Intercostal Drains (ICD)

• Purpose of ICD:

  • ICD aids removal air or fluid from pleural cavity
  • The fluid can be blood, pus or a pleural effusion
  • Allows re-expansion of the underlying lung
  • Must also prevent entry of air or drained fluid back into chest
  • An ICD must have three components
  • An unobstructed tube
  • A collecting container below chest level
  • A one-way mechanism such as water seal
• Purpose of ICD:

  • Tube inserted into pleural space
  • Other end in water filled collection bottle
  • Sealed collection bottle used to restore or maintain negative intra-pleural pressure
  • Additional negative suction can be added to aid restoration of negative pressure and lung inflation
  • IMPORTANT - purpose of ICD is to reinstate negative pressure to allow normal mechanics of breathing and lung inflation
  • Must be kept below level of patient to avoid “siphoning” effect

  
• Diagram showing that the ICD doesnt puncture the lungs, it just sits in the pleural space

  
• Before and after use of ICD:

  • blood/fluid has been removed
  • negative pressure have been reinstated in thoracic space
  • lung has been drained

  
• Location of ICD:

  • What is being drained?
  • Apical drains - air leak/pneumothorax
  • Basal drains - air leak/pneumothorax
  • Mediastinal drains - cardiac surgery
• Monitoring ICD:

  • Drainage of air can be seen bubbling into fluid in collection bottle
  • An air leak is present when fluid level “swings” with respiration
  • Volume of fluid drained monitored using scale on collection bottle
  • Any sudden change in volume may indicate haemorrhage
  • Colour of fluid drained should be noted
• Indications for ICD:

  • Pneumothorax
  • Chest trauma
  • Haemo-pneumothorax
  • Cardiothoracic surgery
  • Pleural effusion
  • Empyema
• Chest Trauma:

  • Will lead to a pneumothorax
  • Stab injury - break in parietal pleura lead to air from atmosphere entering thoracic space
  • Puncture of lung leads to air leak from within the lung entering thoracic space
  • Fractured ribs can cause lung puncture, bleeding causing haemo-pneumothorax
• Cardiothoracic Surgery:

  • Air can enter thoracic space from atmosphere peri-operatively
  • Lobectomy / pneumonectomy increase risk of air leak from surgical anastomosis leading to pneumothorax or pneumo-mediastinum
  • Post cardiothoracic surgery (by-pass grafts or valve replacement) 2 mediastinal drains inserted
• Complications of ICD:

  • “There is no organ in the thoracic or abdominal cavity that has not been pierced by a chest drain”
  • Haemo-pneumothorax
  • Lung laceration
  • Diaphragm and abdominal cavity penetration
  • Bowel injury in presence of unrecognized diaphragmatic hernia
  • Tube placed subcutaneously
  • Tube inserted too far
  • Tube displaced
• Removal of ICD:

  • ICD are removed as soon as fluid or air has been removed and the lung is re-inflated
  • Re-inflation indicated by
  • No bubbling of air
  • No swinging of fluid level
  • Lung inflation on Chest X-ray
  • No change in lung volume with ICD clamped 24 hrs
• Emergencies:

  • Drain pulled out accidently - immediately ask patients to hold their breath and cover incision point, then they can breathe again, ask for help
  • Suction disconnected
• Pigtail Drain:

  • Venflon with small bag
  • Small diameter
  • Blocks
  • Unable cope with viscous liquid

  
• Redivac

  • Used post surgery to drain fluid / blood
  • Ideal where negative intercostal pressure is not an issue
  • abdominal wounds
  • pericardial drains