, on the 3rd day saliva was noticed in the intrapleural drain. At a trial swallow of gentian violet the dye appeared in the extrapleural drain. Gastrografin swallowed showed a leak from the pharynx into the right posterior mediastinum. Attempted oesophagoscopy showed a ragged tear in the right side of the pharynx, which easily admitted the oesophagoscope, immediately above the cricopharyngeus. Bronchoscopic examination was normal. At thoracotomy necrotic extrapleural debris was removed and the extrapleural space was drained. An obvious track leading into the pharynx was seen. Forced insufflation of the right lung showed no evidence of an air leak. It proved impossible to repair the pharyngo-oesophageal tear, and a nasogastric tube was passed with difficulty. The patient was kept on a ventilator for 7 days after the operation. The pharyngeal tear healed without further intervention. The patient was discharged home on the 12th day after the operation. He was on a full diet, was free from dysphagia and had a normal chest radiograph.