Intercostal catheters (ICC), or informally chest tubes, are inserted into the pleural space to drain fluid and/or air. They typically refer to large-bore (10-14 Fr) drains placed under direct vision rather than percutaneous pigtail catheters (6-8 Fr) placed under image guidance.

Indication

The indications are wide and can include ¹:

• pneumothorax

• chest trauma

• pleural effusion

• haemothorax

• chylothorax

• bronchopleural fistula

• post-cardiothoracic surgery

• parapneumonic effusion

• empyema

Technique

• consent

• patient position

  • preferred: sitting at a 30-45° incline with the arm on the side of the procedure abducted

  • alternative: sitting upright and supported onto a table anteriorly or lateral decubitus

• identify triangle of safety, insertions are preferably orientated slightly superior to the border of the inferior rib to minimise the risk of damaging the neurovascular bundle

• sterile preparation and drape

• local anaesthetic infiltration down to the level of parietal pleura

• 1-2 cm incision parallel to the rib

• blunt dissection using index finger or blunt forceps and breech parietal pleura: will be accompanied by a release of blood, fluid or air

• dilate insertion site with index finger

• insert drain with forceps directed towards the lung apex for pneumothorax or basally for haemothorax or fluid drainage

• drain size

  • 10-14 Fr

  • smaller bore drains are recommended to minimise discomfort

  • larger bore drains are recommended for draining haemothoraces

• there should be minimal resistance during drain insertion and an appropriate length should be passed within the pleural cavity

• suture drain superficially and secure

• connect the drain to an underwater seal drain system

• confirmation: chest radiograph post procedure

  • in certain drains, the absence of ‘swinging and bubbling’ in the underwater seal mechanism are concerning signs of dysfunction

Complications

• general complications

  • malpositioning

  • pain

  • pneumothorax/tension pneumothorax

  • infection

  • device failure/malfunction

• complications arising from damage to local structures

  • heart and great vessels

  • lungs and tracheobronchial tree

  • oesophagus and stomach

  • upper abdominal organs especially the liver and spleen

  • intercostal nerves and vessels