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This document should be read in conjunction with the NCCU Disclaimer.

Section: 2 Neonatology Clinical Guidelines
Respiratory problems and management King Edward Memorial/Princess Margaret Hospitals
Date Revised: July 2006 Perth Western Australia
EMERGENCY PROCEDURES
Transillumination of the chest
Needle aspiration of the chest
Intercostal catheter insertion (ICC)
Pigtail intercostal catheter insertion (Pleural effusion)
Managing ICC drainage
ICC removal
RESPIRATORY PROBLEMS AND MANAGEMENT
NCCU CLINICAL GUIDELINES
SECTION: 2
Section: 2 Neonatology Clinical Guidelines
Respiratory problems and management King Edward Memorial/Princess Margaret Hospitals
Date Revised: July 2006 Perth Western Australia
This document should be read in conjunction with the NCCU Disclaimer Page 2 of 11
EMERGENCY PROCEDURES
TRANSILLUMINATION OF THE CHEST
To detect abnormal air collections within the chest cavity in an infant suspected of having an air leak or
any respiratory supported infant who deteriorates with asymmetrical chest wall movement or air entry.
Transillumination can be done by any staff member deemed competent or a trainee under direct
supervision from a competent staff member. If an abnormal air collection within the chest cavity is
suspected, a Medical Officer competent in needle aspiration of the chest must be contacted immediately
to attend the unit.
Any suspicion of an accumulation of air by transillumination should be confirmed by a chest X ray if time
permits.
Emergency needle aspiration equipment is kept in a container at each infant's bay for ICU infants.
For infants suspected of having fluid in the chest cavity see ICC insertion
EQUIPMENT
High intensity fiber-optic cold light source (transilluminator)
Cardiopulmonary monitoring
Blood pressure monitoring
PROCEDURE
1. Lower the lights in the room to enable hyperlucent areas to be seen if present. (use black gown if
needed)
2. Place the transilluminator along the posterior axillary line on the side on which the air collection is
suspected. The transilluminator may be moved up and down along the posterior axillary line and
above the nipple to detect any areas of increased transmission of light.
3. For pneumopericardium: Place the transilluminator in the third or fourth intercostal space on the left
midclavicular line and angle the light towards the xiphoid process to detect any areas of increased
transmission of light.
4. Transilluminate both sides of the chest to give a comparison. Note: Severe subcutaneous chest wall
oedema and pulmonary interstitial emphysema may give false-positives.
Section: 2 Neonatology Clinical Guidelines
Respiratory problems and management King Edward Memorial/Princess Margaret Hospitals
Date Revised: July 2006 Perth Western Australia
This document should be read in conjunction with the NCCU Disclaimer Page 3 of 11
NEEDLE ASPIRATION OF THE CHEST
To remove air from between the parietal and visceral pleura, whilst avoiding laceration to the lung or
blood vessels, in an infant suspected of having an accumulation of air within the pleural space. This is
an emergency procedure only.
Pneumothorax can occur spontaneously in a well term infant or may be associated with resuscitation,
meconium aspiration syndrome, respiratory distress syndrome and positive pressure ventilation. Signs
of a pneumothorax may be subtle and some infants may show no other signs except an increase in
restlessness. A blood gas analysis may be the first indication that a pneumothorax has occurred.
As pneumothorax may complicate resuscitation following delivery, bilateral needle aspiration should be
considered during a failed resuscitation and before ceasing resuscitative efforts.
Air generally accumulates anteriorly and in the apex of the pleural space
EQUIPMENT
10ml luer lock syringe
22 gauge intravenous cannula (for term neonates) 24 gauge cannula for infants < 30 weeks, or
23g butterfly needle
3 way tap
25 cm extension tubing
Alcohol wipe
PROCEDURE
1. Confirm pneumothorax by transillumination
2. Position the infant supine and supported, consider the administer analgesia/local anaesthesia if time
permits.
3. Attach 3-way tap to 10 ml luer lock syringe and turn the 3-way tap so that all ports are in the off
position. Remove the caps from the 3-way tap.
4. Attach a 25 cm extension tube to the other end of the 3-way tap if a cannula is being used.(Figure 1)
5. Add the butterfly needle extension to the 3-way tap when this system is used. (Figure 2)
6. Using the alcohol wipe, swab the infant's skin in the area of the 2nd -3rd rib along the mid-clavicular
line.
7. Place a finger on the infant's 3rd rib. Guide the 22/24 gauge intravenous cannula, or butterfly
needle, along the finger and insert it into the 2nd intercostal space, along the mid-clavicular line, at
an angle of 90deg. AVOID THE NIPPLE. (See Figure 3)
8. Once in position, remove the needle from the intravenous cannula and attach the extension tubing
(with 3-way tap and syringe) to the cannula, or the 3-way tap & syringe, to the butterfly extension.
