Ultrasound / CT guided Chest drain insertions

Image-guided chest drain insertion, also known as ultrasound-guided thoracentesis or chest tube insertion, is a procedure used to drain fluid or air from the pleural space in the chest. 

Indications

1. Pleural Effusion: Accumulation of fluid in the pleural space, which can occur due to various conditions such as pneumonia, heart failure, cancer, or trauma (Click here to read more on Pleural Effusion)
2. Pneumothorax: Presence of air in the pleural space, causing lung collapse. This can be spontaneous, traumatic, or secondary to medical procedures.
3. Empyema: Collection of infected fluid (pus) in the pleural space, often associated with bacterial pneumonia or lung abscess.

Pre-procedure Preparation

1. Patient Assessment:
   • History taking, physical examination, and review of imaging studies (chest X-ray, ultrasound, CT scan) to determine the indication for chest drain insertion and assess the pleural anatomy.
   • Evaluation of coagulation profile and correction of any bleeding disorders if present.
2. Informed Consent:
   • Explanation of the procedure, risks, benefits, and alternatives to the patient or their caregivers. Informed consent is obtained.
3. Patient Positioning:
   • The patient is usually positioned sitting upright or lying on the side opposite to the affected side with the arm raised above the head to expose the chest area.
4. Anaesthesia:
   • Local anaesthesia is administered to numb the skin and underlying tissues at the insertion site to minimise discomfort during the procedure.

Procedure Steps

1. Ultrasound Guidance:
   • Ultrasound imaging is used to visualise the pleural effusion, pneumothorax, or other pleural abnormalities, locate safe entry sites, and avoid injuring underlying structures (such as blood vessels or lung tissue).
   • The ultrasound probe is placed on the chest wall to identify the optimal site for chest drain insertion.
2. Skin Preparation:
   • The skin over the chosen insertion site is cleaned and prepared using antiseptic solutions to reduce the risk of infection.
3. Needle or Trocar Insertion:

   • 

     A small incision is made in the skin at the chosen site under sterile conditions.
   • A needle or trocar is inserted through the incision into the pleural space under continuous ultrasound guidance.
4. Confirmation of Placement:
   • Once the needle or trocar is in the pleural space, the healthcare provider confirms its position using imaging (ultrasound or fluoroscopy) and may withdraw a sample of fluid or air for analysis.
5. Chest Drain Placement:
   • After confirming the correct placement, a chest drain tube (chest tube) of appropriate size is inserted through the needle or trocar into the pleural space.
   • The chest drain is connected to a drainage system (such as a water seal or suction system) to remove fluid or air continuously.
6. Securement and Dressing:
   • The chest drain tube is secured in place using sutures or adhesive dressings to prevent dislodgment.
   • Sterile dressings are applied around the insertion site to maintain cleanliness and monitor for any signs of infection.

Post-procedure Care

1. Monitoring:
   • Vital signs, respiratory status, and drainage from the chest tube are monitored regularly to assess response to drainage and detect any complications.
   • Chest X-rays may be performed post-procedure to confirm lung re-expansion (in cases of pneumothorax) or assess the resolution of pleural effusion.
2. Pain Management:
   • Pain at the insertion site or discomfort due to chest tube placement is managed with appropriate analgesics as needed.
3. Chest Tube Management:
   • The drainage system is maintained and monitored to ensure adequate drainage and prevent blockages or air leaks.
   • The healthcare team provides instructions on chest tube care, drainage monitoring, and when to seek medical attention for any concerns.

Benefits of Image-Guided Chest Drain Insertion

• Accuracy: Ultrasound guidance improves accuracy in identifying the pleural space, reducing the risk of complications such as lung injury or organ perforation.
• Safety: Minimises the risk of accidental injury to surrounding structures (such as blood vessels or nerves) during insertion.
• Optimal Site Selection: Allows for the selection of optimal insertion sites based on pleural anatomy and pathology, improving the effectiveness of fluid or air drainage.
• Patient Comfort: Local anesthesia and precise needle or trocar placement enhance patient comfort during the procedure.

Risks and Considerations

• Bleeding: Risk of bleeding at the insertion site, particularly in patients with coagulation disorders or anticoagulant therapy.
• Infection: Although rare, there is a risk of infection at the insertion site or within the pleural space.
• Pneumothorax: Inadvertent lung puncture during chest tube insertion can lead to pneumothorax, which may require additional interventions.
• Malpositioning: Chest tube malpositioning can result in ineffective drainage or complications such as subcutaneous emphysema.

Conclusion

Image-guided chest drain insertion, often performed under ultrasound guidance, is a safe and effective procedure for draining pleural effusions, pneumothorax, or empyema. It improves accuracy, safety, and patient comfort during the insertion process