Tom Havelock, Richard Teoh, Tom Havelock, Richard Teoh, Diane Laws, et al. Diane Laws, et al.

British Thoracic Society British Thoracic Society pleural disease guideline 2010 pleural disease guideline 2010

Need for chest drain and pleural Need for chest drain and pleural aspiration.aspiration.

Awareness of safe technique.Awareness of safe technique. Despite small chest drains and Seldinger Despite small chest drains and Seldinger

technique serious complications continue technique serious complications continue to occur.to occur.

Need for guidelines.Need for guidelines.

Inadequate training or supervision.Inadequate training or supervision.

Inadequate knowledge and skills.Inadequate knowledge and skills.

All doctors expected to be able to insert a All doctors expected to be able to insert a chest drain should be trained using a chest drain should be trained using a combination of didactic lecture, simulated combination of didactic lecture, simulated practice and supervised practice until practice and supervised practice until considered competent. considered competent.

Theoretical component: Procedure and Theoretical component: Procedure and Risks. Protocols to be followed.Risks. Protocols to be followed.

Practical component: Manikin practice Practical component: Manikin practice and supervision.and supervision.

Pleural aspirationPleural aspiration

Indications for pleural aspiration Indications for pleural aspiration

A. Pneumothorax : A. Pneumothorax : Spontaneous primary pneumothorax (any size).Spontaneous primary pneumothorax (any size). Small secondary spontaneous pneumothorax in Small secondary spontaneous pneumothorax in patients under 50 years patients under 50 years

B. Malignant pleural effusions: B. Malignant pleural effusions: Small volume aspiration for diagnosisSmall volume aspiration for diagnosis Larger volume aspiration to relieve symptoms of Larger volume aspiration to relieve symptoms of dyspnoeadyspnoea

C Pleural effusion associated with sepsis (suspected empyema)C Pleural effusion associated with sepsis (suspected empyema) Diagnostic for decision to drain .Diagnostic for decision to drain . Refer to specific guidelines for further detail. Refer to specific guidelines for further detail.

Timing of the procedure :Pleural procedures Timing of the procedure :Pleural procedures should not take place out of hours except in should not take place out of hours except in an emergency. an emergency.

Aseptic technique :Pleural aspirations and Aseptic technique :Pleural aspirations and chest drains should be inserted in a clean chest drains should be inserted in a clean area using full aseptic technique. area using full aseptic technique.

Clotting disorders and anticoagulation : Clotting disorders and anticoagulation : Non-urgent pleural aspirations and chest Non-urgent pleural aspirations and chest

drain insertions should be avoided in drain insertions should be avoided in anticoagulated patients until international anticoagulated patients until international normalised ratio (INR) <1.5. normalised ratio (INR) <1.5.

Preparation and consent.Preparation and consent. Complications. Pneumothorax, procedure failure, Complications. Pneumothorax, procedure failure,

pain and haemorrhage. The most serious pain and haemorrhage. The most serious complication is visceral injury.complication is visceral injury.

Image guidance: A recent chest radiograph should Image guidance: A recent chest radiograph should be available prior to performing a pleural aspiration. be available prior to performing a pleural aspiration. Thoracic ultrasound guidance is strongly Thoracic ultrasound guidance is strongly recommended for all pleural procedures for pleural recommended for all pleural procedures for pleural fluid. fluid.

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

Patient position and Patient position and site of insertion :The site of insertion :The preferred site for preferred site for insertion of the needle insertion of the needle for pleural aspiration for pleural aspiration should be the triangle should be the triangle of safety. of safety.

Equipment.Equipment. Aseptic technique.Aseptic technique. Size of needle.Size of needle. Technique.Technique.

Volume of removal, re-expansion pulmonary Volume of removal, re-expansion pulmonary edema and the use of pleural manometry : The edema and the use of pleural manometry : The procedure should be stopped when no more fluid procedure should be stopped when no more fluid or air can be aspirated, the patient develops or air can be aspirated, the patient develops symptoms of cough or chest discomfort or 1.5 l symptoms of cough or chest discomfort or 1.5 l has been withdrawn. has been withdrawn.

Follow-up : A chest x-ray after a simple pleural Follow-up : A chest x-ray after a simple pleural aspiration is not required unless air is withdrawn, aspiration is not required unless air is withdrawn, the procedure is difficult, multiple attempts are the procedure is difficult, multiple attempts are required or the patient becomes symptomatic.required or the patient becomes symptomatic.