9. Turn the 3-way tap to aspirate air from the infant's chest into the syringe. Turn the 3-way tap to expel
the air into the atmosphere. Allows operator to measure expelled air.
10. Continue to aspirate until resistance is met. If a butterfly needle is used, it should be removed after
the aspiration is completed
11. Once the infant is stable perform transillumination to confirm air removal. In term infants, or those
with a thick chest wall, transillumination may fail to detect pneumothorax Assess infant, perform
chest x ray and consider the need for an intercostal catheter.
12. The intravenous cannula used for needle aspiration may remain in situ and should not be removed
until requested by a consultant.
13. Chest x ray is definitive diagnostic tool and may assist in deciding further intervention.
Section: 2 Neonatology Clinical Guidelines
Respiratory problems and management King Edward Memorial/Princess Margaret Hospitals
Date Revised: July 2006 Perth Western Australia
This document should be read in conjunction with the NCCU Disclaimer Page 4 of 11
Figure 1: Set-up for emergency drainage of a pneumothorax with the butterfly technique
Figure 2: Set-up for emergency drainage of a pnuemothorax with the cannula technique. This cannula
can be utilised to attach directly to an underwater seal drain in some circumstances.
Section: 2 Neonatology Clinical Guidelines
Respiratory problems and management King Edward Memorial/Princess Margaret Hospitals
Date Revised: July 2006 Perth Western Australia
This document should be read in conjunction with the NCCU Disclaimer Page 5 of 11
Figure 3: Insertion site for emergency needle aspiration.
Section: 2 Neonatology Clinical Guidelines
Respiratory problems and management King Edward Memorial/Princess Margaret Hospitals
Date Revised: July 2006 Perth Western Australia
This document should be read in conjunction with the NCCU Disclaimer Page 6 of 11
INTERCOSTAL CATHETER INSERTION (ICC)
To remove air or fluid from the pleural space or to allow lung re-expansion following surgery. Surgical
chest drains should never be put on suction unless ordered by the surgeon. The insertion of an
ICC is a painful procedure requiring analgesia and/or sedation, depending on the infants condition.
EQUIPMENT
This is a sterile aseptic procedure.
- Skin Prep soln as per protocol
- Lignocaine 0.5% / 1ml syringe / 25g needle
- Scalpel
- Argylle chest drain catheter or Pigtail catheter with trochar or introducer (A size 16Fg cannula
attached to a short extension can be used instead of a chest drain on small infants at the request of
the consultant.)
- Leukostrips / tegaderm (optional)
- Suture and needle
- Underwater seal drainage unit (both sites) / heimlich valve (if applicable)
- Sterile water
- Low pressure suction unit attached to panel at 3 5 cmH
2
O. Non-toothed chest drain clamp (1 per
drain)
PROCEDURE
1. Consider appropriate sedation/analgesia/local anaesthesia before commencing
2. Assemble drainage unit
3. Position the infant supine and supported
4. Prep the skin (care with <27weeks)
5. Placement in most cases should be in the 4th intercostal space in the mid-axillary line. Avoid the
nipple.
6. Infiltrate the area before making the incision
7. Insert ICC directing it anteriorly or posteriorly as indicated.
8. Connect drain to tubing ensuring the water level is correct, the drainage system is on and the
suction is on (if applicable). PICTURE Or drain connected to Heimlich valve if applicable
9. If drain for pleural effusion send specimen for analysis
10. Secure the ICC with a suture and/or leukostrips/tegaderm as applicable.
11. Secure the tubing and drainage unit to prevent dragging and accidental removal
12. CXR for catheter placement and resolution of pneumothrorax /pleural effusion
13. Observe ICC, tubing and drainage device for effectiveness ie. bubbling, swinging and drainage.
Maintain correct water level and suction pressure if in use. Heimlich valves may need
dressing/container for drainage. Label if more than one.
14. Observe insertion site for bleeding / exudate
15. Drainage unit / tubing should not be routinely changed, leave until full or removed
16. Clamping is only necessary when changing unit or raising it above head height. It should be clamped
for the least time possible
Section: 2 Neonatology Clinical Guidelines
Respiratory problems and management King Edward Memorial/Princess Margaret Hospitals
Date Revised: July 2006 Perth Western Australia
This document should be read in conjunction with the NCCU Disclaimer Page 7 of 11
PIGTAIL INTERCOSTAL CATHETER INSERTION FOR PLEURAL EFFUSION OR
PNEUMOTHORAX
The insertion of a pleural drain is a painful procedure requiring analgesia and/or sedation, depending on
the infants condition. A chest ultrasound is often performed prior to drainage to document any
loculations and the point of maximal fluid collection. Pigtails are the ICC of choice in the drainage of
pleural effusions.
