• Treatment of pneumothorax or pleural effusion

• Introducer needle
• Chest drain
• Guidewire
• Dilator
• 3-way tap, connector
• Extension
• Flutter valve
• Steri-Strip™
• Transparent dressing

• It is advisable 2 people are scrubbed for this procedure

Step 1: Analgesia

• Ensure baby has adequate analgesia  
  
  • if ventilated: use morphine bolus
  • if non-ventilated: use low-dose fentanyl (watch for chest wall rigidity) 
  • lidocaine locally

Step 2: Aseptic technique

• Use sterile gloves and gown
• Identify site
• Clean skin according to local policy

Step 3: Insert needle

• Select location for chest drain - usually 5^th intercostal space, anterior axillary line
• Place Steri-Strip™ 1 cm from bevelled end of needle 
  
  • ensures needle not advanced too far 
  • acts as marker in case of needle slipping out 
• Insert needle whilst aspirating syringe
• Stop advancing once air aspirated (<1 cm)

Step 4: Insert wire

• Pass wire through needle ensuring wire is not inserted any further than silver mark. Holding wire still, remove needle 

Step 5: Dilate the skin

• Pass dilator along wire

• Push dilator through skin approximately 1 cm, angling anteriorly

• Skin may require small incision

• Following dilation, dilator can be removed

Step 6: Insert drain

• Advance drain over wire (this often needs an assistant)
• Advance drain through skin so holes are inside baby’s pleural space – i.e. at least 1 cm from the skin and insert to:
  
  • preterm babies: 1^st–2^nd black mark 
  • term babies: 3^rd–4^th black mark 
• Wire can now be removed

Step 7: Add flutter valve or connect to underwater seal

• Assemble drainage equipment

  • extension

  • 3-way tap 

  • connector and flutter valve or underwater seal and suction

  • if connected to underwater seal use 5-8 cm H₂O pressure suction

• Attach valve/underwater drain with suction to end of drain 
• Chest X-ray to confirm position and monitor progress/resolution in pneumothorax or pleural effusion

Step 8: Secure drain

• Carefully secure drain 
  
  • do not use a purse string suture
  • secure chest drain with Steri-Strip™ and Tegaderm™
  • if required, suture may be placed through skin and knotted to drain

• Wear personal protective equipment, i.e. gloves, eye protection
• Remove sutures and Tegaderm™
• Gently pull drain – pigtail will uncurl
• Beware of splashing body fluids – as drain comes out of skin, pigtail catheter will spring back