Insertion technique

1. Use 28Fr drain (or larger) for haemothorax or empyema; 20Fr will suffice for a pure pneumothorax. Seldinger-type drains with an integral guidewire are now also available. The drain is usually inserted through the 5th intercostal space in the mid-axillary line, first anaesthetising skin and pleura with 1% lidocaine. Ensure that air/fluid/blood/pus is aspirated.

2. Make a 1-1.5cm skin crease incision, create a track with gloved finger (or forceps) to separate muscle fibres and open pleura.

3. Insert drain through open pleura with trochar withdrawn to ensure tip is blunt to avoid lung damage. Angle and insert drain to correct position (towards lung apex for a pneumothorax and lung base for a haemothorax/effusion). Connect drain to the underwater seal. CT scan or ultrasound may be useful for directing placement for focal/small collections.

4. Secure drain to chest wall by properly placed sutures.

5. Perform CXR to ensure correct siting and lung reinflation.

6. Place on 5-10cmH2O (0.5-1.3kPa) negative pressure (low pressure wall suction) if lung has not fully expanded.

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