Intercostal catheter

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

 

Aim 

To guide staff in the use of intercostal catheters and needle thoracocentesis.

Needle thoracocentesis

  • Needle thoracocentesis provides rapid emergency decompression of a tension pneumothorax 
  • It is a temporary life-saving procedure - a definitive chest drain will be required to stabilise the ongoing air leak.

Indications

Clinical evidence of a tension pneumothorax:

 

  • hypoxia
  • hypotension
  • tachycardia
  • decreased air entry +/- hyper-resonance on side of pneumothorax
  • deviated trachea to opposite side
  • increased difficulty in ventilation
  • radiographic evidence of a tension pneumothorax in a haemodynamically stable patient.

Equipment

 

  • 14g or 16g cannula
  • 3-way tap
  • 10mL syringe
  • 2% chlorhexidine / 70% isopropl alcohol.

Procedure

 

  • Identify the second intercostal space, mid clavicular line of affected hemi thorax
  • Cleanse the skin
  • Consider local anaesthetic in the conscious child (if time permits)
  • Attach 10mL syringe to the end of the cannula
  • Insert the cannula into the lower half of the second intercostal space, at 90º to the chest wall
  • Aspirate the syringe as the needle enters
  • Continue advancing the cannula until you aspirate air (3-4ml of 0.9% saline in the syringe may help with presence of air bubbles) or until you insert to the maximum depth
  • At either of these end points remove the syringe and needle, leaving the cannula in the chest wall
  • Check for improvement of the child's clinical condition
  • A 3-way tap may be applied for ongoing aspiration, if required
  • Consider a second needle decompression if there is no apparent improvement
    • 1cm adjacent to the original cannula
  • Proceed to chest drain insertion as soon as possible when patient is stabilised
  • Perform the chest X-ray (CXR) after the formal chest drain has been placed.

Intercostal Catheter Insertion

An intercostal catheter provides drainage of pleural air, blood or fluid.

Indications

  • Following a needle decompression of tension pneumothorax
  • Large pneumothoraces (> 20%)
  • Most traumatic haemathoraces
  • Large pleural effusions.

Equipment

 

  • 2% Chlorhexidine/70% isopropl alcohol
  • Sterile surgical drapes, gown, mask
  • Sterile gloves
  • Local anaesthetic, syringe and needle
  • Gauze
  • Scalpel blade
  • Forceps for blunt dissection
  • Chest drain - without trochar
  • Suture - 2.0 silk
  • Sterile transparent occlusive dressing
  • Atrium draining system (underwater seal drain)
  • 2 x large chest drain clamps.

Chest tube size

Size: approximately (in Fr) 4 x ETT size (in mm)

Age  Chest tube size (Fr)
Newborn 8-12
Infant 14-20
Child 20-28
Adolescent   28-36

Procedure

  • Position Patient
    • Supine or sitting 30º upright
    • Arm on affected side positioned above the shoulder behind the head

Patient position for intercostal catheter insertion

 

  • Consider the need for adjunctive analgesia or sedation (within limits of patient safety as determined by the clinical scenario)
    • e.g. intranasal fentanyl or intravenous morphine
  • Identify insertion site 
    • Typically 5th intercostal space anterior to mid-axillary line

Insertion sites for intercostal catheter

 

 

  • Prepare skin with 2% chlorhexidine / 70% isopropl alcohol
  • Drape area
  • Infiltrate local anaesthetic
    • Superficially under the skin
    • Advance needle fully until air aspirated from pleural cavity
    • Slowly withdraw and infiltrate from deep to superficial
  • Perform skin incision in the identified rib space parallel to rib (above the lower rib to avoid neurovascular bundle)
    • Length: approximately twice the width of the drain
    • Depth: until subcutaneous fat is on view
  • Blunt dissect through remainder of the chest wall using blunt dissection forceps
    • Continue until the pleural space is penetrated (evidenced by a 'give' or air hiss)
  • Remove instruments and insert finger through the tract into the pleural space
    • Perform a single sweep with finger internally within the pleural space
    • This is only possible in older children
  • Insert chest drain, without trochar, into pleural space
    • Use forceps to guide the drain, if necessary
    • Aim for apex if draining air and base if draining fluid
  • Insertion depth is approximately the width of the hemithorax - ensure all holes in chest drain are within pleural space
  • Connect chest drain to underwater seal drain
  • Check for fogging of the tube, bubbling of underwater seal or swing of blood, fluid
  • Suture drain in place
  • Place an occlusive dressing over the area
  • Confirm position with CXR
  • Secure connection of chest drainage system with cable ties.

This open technique for chest drain insertion should be used for all trauma patients. A Seldinger technique using commercial intercostal drain kits may be used for spontaneous pneumothoraces or pleural effusions after discussion with senior clinicians.

 

Bibliography

  1. Textbook of Paediatric Emergency Medicine 2nd Edition Cameron Elesevier
  2. Advanced Paediatric Life Support (APLS) 2017 Book 5th Edition



Endorsed by:  Director, Emergency Department   Date:  Mar 2018


 Review date:   Aug 2020


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