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Pneumothorax Drainage

Introduction

Drainage of a Pneumothorax is often a matter of urgency especially when the air collection is under pressure. A pneumothorax diagnosed as an incidental finding on CXR may not require active drainage but when associated with clinical deterioration may require immediate drainage either by needle aspiration or intercostal catheter (ICC) insertion.

Clinical Features

  • sudden deterioration with desaturation
  • increase in respiratory distress and/or diminished chest movements
  • circulation may become compromised
  • blood gases may show hypoxia, respiratory and/or metabolic acidosis.

Clinical signs include

  • unequal or decreased air entry
  • displaced apex beat
  • transillumination. This sign is unreliable in
    • infants with increased thickness of the chest wall e.g. term infants and oedema
    • infants with pulmonary interstitial emphysema (who may show a 'false positive' result)

CXR will confirm the diagnosis but takes time to perform.

 

Preparation

Infants breathing spontaneously should be monitored for the need of intubation and ventilation.

Consider the requirement for approriate pain relief. This may include

  • oral sucrose (link to section)
  • infiltration of the insertion site with 1% Lignocaine 0.5 - 1mL before preparing and draping the field (in order to allow greater time for the anesthetic to take effect)
  • intravenous infusion of morphine

 

Needle Aspiration

Needle aspiration is an emergency procedure only. Care must be taken to avoid laceration of the lung or puncturing blood vessels.

Equipment

  • 21gauge butterfly needle
  • 3 way stopcock
  • 10 ml syringe
  • 70% Isopropyl alcohol swab
  • 1 pair sterile gloves

Procedure

  • Infant supine, prepare area with alcohol wipe
  • Insert needle into the pleural space (directly over the top of the rib in the 2nd or 3rd intercostal space in the mid-clavicular line) until air is aspirated into the syringe, then expel air through the 3-way stopcock

Ongoing Care

Following needle aspiration insertion of an intercostal catheter is required for on-going management. It may be necessary to seek help with this procedure -consultation and assistance will be available with the receiving NICU or NETS.

Needle Aspiration Needle Aspiration


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Intercostal Catheter Insertion

Equipment

  • Sterile surgical instrument pack
  • Size 11 scalpel blade
  • 3/0 black silk suture on a curved edge needle
  • Sterile gown, gloves and drapes
  • Skin preparation
  • Argyle 8, 10 or 12Fr sterile intercostal catheter
  • Semi-occlusive dressing
  • 1% Lignocaine, syringe and needle
  • Underwater seal drainage system or a Heimlich valve

Procedure

  • Observe standard precautions
  • Mask, sterile gown and gloves are required as for any sterile procedure
  • Place infant under radiant heater to maintain infant's temperature, try to maintain some area of the infant visible beyond the sterile field. Place the infant with the effected side uppermost and the arm extended above the head (a nappy cloth roll may help maintain a good position). Ensure limbs are adequately restrained.
  • Monitor infant's heart rate and oxygen saturation level
  • The intercostal catheter is inserted in the 4th or 5th intercostal space in the anterior axillary line. This corresponds to a point 1-2cm lateral to and 0.5-1cm below the nipple. The incision must be well clear of the nipple.
  • Prepare the field with iodine solution
  • Select intercostal catheter size
    Infants > 1500g 10 or 12Fr
      < 1500g 8 or 10Fr
  • Place sterile drape in position
  • Using small (number 11) scalpel blade make a 1cm incision through the skin and subcutaneous tissue
  • Using straight mosquito forceps to bluntly dissect away the subcutaneous tissue and intercostal muscles, the parietal pleura is reached. Aim to dissect a passage just above a rib border in order to avoid the neurovascular bundles running below each rib. Open the parietal pleura by blunt dissection. At this point the hiss of air escaping the pleural space may be heard
  • Remove the trocar from the ICC and grasp the distal end with curved artery forceps. Advance the ICC into the pleural space 3 - 5cm, i.e. at the 1 - 3cm marking on the catheter directing the tip anteriorly as well as superomedially so that the tip lies beneath the anterior chest wall.
  • Connect the ICC to a Heimlich valve or an underwater seal drainage system, and note whether the fluid is swinging and/or bubbling. Fogging within the catheter may be seen when within the pleural space.
  • Place a single stitch through the wound so that the skin is drawn snugly around the ICC. Purse string stitches are not used as they leave an unsightly scar. Wrap the ends of the suture around the ICC several times and tie securely.
  • Secure the ICC to the chest wall as shown in diagram. This helps to maintain the anterior position of the ICC and minimizes trauma to intrathoracic structures due to movement of the extrathoracic portion of the ICC.

Intercostal Catheter Insertion

Ongoing Care

  • Check the tube position and resolution of the pneumothorax by transillumination and x-ray as soon as possible.
  • The need for ongoing analgesia is based on an assessment of physiological and behavioural responses associated with pain.
  • Infants requiring an intercostal catheter should be transferred to an NICU as soon as possible for ongoing care.

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References

Stabilization and Transport of Newborn Infants and At-Risk Pregnancies. Editors ED Bowman, SM Levi, FE Presbury, A McLean. Newborn Emergency Transport Service, 4th Edition,1998.

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