Use of a Nasal Speculum for Chest-Drain Insertion

Abstract

Tube thoracostomy is a very commonly performed procedure in cardiothoracic surgery. Insertion of a chest drain requires expertise to minimize complications. We describe a simple technique of using a nasal speculum to perform this procedure.

Insertion of chest drains is very frequently performed in cardiothoracic surgery units. A wide range of complications can occur, including injury to intrathoracic and intra-abdominal organs—especially when a trocar catheter is used. The reported incidence of complications for traditional tube thoracostomy ranges from 9% to 21%.^1,2 Herein, we present our insertion technique, which enables safe, easy insertion of chest drains without the risks inherent to trocar drains.

Insertion Technique

Before the procedure, a good-quality anteroposterior and lateral chest radiograph or computed tomographic scan is used to define the area where the chest drain should be inserted and directed. A site is usually chosen along the mid-axillary line at the horizontal level of the 5th intercostal space. Local anesthetic (1% xylocaine) is injected intradermally with a 25G needle. Next, a 50-mm, 22G needle (Terumo Medical Corporation; Tokyo, Japan) is used to anesthetize the pleura with the same agent (Fig. 1). The needle is inserted into the pleural space, and aspiration is performed to confirm the depth of the pleura and the diagnosis of pleural effusion or pneumothorax. The needle is withdrawn 2 mm, and 5 mL of 1% xylocaine is injected. It is not necessary to anesthetize the subcutaneous fat or intercostal muscles.

Fig. 1 The 50-mm, 22G needle that is used to inject local anesthetic into the pleural space.

A 1.5-cm incision is made where the tube will be inserted. Blunt dissection of the intercostal muscles is performed with a curved artery forceps over the superior border of the rib. At this stage, a nasal speculum (Fig. 2) is inserted into the intercostal space, and its blades are opened. The speculum acts as a miniature retractor. A suitably sized chest tube (20F–28F) is inserted between the blades of the speculum. Depending on how the blades are tilted, the drain can be directed apically or basally. Because the blade tips are blunt, there is no risk of injury to intrathoracic or intra-abdominal organs.

Fig. 2 A nasal speculum, which is inserted into the intercostal space.

The procedure is completed by securing the chest tube to the patient's skin with a monofilament suture, and then –5 kPa suction is applied to an underwater seal system. The position of the tube is confirmed by chest radiography.

We have used this method routinely in our unit for 10 years without any related complications during that time. We have found that the nasal speculum is a simple, effective, and safe instrument for the insertion of chest drains.