College of Veterinary Medicine

Small Animal DX & Therapeutic Techniques

Placement of a Thoracic Drain


 

Chest drains are usually of large diameter (10 to 32 French depending upon patient size). A large diameter tube is necessary if being used to remove viscous fluid from the pleural space.

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A flexible, rubber feeding tube with additional fenestrations (arrow) can be used as a chest drain. Fenestrations should be in the most distal portion of the catheter (~ last 4 -5 cm). When the tube is in place, all fenestrations should be within the pleural space rather than the subcutaneous space. The white roller clamp is used to occlude the lumen of the tube when it is not being aspirated. This clamp should be closed when placing the tube in the pleural space.

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Pictured is an argyle styleted thoracic drain. The stylet is placed inside the flexible plastic catheter. The end of the flexible catheter is fenestrated for several centimeters. The sharp point is used to drive the catheter through the chest wall.

drain_ball.jpg (21819 bytes) Pictured is a Jackson-Pratt drain which is generally used for abdominal drainage. It also functions well as a pleural space drain. The part of the drain labeled (a) is made of teflon and is very nonirritating to tissues. The small black spots are multiple drainage holes. The teflon portion and part of the clear plastic tubing will be positioned in the pleural space. The other end of the clear tubing is attached to the bulb. The bulb (b) can be compressed to create a source of constant suction to enhance fluid removal from the pleural space.
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Sedation and local anesthetic infiltration are generally adequate for drain placement. The chest wall should be clipped of hair and scrubbed with antiseptic solutions. The animal is placed in lateral recumbancy. The drain should enter the skin surface at the 10th intercostal space, tunnel subcutaneously, 2 to 3 spaces, and penetrate the chest wall at the 7th or 8th intercostal space. The insertion site should be at the junction of the dorsal and middle thirds of the chest. The dog's head is to your right.

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A skin incision is made with a scalpel blade in the 10th intercostal space, caudel to the 10th rib, at the junction of the dorsal and middle thirds of the chest wall.

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Placement of a flexible, rubber feeding tube is demonstrated. Before placing the chest tube, estimate the length of tubing that will be inserted into the pleural space. Excessive length of tubing in the pleural space can lead to the tubing becoming bent or twisted. The ideal position of the tip of the tube is to lie along the sternum, anterior to the heart. Be sure to have ready an adapter that can be firmly attached to the chest drain to allow attachment of a syringe. The tubing should be clamped closed during placement. The feeding tube is held between the jaws of a curved hemostat. Make sure that the jaws of the hemostat extend beyond the tip of the catheter. The tip of the hemostat is used to puncture through the muscle of the chest wall. It is difficult to puncture the chest wall if the tube is at the end of the hemostat.

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Pass the hemostat in an anterior direction in the subcutaneous space for a distance of 2 or 3 rib spaces, then firmly drive the hemostat through the chest wall at the 7th or 8th intercostal space. Keep the hemostat close to the cranial aspect of the rib, in order to avoid the intercostal vessels located on the caudel border of the ribs. It takes a considerable amount of force to drive the hemostat through the chest wall. The hemostat should be at a 90 degree angle to the chest wall when being driven through it. When the hemostat enters the pleural space, open the jaws of the instrument and push the tube into the pleural space. Remove the hemostat. Before the thoracic drain is sutured in place, attach a syringe to the catheter and remove fluid and/or air to improve the patient's breathing ability. Then the catheter is clamped closed and sutured in place.

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You can see the subcutaneous tunnel traversing 3 intercostal spaces anterior to the skin incision and entering the pleural space at the 7th intercostal space.

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Another technique that can be used during insertion of any of the catheter types presented is to pull the skin in an anterior direction so the skin over the 10th intercostal space is located over the 7th or 8th intercostal space. With the skin pulled forward, you can incise the oblique musculature of the chest wall to make it easier to bluntly force the catheter through the rest of the chest wall musculature. The catheter is driven through the chest wall at ~ 80 to 90 degree angle. The operator is pushing the catheter through the chest wall with her right hand and is using her left hand as a "stop" to control the depth of insertion into the pleural space.The subcutaneous tunnel is created when the skin is released. This slide demonstrates placement of a styletted catheter. After penetrating the chest wall, the catheter and stylet are angled forward and parallel to the chest wall, to direct the catheter forward when it is slid off the stylet. (the dog's head is to your right)

drain_cross_sut.jpg (27324 bytes) After the catheter is inserted into the pleural space, a purse string suture is placed in the skin incision around the catheter. The ends of the suture are left long and wrapped up and along the length of the tubing in a finger trap or friction type suture.

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The subcutaneous tunnel is collapsed around the tube with a suture. A 20 gauge hypodermic needle is passed underneath the subcutaneous segment of the thoracic tube, taking care not to penetrate the tube with the needle. Suture is threaded through the hypodermic needle, the needle is removed, and the suture tied around the subcutaneous segment of the tube.

Last Edited: Feb 02, 2009 1:32 PM   

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