Chest drains: Oxford

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Chest drains Oxfords approach?

• Robert JO Davies
• Professor of Respiratory Medicine
• Oxford Centre for Respiratory Medicine
• University of Oxford UK
• robert.davies_at_ndm.ox.ac.uk

Winter BTS Dec 2008
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Conflicts of interest

• Research funding NIHR, HTA trials, MRC, UKCRN,
  CRUK, BLF, BHF, UKNCRI
• Drugs and matched placebos for clinical trials
  Roche, Genentech, Boeringher, Lunamed, Syner-Med.
• Technical equipment for trials Rocket Medical
  UK, ResMed, GE Medical, Embla systems.
• Trials unit funding Roche, Syner-Med, GSK
• Product design consultancy Rocket Medical UK.
• IP Lipoteichoic acid for pleurodesis,
  pneumothorax treatment system

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• Drains the problem
• Dangerous

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Chest Drain Complications

• Oxford audit image guided drains
• All image guided chest drains inserted over a 36
  months
• 352 drains (273) patients
• Major complications in 4 (1.5)
• Haemothorax 3
• Empyema (post pleurodesis) 1
• 1 death (0.3)

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• Drains the problem
• Dangerous
• Use is widespread
• Respiratory Medicine
• Paed respiratory medicine
• Cardiothoracic surgery
• Acute medicine
• AE
• Adult ITU
• Paed ITU
• Neonatal ITU
• Radiology
• Oncology

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• Drains the problem
• Dangerous
• Use is widespread
• Methods differ (appropriately)
• Pneumothorax
• Pleural Effusion
• Imaging
• Medicine
• CT surgery
• Paediatrics
• Neonatology

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Drain insertion

• Strategy
• Quite a lot of work!
• Not amenable to a single strategy
• Solve at local level
• Key principles
• Drain only when really needed
• Only staff trained and active insert
• (applies to both drain insertion and
  ultrasound)
• Equipment should be good condition
• Image guidance where possible
• Audit trail needed

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Thoracic US
www.rcr.ac.uk/docs/radiology/pdf/ultrasound.pdf
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Solution strategy
Coordinating lead RJOD Supporting colleague
Adult respiratory
Paed respiratory
CT surgery
AE
Oncology
Acute medicine
Radiology
Adult/paed/neon ITU
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Solution strategy
Coordinating lead RJOD Supporting colleague
Adult respiratory
Paed respiratory
CT surgery
AE
Oncology
Acute medicine
Radiology
Adult/paed/neon ITU
Clinical management algorithms
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Solution strategy
Coordinating lead RJOD Supporting colleague
Adult respiratory
Paed respiratory
CT surgery
AE
Oncology
Acute medicine
Radiology
Adult/paed/neon ITU
Clinical management algorithms
Hardware kit
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Solution strategy
Coordinating lead RJOD Supporting colleague
Adult respiratory
Paed respiratory
CT surgery
AE
Oncology
Acute medicine
Radiology
Adult/paed/neon ITU
Clinical management algorithms
Hardware kit
Teaching videos
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Solution strategy
Coordinating lead RJOD Supporting colleague
Adult respiratory
Paed respiratory
CT surgery
AE
Oncology
Acute medicine
Radiology
Adult/paed/neon ITU
Clinical management algorithms
Hardware kit
Teaching videos
Chest drain insertion form
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Solution strategy
Coordinating lead RJOD Supporting colleague
Adult respiratory
Paed respiratory
CT surgery
AE
Oncology
Acute medicine
Radiology
Adult/paed/neon ITU
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Solution strategy
Coordinating lead RJOD Supporting colleague
Adult respiratory Lead RJOD Register of
training/activity Coordinate hardware Collect
audit forms Respond to adverse events
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Drain insertion

• What happens at 2 am?
• Does the patient actually need a drain now?
• Will thoracentesis do?
• Is image guidance appropriate?
• Am I on the ultrasound register?
• Yes next question!
• No get help
• Am I on the drain insertion register?
• Yes do it
• No get help
• Who can help?
• Respiratory physician
• Paediatric respiratory physician
• Intensivist (including resus team/neonatology)
• Radiologist (two services)
• CT surgeon
• AE staff

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Drain insertion

• Summary
• Nominated leads
• Management algorithms
• Insertion form
• Training registries
• Drain insertion form
• Chest drain insertion kit
• Large bore training video
• Small bore training video
• Thorough dissemination of form and audit trail

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