Oliver Fisher Neonatal Guideline

Pneumothorax

Relevant to:
Neonatal medical and nursing staff.

Purpose of Guidance:
Safe, consistent care.

Guidance to Follow:

Definition: a condition in which air is present in the cavity between the lungs and the chest wall,
causing collapse of the lung. When the accumulating air is under pressure, a tension pneumothorax
can result. This is a life threatening situation and immediate drainage will be required. In the acute
situation needle aspiration is performed followed by intercostal catheter insertion.

A pneumothorax diagnosed as an incidental finding on CXR and the infant is well may not require
active drainage but when associated with clinical deterioration, it will require drainage.

Diagnosis and Treatment of Pneumothorax

Diagnosis:

 Respiratory distress and/or increase in oxygen requirement

 Reduced air entry on affected side
 Asymmetric chest movement (often looks “full” on affected side)
 Positive trans-illumination using fiber-optic light.

Note: You must confirm the presence of a pneumothorax by trans-illumination and preferably with a
CXR before draining. In a collapsed baby with a tension pneumothorax there may not be time to
wait for a diagnostic CXR.

Figure1: Trans-illumination showing a

large right side pneumothorax. Note the
way the whole hemi-thorax is
illuminated, with the diaphragm and
mediastinum forming a “corner”. False
positives can occur if there is tissue
oedema / lung emphysema or an
enlarged stomach. If in doubt get a
CXR.

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Figure 2: CXR showing large right sided

tension pneumothorax (note
mediastinum shifted to left).

Treatment

 Not every pneumothorax needs draining. If it is just a small rim of air in an asymptomatic
baby you need to carefully consider whether observation and conservative management is
appropriate.
 A significant pneumothorax causing respiratory distress must be drained urgently.
 There are three possible methods: Insertion of a butterfly needle, insertion of a pigtail chest
drain using the Seldinger technique or insertion of a chest drain by incision.
 Whichever treatment is used you must get an urgent repeat CXR to check for resolution of
the pneumothorax.

Needle aspiration

Needle aspiration is an emergency procedure and should only be performed when a baby is in
extremis (bradycardia, sudden hypotension, poor saturations and compromised peripheral
perfusion) and a pneumothorax has been confirmed by trans-illumination. It provides immediate and
short term relief of cardiac compromise and should always be followed by insertion of an intercostal
drain. In situations when there is complete resolution of pneumothorax after needle aspiration, chest
drain may not be required.

Take care to avoid iatrogenic damage from puncturing underlying lung or blood vessels.

Equipment

Sterile gloves, Chlorprep swab, 21G blue butterfly, 10ml syringe and 3-way tap

Procedure

1. Position baby supine.

2. Clean chest area with swab for 30 seconds and leave to dry for 30 seconds.

3. Aspirate as you insert needle into the pleural space (directly over the top of the rib in the 2nd
or 3rd intercostal space in the mid clavicular line).

4. Expel air through 3-way tap and re-aspirate as necessary to drain air and relieve symptoms.

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5. Request CXR and prepare equipment for insertion of an intercostal drain - this will allow time for
some re-accumulation of air around the lung which should reduce the risk of puncturing the lung
when the drain is inserted.

Figure 3: Equipment for emergency aspiration of a tension pneumothorax and correct positioning of
needle in 2nd intercostal space.

Equipment for pigtail catheter insertion

 15 cm long polyurethane Pigtail catheter with 6 side ports

o 10 Fr for > 1500 grams
o 8 Fr for < 1500 grams
 Sterile introducer needle, guidewire, dilator and connector tubing and three-way tap as
packed by supplier
 1% lignocaine, syringe and needle
 Chlorprep
 Underwater seal drainage system or Heimlich valve
 Sterile gown, gloves and drapes
 Semi-occlusive dressing, tapes

Figure 4:
Equipment for
pigtail catheter

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Procedure for intercostal catheter insertion

