Chest drain insertion in pleural effusion

Abstract

Chest drain insertion may have unintended consequences; this procedure should only be carried out when there are clear indications to do so.

Lesson

A 60-year-old Australian woman presented to a UK hospital with progressive breathlessness over a two-week period. Clinical examination and chest radiograph revealed a large right-sided pleural effusion. A chest drain was inserted and the patient was referred to respiratory medicine.

Past medical history included ovarian carcinoma treated with chemotherapy in Australia earlier in the year. She had been admitted to another UK hospital a few weeks earlier, again with a right-sided pleural effusion. This had been treated by simple aspiration without drain insertion and a cytology specimen taken at that time was suspicious for a poorly differentiated carcinoma. The sample was not sufficient to confirm metastasis from the ovarian cancer, or to exclude a second primary.

The patient wished to fly back to Australia to receive any further treatment. In view of this the chest drain was removed. Unfortunately a computed tomography scan of the thorax following drain removal demonstrated a small, apical pneumothorax which was assumed to be iatrogenic in origin. A referral was made to a thoracic surgeon for thoracoscopy to establish a definitive diagnosis and to achieve pleurodesis.

Discussion

Chest drain insertion should generally be avoided in undiagnosed pleural effusions. Breathlessness can normally be managed by simple aspiration of 1–1.5 litres of pleural fluid. The presence of a chest drain may hinder further diagnostic procedures, such as pleural biopsy and medical thoracoscopy. Chest drain insertion requires a hospital admission which may otherwise have been unnecessary and limits the patient's subsequent mobility in hospital.

The procedure may be appropriate after malignant pleural effusion has been confidently diagnosed. However malignant effusions should not usually be treated with chest tube drainage alone, because it leads to an unacceptably high rate of recurrence.¹ Pleurodesis may be achieved via a chest drain, though thorascopic procedures have a higher success rate and should generally be preferred if available locally.²

Chest drain insertion is not a benign procedure. Even in expert hands more than 10% of insertions have some manner of untoward complication.³ Given the concerns raised over the standard of training in chest tube insertion it is vital that unnecessary procedures are avoided.⁴ Genuine indications for chest drain insertion are given in Table 1.⁵

Table 1.

Indications for chest drain insertion.

In this patient, chest drain insertion was complicated by a small pneumothorax, a contraindication to air travel. Our patient's travel plans, and her further treatment in Australia, would not have needed to be delayed if her effusion had been treated with simple aspiration pending a definitive diagnostic procedure once she had returned home. Before inserting a chest drain, clinicians should ask themselves why a chest drain is preferred over simple aspiration.