Always remember–

Be careful about the amount of fluid being removed.

Removing excess fluid can cause the child to go into hypovolemic shock

INDICATIONS

• Pneumothorax

• Tension pneumothorax- pneumothorax causing the collapse of the lung due to air accumulation

• Repeated pneumothorax in spite of needle drainage

• Ventilated patients

• Malignant pleural effusion

• Empyema- generally following abscess of the lung being ruptures or pulmonary tuberculosis

SIGNS AND SYMPTOMS OF PRESENTATION

The presentation depends on the age of the child and the hemodynamic stability as well.

Keep a close eye on the following signs

• Pallor or cyanosis

• Dyspnoea

• Increased respiratory rate

• Reduced breath sounds on the affected side

• Dullness of percussion

• Reduced chest movement on the affected side

• Decreased oxygen saturation

• Pleuritic chest pain

• Transillumination in the affected side in pneumothorax- use a torch and touch it to the skin and look for a rim of over 2 cm.

• Cardiovascular change- tachycardia, decreased blood pressure

PREPARATION

• Before the procedure try to get a chest Xray to confirm the problem.

• In emergencies, you can use needle decompression to buy time.

NEEDLE DECOMPRESSION

• Decompression by large bore needle (14G-22G)

• Anterior 2nd intercostal space in the midclavicular line

• Inset over superior aspect of rib margin

• A subsequent Chest tube is necessary

CHEST TUBE INSERTION

Equipment needed

• Sterile chest tube pack containing gallipot, forceps, scalpel, gauze

• Suture material

• Cleaning solution –

• Sterile gloves

• Local anaesthetic

• Syringes and needles

• Chest drain  and the tubing with a bottle

• Chest drain clamps and suction pump

Method

• Position child with affected side up.

• Entry- 3rd to 5th Intercostal space in mid to anterior axillary line at the level of the nipple.

• Locally Anesthetise with 1% lidocaine.

• 1-3 cm incision once intercostal space below desired insertion point and dissect with haemostat until a superior portion of the rib is reached.

• Push Haemostat on top of rib through Pleural space (not> 1 cm).

• Spread haemostat and insert a chest tube in the clamp.

• For pneumothorax- insert tube anteriorly toward apex and for effusion direct tube inferiorly and posteriorly.

• Attach to drainage system with 20-30 cm H2O pressure.

• Chest X-ray to confirm position.

THORACOCENTESIS

• Confirm fluid in pleural space ( X-ray/Clinically )

• The child in sitting position/ Supine

• Anesthetise skin (1% lidocaine) around 7th intercostal space along the posterior axillary line

• 18-22 G IV catheter attached to syringe into the rib and push through superior aspect of Rib to pleural space with negative pressure until POP

• Remove fluid for investigations/ symptomatic relief

• Chest X-ray to rule out pneumothorax