2. Introduction
• An intercostal drain (also known as a chest drain or pleural drain) is a flexible
plastic tube that is inserted through the chest wall into the pleural space. It is used
to drain pneumothoraces or effusions from the intrathoracic space.
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3. Principle of working
• The idea is to create a one-way mechanism that will let air/fluid out of the
pleural space and prevent outside air/fluid from entering into the pleural
space. This is accomplished by the use of an underwater seal. The distal end
of the drainage tube is submerged in 2cm of H2O.
• Air is eliminated from the pleural space into the drainage chamber when
intrapleural pressure is greater than +2cm H20. Thus, air moves from a
higher to lower pressure along a pressure gradient. The drainage chamber
has a vent to allow air to escape the chamber, and not build up within the
chamber.
• Fluids will drain by gravity into the drainage chamber, and will not spill
back into the pleural space if the bottle is always kept below the level of the
patient's chest.
4. Preparation, patient positioning, and local anesthesia
• Explanation of the procedure, written informed consent from patient, except
in emergency situations. A recent chest radiograph should be taken.
• First step involves positioning the patient according to the location chosen
for drain insertion. Ideally, chest tubes should be inserted at the 4th–5th
intercostal space anterior or mid-axillary line.
• The patient is positioned supine, lying on the bed at 45°–60°, slightly
rotated, and with the ipsilateral arm behind the neck or over the head.
• The British Thoracic Society (BTS) guidelines indicate that the insertion
within the area known as the “safe triangle.”
5. • The lateral decubitus position with the affected hemithorax upmost is also
possible, but many times it is not tolerated by patients with massive pleural
effusions.
• If the patient has a posterior loculated fluid collection (e.g., empyema), he/she will
be in a seated position with the physician standing behind.
• Finally, in patients with pneumothorax, the second intercostal space in the mid-
clavicular line (Monaldi position) has long been suggested as an alternative site
A. Supine position with ipsilateral arm over head. B. Supported sitting C. Lateral decubitus
position
6. Types of techniques
• SBCT are placed using the Seldinger technique, which a guide wire is inserted
into the pleural space through an introducer needle. Then, the needle is removed
and dilators are threaded over the wire using a slight twisting action. Afterwards,
the chest tube is threaded over the guide wire and into the pleural space.
• LBCT (>24F) can be inserted by blunt dissection or the trocar technique. It
requires an incision of the skin and subcutaneous tissue large enough to allow the
introduction of a finger into the pleural space in order to avoid or break down
pleuro-pulmonary adhesions and ensure proper chest tube positioning.
7. Procedure
• Bedside ultrasound (US) should be used to mark the entry point for all chest
tubes in patients with pleural effusions in order to prevent incorrect
placement and reduce risk of accidental organ injury associated with the
procedure
• Chest tube insertion is a full aseptic technique; therefore, sterile gloves,
gowns, surgical mask, and drapes should be used.
• Close 3-way tap once position confirmed and suture drain in place
• This needs to be firm but not pinch the skin or occlude the drain
• Dress the drain so the insertion sight is visible
• Attach drain to chest drain tubing
9. Complications
• Malposition of the chest tube
• Hemothorax
• Lung injury (laceration, bronchopleural fistula)
• Diaphragm injury
• Cardiac and great vessel injuries
• Esophageal injury
• Thoracic duct injury (chylothorax)
• Injury to abdominal organs (stomach, liver, spleen, bowel)
• Chest tube site infection
• Emphysema
• Tube occlusion
• Phrenic nerve palsy
10. Physiotherapy management
• As a part of physiotherapy objective assessment it is important to examine the
intercostal drainage.
• Aspects of intercostal drainage examination:-
1. Swinging- During inspiration a more negative intrapleural pressure causes the
fluid to rise up in tube of drainage chamber. Similarly, during expiration a less
negative intrapleural pressure causes the fluid to move down the tube.
2. Bubbling- Presence of bubbles in underwater sealed chamber indicates an air
leak.
