Thread by @IM_Crit_

British Thoracic Society recently published a must-read Statement on pleural procedures. It is 26 pages long & is accompanied by 13 online supplementary appendices

These are the highlights (I skip paragraphs on pleural biopsy & malignant effusions that are not among an intensivist's daily routine)

Summary of clinical practice points:

Before carrying out a pleural procedure, a review of indications & contraindications should be performed:

Pleural aspiration (PA) (diagnostic & therapeutic):

Thoracentesis should be performed ABOVE A RIB

Thoracic ultrasound MUST be used for aspiration

SMALL bore needles are preferred

For therapeutic aspiration >60 mL, a catheter should be used rather than a needle alone

Use of Veress needle may reduce risk of damaging underlying structures

Therapeutic PA should be performed SLOWLY using manual syringe aspiration or gravity drainage. Vacuum bottles or wall suction should NOT be used.

In general, a max of 1.5 L should be drained in 1 attempt

Routine use of manometry DOES NOT HELP to reduce the risk associated with large volume PA

The procedure should be stopped if symptoms of chest tightness, pain, persistent cough or worsening breathlessness develop

Intercostal drain insertion:

Small-bore drains (< 14 Fr) are suitable for most indications including draining empyema

Larger drains should be considered in unstable trauma & pneumothorax complicating mechanical ventilation

Consider a drain > 14 Fr if pleurodesis is intended

BEFORE drain insertion, aspiration of air or fluid w the needle applying the anaesthetic is necessary, & failure to do so should prompt further assessment

All chest drains should be fixed with a holding suture to prevent fall out

A chest drain inserted for managing pleural effusion should be clamped promptly in patients with repetitive coughing or chest pain to avoid re-expansion pulmonary which is a potentially fatal complication

A follow-up chest xray should be conducted within a few hours of insertion

For pleural fluid, the volume to be drained over specific time periods should be specified in the procedure report & in handover (eg, 500 mL/hr)

In cases of non-functioning intercostal drain where another drain is required, the old track must be avoided when inserting a new one

How to set up a chest drain bottle & underwater seal drain:

Aseptic non-touch technique should be used when changing a chest drain bottle/underwater seal drain or drain tubing

The drain bottle must be kept below the insertion site & the drain must be kept upright at all times

The drain must have adequate water in the system to cover the end of the tube

For patients with pneumothorax and suspected/confirmed COVID-19, a viral filter should be considered to minimise the risk of droplet exposure via the chest drain circuit

Drains should be checked daily for wound infection, fluid drainage volumes & presence of resp swinging and/or bubbling

CLAMPING a bubbling chest tube should be AVOIDED unless under specialist's supervision & in specific circumstances only

Drainage of a large pleural effusion should be controlled to prevent the potential complication of re-expansion pulm edema

Suction & digital chest drain devices:

SUCTION should be AVOIDED soon after drain insertion to minimise the risk of re-expansion pulm edema

Routine use of thoracic suction should be avoided given a lack of data demonstrating clinical benefit

If suction is used, low-pressure, high-volume thoracic suction should be used

Patients receiving suction should have a viral filter or a digital device should be used to minimise the risk of aerosol generation

Other points:

Pleural procedures should be undertaken in normal working hours. They should only be undertaken out of hours in an emergency

No large studies accurately define bleeding risk associated w pleural procedures in pts on antiPLT/anticog meds, or those w coagulopathy

Several small studies have found no increased bleeding risk of thoracentesis or small-bore chest drain insertion in patients on clopidogrel, or with an uncorrected bleeding risk

Pleural fluid diagnostics tests & sample collection guidance:

Assessment of a non-functioning chest drain:

Cessation of fluid swinging in the tubing is usually a
manifestation of drain blockage which can be resolved with simple saline flushing. The full length of the drain/tubing should be inspected to rule out any kinking

Management of problematic sc emphysema:

Surgical (subcutaneous) emphysema following
chest drain insertion is common & often of no clinical consequence. However, sometimes substantial amounts of air can accumulate. Risk factors: drain blockage & poor drain placement or fixation

Kudos to the authors for this comprehensive document!

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