• Treatment of pneumothorax or pleural effusion

• Sterile dressing pack
• Cleaning solution as per unit policy and wash off with sodium chloride 0.9% once dried for babies <26 weeks’ gestation
• Lidocaine 1%, with syringe and needle for preparation and injection
• Chest drains size FG 8,10,12 (use largest possible depending on size of baby)
• Low pressure suction unit
• Scalpel and fine straight blade (size 11)
• Fine blunt forceps
• Underwater seal chest drainage bottle and tubing or flutter (Heimlich) valve
• Steri-Strip™ and transparent dressing (e.g. Opsite/Tegaderm™)

• Site of insertion depends on position of pneumothorax 
  
  • preferred site is in anterior axillary line, between 4^th and 6^th intercostal space, to conceal subsequent scarring and
  • avoid interference with breast development
  • alternative site is just lateral to midclavicular line, in 2^nd or 3^rd intercostal space 
  • if pneumothorax does not drain satisfactorily, it may be necessary to insert >1 drain 
  • for pleural effusion, use midaxillary line between 4^th and 5^th intercostal spaces, and direct drain posteriorly

Preparation and position of baby

• Inform parents and obtain verbal consent as recommended by BAPM (unless emergency procedure)

• Use 10–12 FG pleural catheter (small babies may need 8 FG)

• Position baby supine and flat with affected side slightly tilted up (e.g. by using a folded blanket) 

• Prepare skin with full aseptic technique

• Infiltrate with lidocaine 1%, even in babies being given systemic analgesia

Insertion of tube

• Make small incision in skin with scalpel at lower edge of intercostal space to avoid injury to intercostal vessels
• Dissect bluntly with fine forceps through intercostal muscle and pleura 
• Use fine forceps to gently advance tip of catheter 
• Push and twist tube gently through incision into pleural space
• Insert chest drain 2–3 cm for small preterm and 3 cm for term babies
• If drain has additional proximal hole, ensure this lies within chest cavity
• Use of trocar not generally recommended. If used (in bigger baby), protect lung by clamping artery forceps onto trocar 1 cm from the tip 
• Connect tube to prepared underwater seal or flutter (Heimlich) valve 
• Manipulate tube gently so that tip lies anteriorly in thoracic cavity for pneumothorax, and posteriorly for effusion
• Secure tube with Steri-Strip™, and cover with gauze dressing. A suture may be required; do not use purse-string suture
• Secure tube to chest wall using suitable tape (Opsite/Tegaderm™)

• Check bubbling or oscillation of water column seen with every inspiration 
• Check tube position with chest X-ray (consider lateral X-ray to confirm position)

Suction

• If bubbling is poor/absent and X-ray confirms drain is in correct position but pneumothorax not fully draining on X-ray or cold light, apply continuous suction of 5–10 cm H₂O. Thoracic suction is better suited for this purpose than routine wall suction. Occasionally, a second drain may be necessary

Flutter valve

• As an alternative to underwater chest drain system, especially during transport, a flutter valve can be used

Document

• Record presence of bubbling (continuous/intermittent/none) on nursing care chart
• Record with nursing observations, bubbling and/or oscillation of water column, or fluttering of valve seen with every inspiration

• Remove when no bubbling or oscillation of water column has occurred for 24 hr
• Clamp chest drain for 12 hr and repeat chest X-ray before removal. While removing drain, ask an assistant to hold wound edges close together
• After removing drain, close wound with Steri-Strip™; a suture is seldom necessary
• Close clinical observation after removal of drain is sufficient to diagnose reaccumulation of the air leak, routine chest X-ray not generally warranted