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| (i) Do use tension pneumothorax (PT) after initial needle relief, recurrent PT, in ventilated patients and large secondary spontaneous PT in patients over 50 years. | |
| (ii) Do use malignant pleural effusion, empyema, traumatic hemopneumothorax, and post-op pleural effusions. | |
| (iii) Do not use uncorrected coagulopathy and lung densely adherent to the chest wall throughout the hemithorax. | |
| (iv) Do not drain a postpneumonectomy space until consultation with a cardiothoracic surgeon. | |
| (v) Beware of lung bullous disease and do not confuse with PT and a lung collapse presenting as chest radiograph shows a unilateral “whiteout.” | |
| (vi) Do obtain informed consent and premedicate appropriately. | |
| (vii) Do aseptic technique and make sure all necessary equipment is at hand. | |
| (viii) Do insert the mid axillary line in the “safe triangle” with the patient in bed, slightly rotated, with the arm on the side of the lesion behind the patient’s head. Alternatively, use upright sitting position with the patient leaning over a table with a pillow or in the lateral decubitus position. | |
| (ix) Do not insert drain without further image guidance if free air or fluid cannot be aspirated with a needle at the time of anesthesia. | |
| (x) Do use image guidance preferably ultrasound. | |
| (xi) A CXR must be available at the time of drain insertion except in the case of tension pneumothorax. | |
| (xii) 10–14 French (F) drains are generally used but larger bore catheters are preferred for a hemothorax. | |
| (xiii) Do avoid substantial force during insertion use a Seldinger technique or by blunt dissection through the chest wall and into the pleural space before catheter insertion. | |
| (xiv) Do insert a finger before inserting the intercostal catheter. | |
| (xv) Do not proceed if pulsatile bright red blood comes from the drain. | |
| (xvi) The position of the tip of the chest tube should ideally be aimed apically for a pneumothorax or basally for fluid. | |
| (xvii) Use +“Purse string” sutures to secure drains. | |
| (xviii) Never clamp a bubbling chest drain. | |
| (xix) Do a controlled drainage of large PEs. | |
| (xx) Avoid clamping CD in pneumothorax. | |
| (xxi) If a patient with a clamped CD develops breathlessness or subcutaneous emphysema, the drain must be immediately unclamped. | |
| (xxii) All chest tubes should be connected to a single flow drainage system, for example, under water seal bottle or flutter valve. | |
| (xxiii) Use of a flutter valve system allows earlier mobilization and the potential for earlier discharge of patients with chest drains. | |
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