1. Use WHO surgical safety checklist for intercostal drain insertion. This link accesses the
checklist. (http://qpulsers.medway.nhs.uk/Corporate/Login.aspx?requesturl=/Corporate/
Documents.svc/documents/active/attachment?number=OTLSO19).
2. Mask, sterile gown and gloves are required as for any sterile procedure.
3. Place infant under radiant heater to maintain infant's temperature.
4. Monitor heart rate and saturation levels and ensure infant can still be partly visualized after
draping to create a sterile field.
5. Position the infant with the effected side uppermost and the arm extended above the head (a
nappy cloth roll may help maintain a good position). Ensure limbs are adequately restrained.
6. Monitor infant's heart rate and oxygen saturation level during the procedure.
7. Prepare the field with antiseptic solution (Chlorprep) and drape.
8. Infiltrate local anesthetic (Lignocaine) 0.2 mls at insertion site (fourth or fifth intercostal space
in the anterior axillary line. This corresponds to a point 1-2 cm lateral to and 0.5-1 cm below
the nipple).
9. Mark off 1.5 cm on the introducer needle with a steri-strip or place a clamp in this position.
Connect the needle to a small syringe with a small amount of sterile water (to see air
bubbles whilst aspirating).
10. Advance the needle through the infiltrated skin, gently aspirating until air is obtained.
Continue to aspirate if pneumothorax is under tension.
11. Remove syringe, occlude temporarily, then thread the guidewire through the hub of the
insertion needle via the white plastic tip (fits nicely into the hub and straightens out the
curved tip of the guidewire). Advance until the silver guideline on the wire reaches the white
plastic tip.
12. Remove the needle while not allowing the wire to move.
13. Thread the dilator over the guidewire and insert about 1 cm through the skin withdraw and
remove the dilator.
14. Feed pigtail catheter over the guidewire with the holes facing up. Advance to first to second
black line for a premature infant, fourth to fifth for a term infant.
15. Remove the guidewire.
16. Connect the catheter to the connection tubing via the tap. The other end of the tubing
connects to the Heimlich valve or the underwater drainage system. Note whether the fluid is
swinging and/or bubbling. Fogging within the catheter may be seen when within the pleural
space.
17. Secure the pigtail with a steristrip (Roman sandal around) and then Tegaderm.

Ongoing care

 Check the tube position and resolution of the pneumothorax by trans-illumination and CXR
as soon as possible.
 Determine the need for ongoing analgesia based on an assessment of physiological and
behavioral responses associated with pain.
 Document in the medical record insertion site, date and LOT number.

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Guide for Chest Drain Insertion using Pigtail Catheter

Figure 5: Prepare the chest using ChlorPrep.

Infiltrate the insertion area with local anaesthetic
(0.2 ml 1% lignocaine).

Figure 6: Usual insertion point: above 5th rib, in 4th

& 5th intercostal space, anterior axillary line.

Figure 7: Attach a 3 way tap and 10ml syringe to

the needle and gently advance the needle through
the chest wall, aspirating the syringe as the needle
is advanced. Air will be aspirated as the needle is
advanced into the pleural space.

Figure 8: Remove the syringe and 3 way tap and

attach the wire introducer and guidewire to the
needle.

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Figure 9: Holding the needle in place, gently advance

the guide wire into the chest cavity. There should be
little resistance. Hold the guide wire in place and
remove the needle, leaving the guide wire in place.

Figure 10: Advance the dilator over the guide wire, to

enlarge the track through the chest wall. Then,
keeping the wire in place, remove the dilator.

Figure 11: Slide the chest drain over the guide wire
and advance through the dilated track into the chest
cavity until at least the 1st black marker on the drain
Figure 12: Hold
has entered the drain in situ and remove the guide
the chest.
wire. Attach the adaptor to the drain. The end of the
collection tubing may require cutting to fit the adaptor.
The drain is pigtailed and does not routinely require
stitching in place; it can be held in place with a
‘Tegaderm’ dressing against the chest wall. Connect
collection tubing to an underwater seal and apply
suction.

