The patient is positioned sitting at 45 degrees, and hands above head to retract scapula.
Scrub up (wash hands, hat, mask, gown, sterile gloves)
Identify the triangle of safety: anteriorly the lateral border of pectoralis major, posteriorly the lateral border of latissimus dorsi and inferiorly the superior border of the 5th or 6th rib. Prep the entire area with chlorhexidine or povidone-iodine solution.
Use a size 20 scalpel to make a 2-3cm transverse incision parallel to the rib and just above it, between the mid-axillary and the anterior axillary line in the 4th or 5th intercostal space, to reach a depth just above the external intercostal muscle. Ensure incision remains the same length throughout its depth.
Use an artery forceps for blunt dissection. Spread the external intercostal muscle (travelling in the superolateral to inferomedial direction) and internal intercostal muscle (fibres are perpendicular to the external intercostals). Spread the intercostals all along the incision.
Push the closed blunt tip of the artery forceps into the intercostal space to enter the (innermost intercostal muscle and) parietal pleura. Recognise entry into the pleural cavity with a sudden jerk/giving way or ‘pop’. Spread the artery forceps to create a sufficient space to pass a finger into the pleural cavity and perform a finger sweep to remove any lung adhered to the the parietal pleura.
The chest drain tubing is grasped at its tip (pinched along its circumference or the forceps’ blade inserted into the tubing holes) with an artery forceps. The other end is clamped. Any trocar inside the tube is removed.
As it is pushed into the cavity, the tip of the forceps and hence the chest tube is pointed upwards for a pneumothorax or downwards for a liquid collection.
Push the tube in until all its fenestrations are inside the pleural cavity.
Use a braided/polyfilament large-calibre (1-0, 2-0) suture with a large needle to make an anchoring interrupted stitch at the corner of the wound with at least 3 knots. Each end of the thread is passed in opposite directions around the tube and knotted again. This is repeated 2-3 times as necessary to secure the tube.
The wound is then closed using vertical mattress sutures so the chest drain is air-tight.
A horizontal mattress suture is placed around the tube but left unknotted. This will be used to close the drain site on removal.
The tube is connected to a under-water seal drain which has already been filled with water, and unclamped. Ensure suction is off or turned on when necessary.
Adhesive dressings and tape are used to secure the drain site.
Correct intrapleural placement is verified by checking for condensation in the tube, swing in the chest drain tubing and drainage of intrapleural contents (blood, bubbles signifying air, pus signifying empyema) and later with a chest radiograph.
Drainage of blood more than >1.5L or >200ml/hour indicates massive haemothorax and the drain should be clamped if the loss is massive, to allow tamponade of the bleed.
Excessive bubbling can indicate a leak, suction being on, or a broncho-pleural fistula.
At removal of the chest drain, the tube is held in place while all dressings and securing sutures are removed. The horizontal mattress suture threads are lifted to snug down on the drain. A quick single motion is used to pull the tube out while simultaneously tightening the suture which is secured with a surgical knot. This ensures no air leaks in during removal.