Epstein, Jayathissa and Dee report (in this issue of the Journal) on their review of small-bore chest tube insertion practices for drainage of pleural fluid at Hutt Valley District Health Board (HVDHB). They report a surprising number of complications and conclude that specialist societies need to take leadership in providing guidance on chest drain insertions to secondary and tertiary hospitals in Australia and New Zealand. This appears to abdicate the responsibility of education away from the teachers of our resident staff.

The ability to place a safe chest tube should be in the repertoire of all doctors of registrar or greater positions. Unfortunately, bad techniques are often passed down to generations of resident medical officers (RMOs) based on a teaching principle of “see one, do one, teach one”.

On of the authors (DS) of this editorial, a cardiothoracic surgeon, has been involved with/made aware of/consulted on complications inclusive of cardiac insertion, lung parenchyma insertion, liver insertion, IVC insertion (via liver), splenic insertion, damage to intercostal vessels, pulmonary artery, axillary vein, portal vein, bowel, and so on. Informal analysis of these errors has led us to the conclusion that they are almost universally avoidable and a product of inexperience and ignorance on the part of the operator with regard to anatomy, physiology, and dealing with complications.

The objective is simple. A tube is to be placed within the pleural cavity through the chest wall without damaging contents of the chest cavity or chest wall and if damage occurs it is noted and managed appropriately. In order to do this, a very basic understanding of anatomy, physiology and human factors is required.

Kindergarten anatomy for chest tube insertion:

Fortunately the majority of structures one wishes to avoid are located medially hence the thoracic surgical axiom “go high, go laterally”.

The plane of the manubriosternal angle denotes the bifurcation of the pulmonary artery, inside arch of aorta, and so forth. Classic teaching of mid clavicular lines/second interspace for emergency chest tube placement is, in the opinion of the authors, inherently dangerous. Tales of pulmonary artery injury etc nearly always associated with this site. It should only be used by experienced personnel when lateral access is not an option.

The surgical teaching, that the safest way to place a tube in the chest is to place a finger in first, still holds. There is an illusion that the ease of a Seldinger technique makes it inherently safer. This is wrong. Unfortunately there is a generation of RMOs ignorant in the skills to place a tube in the classic manner. This had led to the inappropriate approach of “only one screwdriver for all screws”.

While it is not the intention of this editorial to provide detailed instructions of the technique of inserting a classic chest drain please bear in mind the following:

A thoracic drain connected to an underwater seal system is simply a manometer within the chest. With inspiration there is negative intrathoracic pressure that not only draws in air for breathing but will “suck” the “water” up the tube. The water goes down during inspiration then the tube is not measuring intra thoracic pressure, it is most likely in the abdominal cavity and thus an urgent general surgical opinion should be sought.

While good technique and an understanding of relevant anatomy/physiology will not guarantee freedom from complications, a poor technique applied without understanding will guarantee avoidable complications.

Author information: Frank A Frizelle, Professor of Colorectal Surgery, Department of Surgery; David Shaw, Cardiothoracic Surgeon, Cardiothoracic Surgery; Christchurch Hospital, Christchurch

Correspondence: Professor Frank Frizelle, Department of Surgery, 2F Parkside, Christchurch Hospital, PO Box 4345, Christchurch, New Zealand. Email: FrankF@cdhb.govt.nz