Chest drain insertions

Of 867 records submitted, 824 fulfilled inclusion criteria (585 drains for pleural effusion and 239 for pneumothorax).

Eighty per cent of drains were inserted by the Seldinger technique and 83% for those where size was documented were of small bore (6–14F).

• Procedure consent. Consent was taken for 549 (67%); written in 271 (33%) and verbal in 278 (35%). There was no documented evidence of consent in 257 (31%) and no data entered for 18 (2%). Drain insertion for pneumothorax appears to be associated with less reliable consent practice; written in only 24% and no evidence of consent at all in 40% of procedures in this series.

• Location and timing. The patient bedside remains the most common location for chest drain insertion (48%) overall, although drains for pneumothorax were most often placed in the Emergency Department (41%). While most drains overall were inserted within daytime working hours, 36% for pneumothorax were placed OOH (Supplementary appendix WA 2).

• Complications (table 1). The most serious possible complications were rare in this series, with no instances of organ trauma and one death (mechanism unclear). Patient-reported pain was common both during (4.1%) and following (18%) drain insertion, and is significantly more frequent with drains placed for pneumothorax (Fisher exact test p<0.01). When drains fell out (7.3%), 22/60 (37%) patients underwent another drain insertion and a further 3/42 effusion patients had pleurodesis deferred until fluid re-accumulation. A drain blockage rate of 8.5% among pleural effusions was associated with regular flushing in only 110/585 (19%) of drains and 42/101 (42%) of drains for pleural infection.

• Specialist care. A total of 62% patients were nursed on specialist respiratory wards. The medical respiratory team was involved with inpatient management of 78% of patients and 80% were reviewed by a respiratory consultant during their admission. A member of the respiratory team performed or supervised drain insertion in 423/824 (51%) cases overall but only in 90/239 (38%) of drains for pneumothorax.

• Drains for pneumothorax. A total of 102 drains were placed for secondary spontaneous pneumothorax (SSP) in patients with median age 71 (range 20–90) years, 88 for primary spontaneous pneumothorax (PSP) (median age 32 (16–87) years) and 47 for traumatic or iatrogenic pneumothorax. There was a failure to attempt aspiration before drain placement in 37/88 (42%) PSPs, and an inappropriate attempt at aspirating SSPs had been made in 13/102 (13%) of cases (Supplementary appendix WA 3). For the small (<2 cm) pneumothorax cases in this chest drain series (41/239 (17%)), conservative management may have been appropriate and preferable.

• Drains for pleural effusions. Patients had a median age of 71 (18–97) years. A total of 41% patients had an undiagnosed effusion, 34% malignant effusion and 18% pleural infection. Of patients drained for pleural malignancy, 96/201 (48%) underwent talc pleurodesis.

Thoracic ultrasound

A majority of respiratory departments had at least one ultrasound machine (45/58 (77%)). In 34 of 58 departments at least one member of the respiratory team was trained to level 1 competence (Supplementary appendix WA 4) with 27 departments having ≥1 consultant and 25 departments having ≥1 trainee who has been formally accredited in thoracic ultrasound.

There was appropriate real-time ultrasound guidance for 52% of procedures. The remote X-marks the spot approach (carrying no advantage over a blind procedure and potentially being falsely reassuring) was employed for 17% of drains for fluid (Supplementary appendix WA 5).

Chest drain insertion training

Formal training in chest drain insertion (didactic lectures and/or simulated practice sessions) is available to F2-ST2 trainees in 44/58 (76%) participating hospitals. A smaller proportion offer training to ST3+/SPR level trainees (21/58 (36%)).