Introduction

An intercostal drainage tube (ICD), also called a chest tube or chest drain, is a flexible hollow tube placed inside the chest to drain fluid, air, or blood that has collected in the space between the lungs and the chest wall. This space is called the pleural cavity.

In children, the pleural cavity can fill up with air or fluid due to infections, injuries, or other medical conditions. When this happens, the lung cannot expand properly, and breathing becomes difficult. An ICD removes whatever is collecting in that space and allows the lung to function normally again.

Purpose and Where It Is Used

An intercostal drainage tube is used to remove abnormal collections from the pleural space. The most common reasons for placing an ICD in children include:

Settings Where ICD Is Used

• Pediatric emergency departments
• Neonatal and pediatric intensive care units (NICU/PICU)
• Post-operative care after chest or heart surgery
• Inpatient wards managing complicated pneumonia or pleural effusion

Types of Intercostal Drainage Tubes

Different types are chosen based on the child's age, size, and what needs to be drained.

Tube Size (French Scale - Fr)

Tube size is selected based on the child's age and weight. Larger tubes drain thick fluid better; smaller tubes are more comfortable for thin fluid or air.

Note: Size selection may vary depending on the clinical condition and the practitioner's judgment.

Components of an ICD System

• Chest tube: The main tube inserted into the chest
• Connector: Links the tube to the drainage system
• Underwater seal drainage (UWSD) bottle: A bottle with water that allows air/fluid to drain out but prevents air from entering back
• Suction source (optional): Applies gentle negative pressure to help drain fluid or air faster
• Tubing and clamps: To connect and control flow
• Sterile dressing: To cover and seal the insertion site

How It Is Used: Step-by-Step

Before the Procedure

1. Patient preparation Confirm the diagnosis with chest X-ray or ultrasound. Explain the procedure to caregivers and obtain consent.
2. Positioning Place the child in a comfortable position - usually lying down with the affected side slightly elevated, arm raised above the head to open up the rib spaces.
3. Pain management Give appropriate sedation and/or local anaesthesia to minimize pain and distress. In smaller children, procedural sedation is commonly used.
4. Prepare equipment Gather sterile gloves, drapes, antiseptic, appropriate tube size, UWSD bottle filled with sterile water to the 2 cm mark, sutures, and dressing materials.
5. Assemble drainage system Fill the UWSD bottle with sterile water, connect tubing, and confirm the system is airtight.

Insertion Site

The standard insertion site in children is the 5th intercostal space, anterior axillary line (the "safe triangle" area). This area avoids major vessels and nerves.

During Insertion

1. Clean and drape Clean the insertion site with antiseptic solution (e.g., povidone-iodine or chlorhexidine). Apply sterile drapes around the area.
2. Local anaesthesia Inject local anaesthetic (e.g., lignocaine) into the skin, subcutaneous tissue, and around the rib periosteum.
3. Incision Make a small skin incision (1-2 cm) along the upper border of the lower rib to avoid the nerve and blood vessels that run below each rib.
4. Blunt dissection Using a clamp, tunnel through the soft tissue into the pleural space. A gush of air or fluid confirms correct placement.
5. Tube insertion Insert the chest tube through the opening, directing it towards the apex for pneumothorax or the base for fluid drainage.
6. Connect to drainage system Immediately connect the tube to the UWSD bottle. Observe for bubbling (air drain) or fluid flow.
7. Secure the tube Suture the tube firmly to the skin. Apply an occlusive sterile dressing around the site.
8. Confirm position Obtain a chest X-ray to confirm correct tube position and improvement in the lung.

After Insertion - Monitoring

• Check that the UWSD bottle shows swinging (water level moves with breathing) - this confirms the tube is in the pleural space
• Measure and record the amount of fluid drained every few hours
• Note the colour of the drained fluid (clear, yellow, bloody, turbid)
• Watch for continuous bubbling at rest in the UWSD bottle (may indicate an air leak)
• Keep the drainage bottle always below the level of the chest
• Do not clamp the tube unless specifically instructed
• Monitor the child's breathing, oxygen levels, heart rate, and comfort

Removing the Tube (Tube Removal / Decannulation)

The tube is removed when the condition has resolved: air leak has stopped for 24-48 hours, or drainage has reduced to a very small amount. Removal is done during a breath-hold (Valsalva) or end-expiration to prevent air from entering during removal. The site is then closed and covered with an occlusive dressing.

Precautions and Possible Complications

Common Precautions During ICD Care

• Always keep the drainage bottle below chest level - lifting it above the chest can push fluid back into the pleural cavity
• Never clamp the tube without a specific medical instruction
• Do not allow the tubing to kink, loop, or get blocked
• Keep the insertion site clean and dry; change dressing as instructed
• Ensure all connections are airtight and secure
• Do not allow the water level in the UWSD bottle to fall below 2 cm
• When moving the child, keep the bottle upright and below chest level at all times

Possible Complications

How to Keep the ICD System Safe

Handling the Drainage Bottle

• Keep the bottle upright at all times - never tip it sideways
• Maintain the sterile water level at the 2 cm mark
• Change the bottle only when instructed and using proper technique to avoid air entry
• Label the bottle with date and time of setup

Securing the Tube

• Confirm that the tube is well-secured with suture and dressing after each dressing change
• Use adhesive tape or tube-holders to prevent accidental tugging
• In active or restless children, extra care must be taken to prevent the child from pulling at the tube
• Place soft padding around the insertion site to prevent pressure from the tube on the skin

Dressing Care

• Change dressing every 48-72 hours or when wet, soiled, or loose
• Use sterile technique during dressing changes
• Inspect the insertion site during each change for redness, swelling, discharge, or skin breakdown

Tubing and Connections

• Check all connections daily for tightness
• Ensure no loops or kinks in the tubing between the chest and the bottle
• If the tube disconnects accidentally, immediately seal the open end (clamp or submerge in sterile water) and reconnect
• If the tube falls out, cover the insertion site with a sterile occlusive dressing immediately and seek medical help

Additional Important Points

Pain Management

An ICD can be uncomfortable. Adequate pain relief is important throughout the period the tube is in place. This can include paracetamol, ibuprofen, or stronger medications depending on the child's age and condition. Oral analgesia is routinely provided, and the site can be supported during movement to reduce pain.

Position and Mobility

Children with an ICD can generally be positioned sitting up or lying down. Sitting upright can aid drainage by gravity. Gentle position changes are encouraged to prevent complications of prolonged bed rest. The drainage system must move with the child at all times.

Feeding and Hydration

There is no direct dietary restriction due to an ICD. Adequate nutrition and hydration support recovery from the underlying condition.

How Long Does an ICD Stay In?

The duration depends on the underlying cause. For simple pneumothorax it may be 1-3 days. For empyema or complicated effusions it may be 1-2 weeks or longer. The tube is removed only when the drainage stops or becomes minimal and the lung has re-expanded on X-ray.

Suction

Sometimes suction is applied to the drainage system to speed up lung re-expansion. Low-pressure suction (usually -10 to -20 cm H2O) is used. Suction settings in children are carefully chosen based on age and condition.

Milking or Stripping the Tube

Routine milking or stripping of chest tubes is no longer recommended in most guidelines, as it can create excessively high negative pressure inside the chest. It may be done in specific situations only on medical instruction.

Frequently Asked Questions (FAQs)