Department of Paediatrics
Neonatal Chest Drain Insertion
Indications
 Treatment of pneumothorax
 Treatment of pleural effusion
Complications
 Haemorrhage may occur if the vascular bundle below the rib is
damaged
 Distortion of breast growth
 Lung perforation (high risk if trocar is used)
 Pericardial damage
 Thoracic duct damage
 Phrenic nerve injury
 Diaphragmatic eventration
The decision and plan for insertion of chest drain must be discussed
with the consultant on call.
Chest drain insertion should be performed by an experienced registrar
who has previously carried out the procedure competently under
consultant supervision. Alternatively the consultant should attend to
insert the drain or directly supervise the ST doctor or ANNP.
Consent
This procedure usually needs to be done as an emergency and should not be
delayed while explicit consent is obtained. Admission to NICU carries implicit
consent for such emergency procedures. However, it does carry risks and
parents need to be fully informed about the procedure at the first suitable
opportunity, with full documentation in the notes of the discussion.
In the event of the procedure being more elective, evidence of explicit parental
consent should be documented in the notes.
Equipment
 Sterile dressing pack and exchange transfusion pack
 Cleaning solution appropriate to gestation of baby (chlorhexidine 0.05%
or saline)
 Lignocaine 1% with syringe and needles for preparation and injection
 Chest drains size FG 8, 10, 12 (use largest size possible depending on
size of baby)
 Scalpel and fine straight blade (size 15)
 Underwater seal chest drainage bottle
 Pressure suction system
 Suture and tape for fixing
Department of Paediatrics
Preparation
 Give sucrose if time allows and no contraindications
 Confirm correct side of chest for insertion
 Aseptic technique
 Position baby with the affected side elevated 45º to the horizontal, with
a roll under the back. The baby should be held with the ipsilateral arm
above the head.
 Clean the skin and infiltrate with 0.125-0.25ml 1% lignocaine
 Calculate approximate length of insertion of chest tube as distance
from insertion site to mid clavicle (term baby 3-4cm: preterm 2-3cm
approx guide)
Site
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Anterior axillary line between 4-6th intercostal space (ICS), to avoid
unsightly scarring and disruption of breast tissue
Some evidence suggests that breast tissue may extend beyond 4th
ICS, therefore 5th ICS is preferable
For drainage of free air, the drain should be sited anteriorly
For drainage of fluid, the drain should be sited posteriorly
Procedure (pneumothorax)
In a baby you are unable to saturate at >90% you must perform needle
thoracocentesis first, without delay, as an emergency.
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Make small incision, of similar size to diameter of the chest tube (0.51cm) in ICS, just above and parallel to the rib to avoid damage to the
subcostal neurovascular bundle
The tissues down to the pleura should be dissected bluntly using a
curved haemostat or fine artery forceps. As the pleural space is
reached a small ‘give’ may be felt and there may be a rush of air.
The drain should be introduced into the pleural cavity with the aid of
artery forceps to the calculated depth.
The trocar must not be used to introduce the drain tube due to the
risk of lung perforation.
In bigger babies, it may be helpful to use the trocar to stabilise the
chest tube, in which case a clamp must be put across the chest tube 12 cm from the end to prevent the end of the trocar advancing further.
The chest drain should be advanced anteriorly and towards the apex.
The end of the chest drain should be attached to an underwater seal,
bubbles should appear indicating successful drainage of free air.
Resolution of the pneumothorax will be aided by the application of
suction at 5-15cm H2O
Department of Paediatrics
Fixation
 Purse string sutures are not recommended due the risk of
unsightly scarring
 A suture should be placed across the wound to close the hole tightly
around the drain. If the incision is larger, 2 sutures may be needed.
 The sutures should then be wrapped round the drain to secure it or
inserted through a zinc oxide tape flag positioned round the drain close
to its insertion.
 A transparent dressing should be applied.
Aftercare
 Check that bubbling or oscillation of the water column is seen with
every respiration
 Confirm tube position with chest X-ray (lateral and AP to confirm
anterior positioning)
 Document procedure in notes, including site of insertion and batch
number of equipment and method of fixing, with a signed, dated and
timed entry
Removal
 When no bubbling has been seen for 24 hours, suction can be
discontinued and the drain clamped.
 Repeat AP chest X-ray at 4-6 hrs to ensure no re-accumulation
 Give sucrose if no contraindications
 Remove dressings and cut anchoring sutures
 Withdraw drain rapidly, while asking an assistant to hold the skin on
either side of the drain site together to close the incision.
 Close the wound with steristrips, a suture is rarely necessary
 Close clinical observation after removal of drain is sufficient to
diagnose re-accumulation of the air leak- routine Chest X-ray is not
warranted.
References
Roberton’s Textbook of Neonatology 4th Ed Janet Rennie
Archives of disease in childhood; fetal and neonatal edition;Vol92(1)January
2007pp F46-F48
Chest radiographs after removal of chest drains in neonates: clinical benefit
or common practice?
van den Boom, J1; Battin, M2
Pediatrics Vol 111 (1) Jan 2003 pp80-86
Breast deformity in adolescence as a result of pneumothorax drainage during
neonatal intensive care.
Rainer et al
BAPM Consent in neonatal clinical care: Good practice framework October
2004
CC/LAW March 2009 (Review March 2011)
Gosset guidelines/chest drain insertion