3. Drainage- Amount and color of drained fluid should be observed.
4. Pain
11. Pain Management
1. TENS:- TENS around the incision site with alternating low and high frequency
current for 20-30 minutes for 2-3 times a day.
2. Cryotherapy:- Ice pack application over incision. Ice pack during
huffing/coughing and deep breathing exercises.
Positioning
Proper and early positioning enhances proper ventilation, less strain on incision and
less strain on the affected area and breathing muscles.
1. Early upright sitting
2. Lateral side lying with operated lung on top position
12. Wound support
• Support the patient’s intercostal drain sites with firm but gentle pressure, taking
care not to press directly on the drain site. This reduces pain and allows the patient
to breathe in deeply and/or to cough with little discomfort.
• One method involves the physiotherapist standing on the contralateral side, with
one hand placed on the anterior chest wall to stabilize the incision from the front,
and the other hand placed on the posterior chest wall to stabilize the incision from
behind, while at the same time the physiotherapist’s forearms stabilize the entire
chest.
13. • The patient can support by placing the hand of the un-operated side across the
front of the thorax as far as possible, resting firmly over the incision and drain
sites, while the other hand reinforces the back of incision.
• Assisted huffing/coughing is taught to the patient while supporting the wounds.
Deep Breathing Exercises
• Deep breathing exercises improves ventilation and oxygenation, prevent basal
atelectasis, re-inflate collapsed lung regions, and reverse minimal postoperative
atelectasis
• Recommended protocol is 5 deep breaths with a 3-second end-inspiratory hold per
every waking hour.
14. Mobilization
• Mobilization on the first postoperative day can begin by having the patient sit on
the edge of bed or in a chair out of bed, and then taking short steps to walk around
the bed.
• All patient's connections should be checked before mobilization and/or
ambulation, and care should be taken not to pull any of the patient’s drains, or
tubes.
• Ambulation should start low and go slow; that is, to start with sessions that are
short (i.e., 3–5 minutes), more frequent (i.e., 2–3 times/day), and relatively non-
intense.
• The patient must receive appropriate analgesia prior to ambulation because chest
drains can cause severe pain, limiting the patient’s ability to ambulate and to
cooperate with the physiotherapy.
15. • Symptoms of tachypnea, dyspnea, increased use of the accessory muscles,
orthopnoea, a restless or increased heart rate, or cyanosis may indicate
malfunctioning of the drain system.
• Care should also be taken that the patient keeps the drainage system upright and
below the level of the patient’s chest by least 0.5 m during all mobilization
activities.
• Mobilization activities for patients who are connected to wall suction include bed-
side marching on the spot or doing steps up on a fixed single step.
• If tube gets disconnected ask patient to exhale and press gauze against the wound
at end exhalation and call for medical help.
16. Exercises
• Active-assisted or active ROM exercises for the shoulder (e.g., arm elevation)
within pain limits can be starterted.
• The scapula on the operated side can be mobilized gently through its full range of
protraction, retraction, elevation, and depression, while the patient is in the side-
lying position. These exercises need to be performed 3–4 times daily.
• Shoulder abduction and external rotation are initially avoided to prevent increased
stress on the incision.
• Non-resistance leg exercises (i.e., quadriceps and ankle exercises) can be started
on the first postoperative day to minimize circulatory stasis.
17. References
• Anitha N, Kamath SG, Khymdeit E, Prabhu M. Intercostal drainage tube or
intracardiac drainage tube?. Ann Card Anaesth. 2016;19(3):545-548.
doi:10.4103/0971-9784.185561
• Ahmad AM. Essentials of Physiotherapy after Thoracic Surgery: What
Physiotherapists Need to Know. A Narrative Review. Korean J Thorac Cardiovasc
Surg. 2018;51(5):293-307.
• Porcel JM. Chest Tube Drainage of the Pleural Space: A Concise Review for
Pulmonologists. Tuberc Respir Dis (Seoul). 2018;81(2):106-115.
• Merkle A, Cindass R. Care Of A Chest Tube. [Updated 2020 Nov 24]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;Jan 2020
