**5. Controversies surrounding chest drain insertion**

Who should and who should not insert a chest drain? There is no consensus on this matter. However, surgical abilities even of a minor order are required to safely insert a chest drain; after all this is a surgical procedure. Therefore, proctored training is mandatory before any trainee is allowed to do it alone. Should one be certified before being allowed to perform this procedure unsupervised? This is debatable. Thoracic surgeons and their trainees are the most experienced to deal with chest drains; however, the idea that surgeons should look after all chest drains in the hospital is ludicrous and logistically unachievable.

The technique of drain insertion keeps changing. The BTS guidelines in 1993 recommend using a trocar (harpoon!); however, deaths had been reported from

**61**

**Figure 5.**

*Controversies in Pneumothorax Treatment DOI: http://dx.doi.org/10.5772/intechopen.87141*

improves the chances of pleurodesis.

*overtight anchorage stitch obliterated the drain lumen.*

their use, and subsequently, the BTS changed its recommendations in an updated report in 2010 [10, 44]. Harris et al. reported on current practice and adverse incidents related to chest drains at 148 acute hospitals in the UK between 2003 and 2008 [45]. Thirty-one cases of chest drain misplacement were reported with seven deaths. Misplaced drains were inserted in the liver (10), peritoneal space (6), heart (5), spleen (5), subclavian vessels (2), colon (1), oesophagus (1) and inferior vena cava (1). One of my previous mentors at the University Hospital of Wales, the late Mr. Ian Breckenridge, has previously stated that "I regard trocar systems as potentially lethal weapons, and their misuse has been responsible for the few fatalities that I have seen, when heart, lung and liver have been lacerated" [46]. Similar serious injuries and fatalities were reported elsewhere [47–57]. Trocars are now banned from the UK. It is stating the obvious that the litigation expenses accompanying these cases are exorbitantly costly to the hospital trust and the taxpayer in the UK. Clinicians differ about the choice of drain type and size [58]. Physicians and interventional radiologist tend to choose small calibre drains (medical drains), such as pigtails, 12F or 14F, whereas surgeons tend to put larger tubes +24F (surgical drains) [10, 59, 60]. Drain kinking, blockage and accidental dislodgment are common complications of small-bore drains (**Figure 5**). Per contra, Riber et al. in a retrospective study concluded that surgical (wide-bore) drains significantly increase the dwell time in primary SP [61]. Although they may be effective in managing pleural infection and less painful than large drains, small-bore drains may be less effective for pleurodesis [58]. The war between chest physicians and chest surgeons around the calibre of the chest drain will continue. Chest physicians have evidence that for air drainage size does not matter and a 16F drain is as good as any. Surgeons see the dysfunctional spectrum of these drains and correct the situation by inserting larger drains.

A persistent air leak with or without re-expansion of the lung is the usual reason for consideration of the use of suction, although there is no evidence for its routine use. The optimal level of suction on the drain is controversial, and so is the optimal time of its removal [62–66]. Data on the actual intrapleural pressure during the use of these systems is lacking [67]. Most of the knowledge is extrapolated from studies after lung resection, and protocols for pneumothorax drain insertion are scanty. It seems that the practice is a personal preference rather than evidence driven. We tend to believe that initial suction will guarantee the full expansion of lung and

Recent introduction of the digital drainage systems seems to offer more physiological and dynamic mobile suction, assisting in enhanced early recovery [68, 69]. Its

*Dysfunctional medical drain (14F) removed to insert a surgical drain (28F) for pneumothorax. Twisting and* 