The NCCU currently has in stock 3 types of pigtail ICCs. The end of the Cook catheter is metal
therefore patients cannot have an MRI with one of these catheters in situ.
- Cook 8.3 Fr
- Cook Wood 6 Fr
- Cook 5fr (this is going to be phased out in the NCCU. They have the disadvantage of a long J-
wire, so be very careful with your aseptic technique).
ADVANTAGES OF PIGTAILS
Less traumatic insertion and smaller diameter therefore potentially less complications. This is
particularly the case for the very preterm infant where Argyle ICCs have a high rate of complications.
Can be used successfully to drain pneumothoraces in very preterm infants and in paediatric patients.
DISADVANTAGES
Softer therefore can kink and obstruct.
May not satisfactorily drain a pneumothorax where there is an ongoing air leak
It is important to remember that the insertion of any ICC must be done with close attention to anatomy.
The preferred location for both pigtail catheters is the 4
th
or 5
th
intercostal space, above a rib in the mid
axillary line, well clear of the nipple (remembering the intercostal vessels run under the rib so going
above a rib should miss piercing these vessels).
COOK 8.3FR AND 5 FR PIGTAIL - USE THE SELDINGER APPROACH
1. Glove and gown as for a sterile aseptic procedure
2. Prepare the skin as per NCCU protocol.
3. Insert xylocaine into the chosen site. Lignocaine 0.5 -1% ( 0.5% for preterm infants, 1% may be
used for term infants). Do not use more than 1mL.
4. Open the packet and assemble the needle and syringe
5. If draining pleural fluid insert needle above the rib, aim posteriorly and aspirate until fluid obtained.
6. If draining air insert needle above the rib, aim anteriorly and aspirate until air obtained.
7. Remove the syringe and advance the soft tipped j-wire (j end first) through the needle. Only about
5cm of the wire needs to be in the chest.
8. Remove the needle, holding onto the J-wire where it exits the body as soon as the needle tip leaves
the skin to avoid inadvertently removing the j-wire.
9. Advance the dilator over the wire using a rotating action to pass through the chest wall. Only need
the dilator to enter the chest cavity and remove the dilator (again holding onto the J-wire where it
exits the body as soon as the dilator leaves the skin to avoid inadvertently removing the j-wire
10. Feed the pigtail catheter over the wire, and advance through the chest wall into the chest cavity.
11. Remove the J-wire
12. Suture or use steri-strips to anchor catheter to skin
13. Place tegaderm dressing over catheter insertion site, if gestation allows.
14. Connect the catheter to drainage unit, making sure there is a 3 way tap attached to the pigtail
15. Confirm location of catheter with Xray
Section: 2 Neonatology Clinical Guidelines
Respiratory problems and management King Edward Memorial/Princess Margaret Hospitals
Date Revised: July 2006 Perth Western Australia
This document should be read in conjunction with the NCCU Disclaimer Page 8 of 11
16. Document procedure in the medical notes, noting Xray findings.
COOK WOOD 6FR PIGTAIL
This pigtail is inserted using a technique akin to the emergency draining of a pneumothorax using a IV
cannula.
1. Glove and gown as for a sterile aseptic procedure
2. Prepare the skin as per NCCU protocol.
3. Insert xylocaine into the chosen site. Lignocaine 0.5 -1% (0.5% for preterm infants, 1% may be used
for term infants). Do not use more than 1mL.
4. Open the packet and assemble the catheter and needle, using the grey plastic straightener and then
peel this off.
5. Attach a syringe to the needle
6. Pass the needle through the chest wall (see anatomy above for description of location) and as soon
as air is aspirated, maintain a stable position and slide the pigtail catheter off the introducer needle
7. Connect a 3 way tap and luer lock to drainage unit.
8. Suture or use steri-strips to anchor catheter to skin and cover insertion site with tegaderm dressing if
skin allows.
9. Confirm location of catheter with Xray
10. Always send off fluid for microscopy & culture, as well as biochemistry (glucose, protein,
triglycerides - for a chylous effusion).
11. Document procedure in the medical notes, noting Xray findings.
MANAGING INTERCOSTAL CATHETER DRAINAGE
The purpose of drainage devices are to help expand the lungs and re-establish normal negative
pressure in the thoracic cavity by removing air or fluid in a closed, one-way fashion. There are 2
systems in use: the Atrium (6B) and under water seal (SCN)
KEY POINTS
Always place the drain below the level of the infants chest. Avoid milking of chest drains as this
generates a high negative pressure and causes lung tissue to be sucked into the trochar catheter.
