Intercostal Drainage (ICD) / Chest Tube Thoracostomy

Indications

• Pneumothorax - especially tension, large spontaneous, or failed aspiration
• Haemothorax
• Empyema / complicated parapneumonic effusion
• Large pleural effusion causing respiratory compromise
• Chylothorax
• Post-operatively following thoracic surgery

• Second ipsilateral pneumothorax
• First contralateral pneumothorax
• Bilateral spontaneous pneumothorax
• Pneumothorax failing to settle despite drainage
• Pregnancy, or professions at risk (pilots, divers)

Equipment Required

• Sterile drapes, gown, gloves, mask, goggles
• 10-20 mL syringe + needles for local anaesthetic (1-2% lidocaine)
• Antiseptic solution
• Scalpel (No. 10 blade)
• Large Kelly clamps
• Chest tubes - 12-42 Fr (smaller for pneumothorax; minimum 36 Fr for haemothorax/empyema)
  • Paediatric: 14, 16, 20, or 24 Fr
• No. 0 or 1-0 silk suture, needle holder, forceps
• Petroleum gauze (occlusive dressing)
• Drainage apparatus with sterile water for underwater seal

Site of Insertion - "Triangle of Safety"

• Anterior to the mid-axillary line
• Above the level of the nipple
• Below and lateral to the pectoralis major muscle

Insertion Technique (Step by Step)

1. Meticulous sterility throughout
2. Local anaesthesia - infiltrate generously, including down to the pleura (this is the most painful step)
3. Make a transverse skin incision 3-5 cm long, lateral to pectoralis major and breast tissue
4. Blunt dissection with Kelly clamps through muscle layers (serratus anterior + intercostals)
5. Always pass over the upper border of the rib - the neurovascular bundle (intercostal vessels and nerve) runs beneath each rib
   
6. Penetrate the parietal pleura with firm forward pressure - a palpable "pop" and rush of air/fluid confirms entry
7. Digital examination - sweep 360 degrees to verify correct space, feel for adhesions, ensure no solid organ penetration
8. Insert the tube over/beside the guiding finger:
   • For pneumothorax or haemothorax - direct towards the apex
   • For pleural effusion or empyema - direct towards the base
9. Ensure all drainage holes are within the pleural space
10. Secure with stay suture; insert a vertical mattress suture for later wound closure (omit for empyema if pleura is adherent, so the tract stays open)
11. Apply occlusive dressing (petroleum-impregnated gauze at skin)
12. Chest X-ray to confirm position - the gap in the radiopaque line must be within the pleural cavity

Underwater Seal Drainage System

1. A one-way valve (prevents air re-entry)
2. A suction mechanism to increase drainage rate

How it works:

• The fluid level in the drainage tube fluctuates with respiration when functioning correctly (swings in with inspiration, out with expiration)
• The collection bottle must remain below chest level at all times
• Bubbling in the air-leak chamber indicates an air leak - check connections and tube position first; persistent bubbling = ongoing lung air leak
• Absence of fluctuation = tube blocked or lung fully expanded

Suction:

• Use suction initially for pneumothorax and haemothorax
• Replace with water seal once drainage is satisfactory and no air leak persists
• Wall suction at -80 mmHg is standard; suction amount depends on depth of water in chamber, not wall dial setting
• Vigorous bubbling does NOT equal more suction

Important Management Rules

Drain Removal

• Lung fully re-expanded on CXR
• No air leak (no bubbling)
• Fluid drainage < 100-200 mL/day (for effusions)

Complications

History Taking - Respiratory Patient for Intercostal Drainage

1. Presenting Complaint (PC)

• Chest pain - onset, site, character, radiation, severity (1-10), timing, aggravating/relieving factors
• Breathlessness (Dyspnoea) - onset (sudden vs gradual), at rest or on exertion, quantify (how many stairs/meters before stopping)
• Cough - dry or productive, duration
• Fever / rigors - suggests infection/empyema
• Trauma - history of chest injury (haemothorax)

2. History of Presenting Complaint (HPC)

For Pneumothorax:

• Sudden onset sharp pleuritic chest pain + breathlessness
• Tall, thin young male? (primary spontaneous)
• Previous pneumothorax on same or opposite side?
• Underlying lung disease (COPD, asthma, cystic fibrosis, Marfan's)?
• Recent procedure or trauma (secondary/iatrogenic)?

For Pleural Effusion / Empyema:

• Recent respiratory infection, cough with purulent sputum
• Gradual increasing breathlessness
• Night sweats, weight loss, fever (TB, malignancy, empyema)
• Haemoptysis - raises concern for malignancy or TB

For Haemothorax:

• History of chest trauma, recent surgery, or coagulopathy
• Anticoagulant use

Symptom Progression:

• How rapidly did symptoms develop?
• Acute (minutes-hours) = pneumothorax, tension pneumothorax
• Subacute/chronic (days-weeks) = effusion, empyema

3. Past Medical History (PMH)

• Respiratory disease: COPD, asthma, TB, previous pneumothorax, lung cancer, cystic fibrosis, ILD
• Cardiac disease: heart failure (transudative effusion), pericarditis
• Connective tissue disease: SLE, rheumatoid arthritis, scleroderma (associated pleural and ILD)
• Malignancy (primary lung or metastatic - cause of effusion)
• Renal / liver disease (hypoalbuminaemia - transudative effusion)
• HIV/immunocompromise (opportunistic infections)
• Previous thoracic surgery or procedures
• History of DVT/PE (pleuritic pain, pleural effusion)

4. Drug History (DH)

• Ask about allergies (especially to local anaesthetics - lignocaine used for ICD)

5. Occupational & Environmental History

• Asbestos exposure - electricians, plumbers, ship builders, construction workers (pleural plaques, mesothelioma - causes effusion)
• Silica - miners, stone cutters, sand blasters
• Hard metals/Beryllium - metal workers, electronics, nuclear industry
• Organic dusts - farmers, bird keepers (hypersensitivity pneumonitis)
• Current occupation - relevant for return to work planning post-ICD

6. Social History (SH)

• Smoking: pack-year history (COPD, lung cancer, respiratory bronchiolitis)
• Alcohol: liver cirrhosis → transudative pleural effusion
• Recreational drugs - IV drug use (septic emboli, empyema)
• Travel history - TB, hydatid cyst (Echinococcus), parasitic causes
• Pet ownership - bird/pigeon fancier (hypersensitivity pneumonitis)
• Living conditions - overcrowding (TB risk)
• Functional status - baseline exercise tolerance before this illness
• Occupation / hobbies (overlaps with occupational history)

7. Family History (FH)

• TB contacts
• Lung cancer
• Familial ILD (2-20% of idiopathic interstitial pneumonias are familial)
• Connective tissue disease
• Genetic conditions: Marfan's syndrome (tall, thin build - pneumothorax risk), cystic fibrosis

8. Systems Review

Summary: Key "Red Flags" Requiring Urgent ICD