What are the indications for insertion of a chest drain?

The main purpose of a chest drain is to remove or prevent the collection of pleural contents that result in ventilatory compromise. Some of the indications are listed below:

• Pneumothorax

• Haemothorax

• Pleural effusion (infective, malignant, congestive)

• Empyema

• Chest trauma (especially those with open or penetrating chest wounds)

• Chylothorax

• Post-operative (prophylactic)

• Prior to positive pressure ventilation

What surface makings help in deciding the site of chest drain insertion?

The safe site for a chest drain is within an imaginary triangle on the side of the chest wall, and, on the superior border of the rib that forms the inferior border of the chosen intercostal space.

The three sides of this triangle are marked anteriorly by the lateral border of the pectoralis major muscle, posteriorly by the anterior axillary line and inferiorly by the sixth rib.

What are the anatomical reasons for the site chosen in Question 2?

• Intercostal neurovascular bundles are at the inferior border of the rib and away from the site of tube insertion.

• The long thoracic nerve is marked by the midaxillary line and thus outside the above triangle.

Describe how you would insert an intercostal chest drain

Position The patient is placed supine at a 45-degree angle and tilted away from the side of the procedure. The shoulder is then abducted (resting hands on top of head) to allow better access to the chest wall.