ABSTRACT
If it is decided that an intercostal tube is needed, this is done in a similar fashion to that described for pleural fluid drainage. All of the following steps are important: • the drain must be performed under full sterile conditions with the patient
being given a premedication; • infiltration of skin and intercostal space with 1% lignocaine; • the site of insertion should be over the upper edge of the rib in the fourth
or fifth intercostal space just behind the anterior axillary line; • the alternative of the second intercostal space anteriorly (although a well
described site) may lead to problematical scars, particularly in young women;
• a scalpel is used to cut a hole through the chest wall skin large enough to insert the intercostal tube using blunt dissection with scissors or Spencer Wells forceps down to the pleura;
• a hole big enough for the insertion of the tube is made; • the tube is then placed gently through this preformed hole and then
stitched in place with a purse string suture; • the tube is connected to a bottle containing 500 ml of 0.9% saline forming
an underwater seal; • clamps are left by the bedside so the tube can be clamped off in an
emergency; • the patient is then asked to cough to re-inflate the lung; • the tube is left in place for 24 hours after it has stopped bubbling and then
removed;
• the wound is sealed by tying the purse string suture; • if the lung fails to re-inflate and the tube keeps bubbling, this signifies a
continuing air leak through the pleura (a bronchopleural fistula). Gentle suction using a pump is then applied and after several days or even weeks, the bubbling usually ceases;
• very rarely, thoracotomy is needed to seal an emphysematous bulla or divide pleural adhesions.