Chest DrainsChest Drains

IndicationsIndications Pneumothorax Pneumothorax In any ventilated patientIn any ventilated patient Tension pneumothorax after initial needle relief Tension pneumothorax after initial needle relief Persistent or recurrent pneumothorax after simple Persistent or recurrent pneumothorax after simple aspirationaspiration Large secondary spontaneous pneumothorax in Large secondary spontaneous pneumothorax in patients aged >50 years patients aged >50 years Malignant pleural effusions +- pleurodesis.Malignant pleural effusions +- pleurodesis. Emphysema and complicated parapneumonic pleural effusion.Emphysema and complicated parapneumonic pleural effusion. Traumatic haemopneumothorax Traumatic haemopneumothorax Post-surgical (eg, thoracotomy, oesophagectomy, cardiac Post-surgical (eg, thoracotomy, oesophagectomy, cardiac

surgery) .surgery) .

Written consent should be obtained for Written consent should be obtained for chest drain insertions, except in chest drain insertions, except in emergency situations.emergency situations.

Pain, intrapleural infection, wound infection, drain Pain, intrapleural infection, wound infection, drain dislodgement and drain blockage are the most dislodgement and drain blockage are the most frequent complications of small-bore chest drain frequent complications of small-bore chest drain insertion. Visceral injury is the most serious insertion. Visceral injury is the most serious complication. All of these possible sequelae complication. All of these possible sequelae should be detailed in the consent process. should be detailed in the consent process.

Pain, intrapleural infection, wound infection, drain- Pain, intrapleural infection, wound infection, drain- related visceral injury and drain blockage are the related visceral injury and drain blockage are the most frequent complications of large-bore chest most frequent complications of large-bore chest drain insertion. All of these possible sequelae drain insertion. All of these possible sequelae should be detailed in the consent process. should be detailed in the consent process.

Antibiotic prophylaxis is not Antibiotic prophylaxis is not recommended for non- trauma patients recommended for non- trauma patients requiring a chest drain.requiring a chest drain.

Antibiotic prophylaxis should be Antibiotic prophylaxis should be considered for trauma patients requiring considered for trauma patients requiring chest drains, especially after penetrating chest drains, especially after penetrating traumatrauma

Sterile gloves and gown Sterile gloves and gown Skin antiseptic solution (eg, iodine or chlorhexidine in alcohol) Skin antiseptic solution (eg, iodine or chlorhexidine in alcohol) Sterile drapes Sterile drapes Gauze swabs Gauze swabs A selection of syringes and needles (21e25 gauge) A selection of syringes and needles (21e25 gauge) Local anaesthetic (eg, lidocaine 1%) Local anaesthetic (eg, lidocaine 1%) Scalpel and blade < Suture (eg, 0 or 1-0 silk) Scalpel and blade < Suture (eg, 0 or 1-0 silk) Instrument for blunt dissection if required (eg, curved clamp) Instrument for blunt dissection if required (eg, curved clamp) Guide wire and dilators for Seldinger technique Guide wire and dilators for Seldinger technique Chest tube Chest tube Connecting tubing Connecting tubing Closed drainage system (including sterile water if underwater seal Closed drainage system (including sterile water if underwater seal

being used) being used) Dressing Equipment may also be available in kit form. Dressing Equipment may also be available in kit form.

Small drains should be used as firstline Small drains should be used as firstline therapy for pneumothorax, free flowing therapy for pneumothorax, free flowing pleural effusions and pleural infection. pleural effusions and pleural infection.

To reduce pain associated with chest drains, To reduce pain associated with chest drains, analgesia should be considered as analgesia should be considered as premedication and should be prescribed for premedication and should be prescribed for all patients with a chest drain in place.all patients with a chest drain in place.

If formal sedation is used during the If formal sedation is used during the procedure, this should be given in line with procedure, this should be given in line with the recommendation of the Academy of Royal the recommendation of the Academy of Royal Colleges for conscious sedation and include Colleges for conscious sedation and include oximetry recording throughout the procedure. oximetry recording throughout the procedure.

During chest drain insertion an attempt to During chest drain insertion an attempt to aspirate the pleural contents with a small aspirate the pleural contents with a small needle should be made. If this is not needle should be made. If this is not possible, chest drain insertion should not possible, chest drain insertion should not continue. continue.

It is strongly recommended that all chest drains It is strongly recommended that all chest drains for fluid should be inserted under image for fluid should be inserted under image guidance. guidance.

Aseptic technique

Chest drains should be inserted in a clean area Chest drains should be inserted in a clean area using full aseptic technique including gowns, using full aseptic technique including gowns, drapes, sterile gloves and skin cleansing. drapes, sterile gloves and skin cleansing.

Lidocaine 1% should be infiltrated prior to Lidocaine 1% should be infiltrated prior to the procedure, paying particular attention the procedure, paying particular attention to the skin, periostium and the pleura. to the skin, periostium and the pleura.

Drains should never be inserted using Drains should never be inserted using substantial force. substantial force.

The dilator should not be inserted The dilator should not be inserted further than 1 cm beyond the depth from further than 1 cm beyond the depth from the skin to the pleural space. the skin to the pleural space.