Chest drain insertion by incision

Equipment

Sterile dressing pack, ChloraPrep, Scalpel and fine straight blade, Artery forceps, Fine blunt
forceps, Size 8 or 10 FG pleural drain, Steristrips (¼ inch), Underwater seal drain, Tegaderm

Procedure
 Use WHO surgical safety checklist prior to insertion. Link is
(http://qpulsers.medway.nhs.uk/Corporate/Login.aspx?requesturl=/Corporate/
Documents.svc/documents/active/attachment?number=OTLSO19).
 Proceed using sterile technique.
 Clean the skin over the area in which drain is to be inserted.
 Landmarks for insertion: either laterally 5th or 6th intercostal space anterior axillary line or
anteriorly 2nd intercostal space midclavicular line.
 Make sure you avoid nipple and areolar area.
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1. Infiltrate the skin with local anaesthetic (1% lignocaine 0.5 mls) or give a small dose of
analgesia; this avoids unnecessary pain and minimises struggling.
2. Make a small incision (scalpel) in the skin and intercostal muscles above the rib at the
selected site. Separate the muscle fibres using fine blunt forceps until you see the pleura (a
shiny grey membrane).
3. Pierce the pleura and enter the pleural space using the fine blunt artery forceps. Keep
forceps in place to keep the tract open.
4. Remove the trocar from the chest drain. Then insert the flexible chest drain along the line of
the tract (you may need to grasp the end using the artery forceps).
5. Insert the drain 2-3 cm in preterm infants and 3-4 cm in term infants, aiming anteriorly and
superiorly so that the drain lies in front of the lung.
6. Connect the drain to the underwater seal drain. Correct positioning of the cannula will be
signified by bubbling or oscillation of the underwater seal.
7. Secure the chest drain by stitching into place with a single suture. Tie the suture around the
chest tube tightly. Do not put a purse string around the entry site as this will cause scarring.
8. Secure to the chest wall using steristrips and Tegaderm dressing.
9. Order an urgent CXR to check position of drain and ensure adequate evacuation of air. If in
doubt about anterior position perform a lateral CXR also.
10. After inserting the drain ensure that the tubing connecting the cannula to the underwater
seal is secured to a fixed site (e.g. baby’s mattress) to prevent accidental dislodgement.
11. Place underwater seal unit on gentle suction.
12. Document the procedure fully in the patient’s notes with site, date and LOT number.

Removal of chest drains

• Once a pneumothorax has been drained it may be safer to leave the drain in situ until the
patient is no longer on positive pressure ventilation. However, if this is likely to be long term
then you may consider removing the drain earlier.
• Once no longer bubbling for 24 hours cross clamp the drain with artery forceps for
conventional drain and by turning off the 3 way tap for pigtail drain.
• Perform CXR after 4 hours (or earlier if symptomatic). If no re-accumulation of
pneumothorax after 4 hours then remove the drain.
• Remove drain and rapidly close the incision with steristrips. If the wound is gaping and
cannot be closed with steristrips use one or two interrupted stiches. Do not use a purse
string suture as this leads to scarring.
• Observe carefully for 24 hours. Repeat CXR if symptoms recur.

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Implications of not following guidance
Inconsistent care

Useful Contacts:
Dr Ghada Ramadan, Consultant Neonatologist

Monitoring the Process:

Audit.

National Definitions:
N/A

Reference Material & Associated Documents:

References:
Effect of needle aspiration of pneumothorax on subsequent chest drain insertion in new-
borns. A Randomized Clinical Trial. Madeleine C M et al. JAMA Pediatr. 2018; 172(7):664-
669.

Revision History
Revision Date
Reason for change
No
November
3
2018

Approval Signatures:
Revision No: 3 ID No: GUDPCM001-3BU
Distribution: Intranet
Date Approved: December 2018
Approved By: Neonatal Governance Group
Review date: December 2021
Author: Monica Fedeles
Document Owner: Helen Gbinigie

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