Check tubing is secure and not kinked and no dependant loops. Lay tubing across the bed before
dropping directly to the drainage unit. Tubing may need to be cut to the required length and may
need to be secured to the bed. Ensure the drainage units are secured at the bedside.
The drainage unit or tubing should not be changed routinely as this can increase the incidence of
infection. It is safe practice to leave drainage units and tubing in place for 6 days. Change dressing if
there is obvious blood or exudate staining.
Clamping of chest drain tubing should be avoided, especially a bubbling chest drain. This may lead
to a tension pneumothorax. The tubing should only be clamped if raising the drainage unit above
chest height or if changing the unit. It should be clamped close to the chest wall and unclamped as
soon as possible. There should be a non-toothed clamp at the bedside at all times one clamp for
each tube.
The addition of suction helps to overcome a large air leak by improving the rate of air and fluid out of
the chest.
Hourly observations of bubbling, swinging and drainage measurements should be recorded on the
observation chart.
Excessive bubbling or a sudden decrease in bubbling may indicate a system leak or a tension
pneumothorax.
Blocking of the tubing may create a tension pneumothorax or surgical emphysema.
Section: 2 Neonatology Clinical Guidelines
Respiratory problems and management King Edward Memorial/Princess Margaret Hospitals
Date Revised: July 2006 Perth Western Australia
This document should be read in conjunction with the NCCU Disclaimer Page 9 of 11
Label drainage units if there is more than one. Mark the level of drainage per shift.
EXTRA INFORMATION
Atrium (See booklet)
- Always fill suction control (A) to 5 cmH
2
O unless directed otherwise.
- Always fill water seal (B) to 2 cm line. This compartment is where you observe for bubbling,
swinging NOT column A.
- The suction control stopcock must be ON for initial setup and should not be turned OFF during
patient use.
- To connect multiple chest drains to one suction source insert a Y connector onto the wall
suction tubing then connect each drain onto one end of the Y.
Section: 2 Neonatology Clinical Guidelines
Respiratory problems and management King Edward Memorial/Princess Margaret Hospitals
Date Revised: July 2006 Perth Western Australia
This document should be read in conjunction with the NCCU Disclaimer Page 10 of 11
CHEST DRAIN REMOVAL
Chest drains are removed on medical orders when air and fluid accumulation has resolved. This is
indicated when drainage, bubbling and fluid fluctuations have ceased, air movement is symmetrical and
lung fields are clear and equal. The chest tube should be clamped for up to 6 hours prior to removal.
Chest X-ray confirmation of resolution should be obtained prior to removing the drain. Chest drains can
be removed by medical staff or a nurse deemed competent in the procedure, however because of the
risk of reaccumulation, a medical officer should be in the unit when the drain is removed. This is a clean
aseptic technique. Consider appropriate sedation / analgesia.
EQUIPMENT
Dressing pack
Gauze
N/Saline
Stitch cutter
Dressing
Leukostrips
Tegaderm (optional)
PROCEDURE
1. Clamp drain and turn off suction if not already done
2. Remove existing dressing and suture
3. Place gauze over drain site and remove drain on inspiration. Send tip if indicated
4. Seal insertion site with gauze and tegaderm (may need leucostrips if large incision)
5. Watch for signs of reaccumulation. Repeat CXR as necessary
6. Document the chest drain removal in the infants progress notes and on the observation chart and fill
in an ICC record sheet (see below). The volume of exudate in the drainage unit should be
documented in the output column of the observation chart.
Section: 2 Neonatology Clinical Guidelines
Respiratory problems and management King Edward Memorial/Princess Margaret Hospitals
Date Revised: July 2006 Perth Western Australia
This document should be read in conjunction with the NCCU Disclaimer Page 11 of 11
INTERCOSTAL CATHETER (ICC) RECORD SHEET:
PLEASE COMPLETE FOR EACH ICC. WHEN ICC REMOVED PLEASE GIVE RECORD SHEET TO
CO-ORDINATOR, WHO WILL THEN GIVE TO NURSE MANAGER.
Adressograph label:
Please circle option for this patient:
ICC type: Argyle
Pigtail
Intravenous catheter
Other__________
Size: 5
6
8.3
10
other___________
Indication: Pneumothorax
Pleural effusion
Post-operative
Other____________
Location: Left / Right
Suction: No / Yes suction pressure_________
Date inserted:_________________
Date removed:_________________
Problems:_______________________