Twenty-nine-year-old Meghna (surname withheld on request) was experiencing breathlessness and recurrent fever. The Mumbaikar also complained of a loss of appetite. Her X-ray and CT scan indicated an accumulation of fluid in the left pleural space (space between the lung and rib). It was deduced that she had tuberculosis in the lungs.
Initially, the fluid was removed with an injection, on an outpatient basis. However, her symptoms returned within a week, and the fluid filled up the pleural cavity again. She was admitted to a hospital and a tube was inserted in her chest to drain the fluid out. She had the chest tube on for four to five days.
When the fluid had drained out completely, the tube was removed. Meghna was kept under observation for two days with daily X-rays done to monitor if the fluid was filling up again. But no fluid was observed after the removal of the tube, and she was discharged. She has now recovered completely.
The procedure that Meghna underwent was a chest drain, also known as the underwater sealed drain (UWSD) or intercostal drain (ICD).
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When air enters between the lungs and ribs
“There is a space between the lungs and the ribs called pleural space,” says Dr Amit Gawnde, a consultant pulmonologist and critical-care specialist from Mumbai. “Normally, this is a frictionless space filled with 20-50ml of lubricating fluid that facilitates the movement of the lungs and ribs during respiration. Sometimes, this space gets filled with fluid or water. This puts pressure on the lungs, causing breathing difficulties. An intercostal drainage tube (a hollow plastic tube) is introduced into the area to eliminate air and fluid from the pleural space.”
The opposite end of the chest tube is submerged in water. Dr Gawnde says this is done for two reasons:
- it prevents the backflow of air or fluid into the pleural cavity
- the bubbling of the water indicates that the air or fluid is being expelled.
“The chest tube is kept until the bubbling stops,” he says. “When the bubbling ceases, it implies that the air or fluid has drained out completely.”
Conditions that may need a chest drain
In the case of pneumothorax, a condition where air enters the pleural space, expelling the trapped air through a chest drain is the primary mode of treatment. Pneumothorax can develop through trauma or underlying conditions like chronic obstructive pulmonary disease, where numerous bullae (air sacs) may rupture spontaneously and develop into a pneumothorax.
Pleural effusions do not always entail a chest drain. Intercostal drainage is advised only in cases where the person has malignancy in the effusion or a massive recurrent effusion despite three to four sessions of pleural tapping.
Inserting the chest tube
“The chest tube is placed in the safety triangle located in the mid axillary line (an imaginary landmark line that divides a person’s torso into front and back halves) at the level of the fifth intercostal space (the space between the fifth and sixth ribs),” says Dr Abhinav Das, consultant pulmonologist, Nemcare Super Speciality Hospital, Guwahati, Assam. “The reason this area is called the safety triangle is that there is very [little] nerve supply in this region and minimum chances of damage to the underlying lungs.”
Elaborating on the preparations before the procedure, Dr Gawnde says, “Since the insertion of the chest tube is an invasive procedure, the person must undergo blood tests to evaluate if they are fit for the procedure. The person is given local anaesthesia before inserting the chest tube. Sometimes, they are put to sleep by giving generalised anaesthesia.”
According to Dr Das, the chest tube could be an external source of infection. It should be extremely clean and should be emptied daily. “During movement, the person should take extra care so that the tube isn’t dislodged,” he says.
Who should not undergo a chest drain?
If the person has bleeding diathesis (an increased tendency to bleed), performing an invasive procedure like chest tube insertion will be difficult, according to a study published in the US National Library of Medicine in 2022.
According to Dr Gawnde, certain physical traumas can also act as an obstacle to inserting an ICD tube.
How long does a chest drain take?
Dr Das says that the duration differs from person to person. “In some people, the chest drain is continuous,” he says. “In case of complicated effusions, where there are thick materials like puss, the drain will occur inconsistently. Usually, the fluid drains continuously.”
Post-procedure
Dr Das recommends getting a tetanus toxoid (vaccine to provide immunity against tetanus) after the procedure. Some form of painkillers in the form of tramadol and diclofenac are also administered as part of post-procedure care.