Blunt dissection should be employed in Blunt dissection should be employed in cases of trauma or insertion of large-bore cases of trauma or insertion of large-bore drains. drains.

If malposition of a chest drain is suspected a If malposition of a chest drain is suspected a CT scan is the best method to exclude or CT scan is the best method to exclude or confirm its presence. confirm its presence.

A chest drain may be withdrawn to correct a A chest drain may be withdrawn to correct a malposition but should never be pushed further malposition but should never be pushed further in due to the risk of infection. in due to the risk of infection.

A further drain should never be inserted A further drain should never be inserted through the same hole as a previously through the same hole as a previously dislodged drain as this can introduce infection. dislodged drain as this can introduce infection.

A chest drain should be connected to a A chest drain should be connected to a drainage system that contains a valve drainage system that contains a valve mechanism to prevent fluid or air from mechanism to prevent fluid or air from entering the pleural cavity. This may be entering the pleural cavity. This may be an underwater seal, flutter valve or other an underwater seal, flutter valve or other recognised mechanism. recognised mechanism.

All patients with chest drains should be All patients with chest drains should be cared for by a medical or surgical team cared for by a medical or surgical team experienced with their management and experienced with their management and nursed on a ward familiar with their care. nursed on a ward familiar with their care.

A bubbling chest tube should never be A bubbling chest tube should never be clamped. clamped.

A maximum of 1.5 l should be drained in A maximum of 1.5 l should be drained in the first hour after insertion of the drain. the first hour after insertion of the drain.

Drainage of a large pleural effusion Drainage of a large pleural effusion should be controlled to prevent the should be controlled to prevent the potential complication of re-expansion potential complication of re-expansion pulmonary oedema. pulmonary oedema.

There is no evidence to recommend or There is no evidence to recommend or discourage the use of suction in a discourage the use of suction in a medical scenario, however it is common medical scenario, however it is common practice especially in the treatment of practice especially in the treatment of non-resolving pneumothoraces.non-resolving pneumothoraces.

Chest drains should be managed on Chest drains should be managed on wards familiar with chest drains and their wards familiar with chest drains and their management. management.

Drains should be checked daily for Drains should be checked daily for wound infection, fluid drainage volumes wound infection, fluid drainage volumes and documentation for swinging and/or and documentation for swinging and/or bubbling. bubbling.

The chest tube should be removed once The chest tube should be removed once the fluid drainage has decreased to less the fluid drainage has decreased to less than 200 ml per day, resolution of the than 200 ml per day, resolution of the pneumothorax (see specific guidelines) pneumothorax (see specific guidelines) or when the drain is no longer or when the drain is no longer functioning.functioning.

Ultrasound physics.Ultrasound physics. Normal thoracic ultrasound appearance.Normal thoracic ultrasound appearance.

Pleural effusions.Pleural effusions. Pleural thickening.Pleural thickening. Malignant pleural effusions.Malignant pleural effusions. Pulmonary consolidation.Pulmonary consolidation. Parapneomonic effusions and empyema.Parapneomonic effusions and empyema. Pneumothorax.Pneumothorax.

Sitting or lateral decubitus position.Sitting or lateral decubitus position. Chest X ray review before ultrasound.Chest X ray review before ultrasound. Ambient light reduced.Ambient light reduced. 3.5-5 Mhz sector transducer.3.5-5 Mhz sector transducer. Apply acoustic gel.Apply acoustic gel. Hold transducer like pen.Hold transducer like pen. Optimize image by adjusting depth, gain and focus.Optimize image by adjusting depth, gain and focus. Commence from posterior chest wall. Diaphragm to be Commence from posterior chest wall. Diaphragm to be

identified. Use contralateral thorax as control.identified. Use contralateral thorax as control.

The site chosen should have The site chosen should have

(1) sufficient depth of pleural fluid (at (1) sufficient depth of pleural fluid (at least 10 mm).least 10 mm).

(2) no intervening lung at maximal (2) no intervening lung at maximal inspiration andinspiration and

(3) minimal risk of puncture of other (3) minimal risk of puncture of other structures such as the heart, liver and structures such as the heart, liver and spleen.spleen.

Ultrasound guidance reduces the Ultrasound guidance reduces the complications associated with pleural complications associated with pleural procedures in the critical care setting and procedures in the critical care setting and its routine use is recommended.its routine use is recommended.

At least level 1 competency is required to safely At least level 1 competency is required to safely perform independent thoracic ultrasound.perform independent thoracic ultrasound.

UK the Royal College of Radiologists has UK the Royal College of Radiologists has published guidelines establishing the minimum published guidelines establishing the minimum standard.standard.

Start with patients with simple free-flowing Start with patients with simple free-flowing pleural effusions before moving on to patients pleural effusions before moving on to patients with complex pleural or pleuroparenchymal with complex pleural or pleuroparenchymal disease.disease.