Chest Drain Insertion-Made Easy with Gum Bougie

Background: Surgical Chest drain insertion is a lifesaving procedure. It re-quires skills and experience towards its prompt insertion. Quite often there is delay or failure caused in its insertion due to excessive fat and loose skin in the axillary area while using the conventional methods. Numerous guidelines exist advising its safe placement, but mishaps still occur, as reported multiple times, while placing the chest drain. In addition to this, a delay or failure of its successful insertion can lead to disastrous consequences. Case: We would like to share, with fellow readers, a novel technique which we used in placing a surgical chest drain successfully. We used a gum bougie to guide the chest drain into the pleural cavity instead of using metal trocar, stellate or long forceps. Conclusion: By using this method, we experienced that not only it re-duced the amount of time taken for the procedure, but it also had positive impact on the ease of insertion without fear of causing damage to internal organs, which ultimately boosted the operator’s confidence.


Background
Surgical chest drain insertion is often a lifesaving procedure required to treat pneumothorax and haemothorax [1] [2] [3]. Surgical chest drains are also used frequently in Emergency Rooms and Intensive Care Units to treat massive pleural effusions and empyema [4].
Numerous guidelines have been published regarding its indications and safe placement, but mishaps still happen due to the complexities of the procedure How to cite this paper: Arya, S., Belwal, S. and Tyagi, P. (2019) Chest Drain Inser-Case Reports in Clinical Medicine specially when it is a blind technique [5]- [10].
A prompt placement of surgical chest drain warrants good skills and experience. A delay or technique failure which includes its wrong placement often leads to disastrous consequences. And for these reasons often, the intensivists depend on their colleague surgeons to insert one [11] [12] [13] [14].
Using "conventional technique" which includes narrow bore pigtail tube insertion or a wider bore tube insertion using pointed trocar, stylet or forceps can lead to accidental puncturing of lung, liver and the heart [15] [16] [17] [18] [19].
Many at times, the reason behind the delay and procedure failure are caused by presence of excessive subcutaneous fat with looseness of skin in and around the axillary area specially seen in obese and fragile patients [20] [21].
Often, while putting a surgical chest drain, the operator loses track of the tunnel which is made by dissecting the subcutaneous tissue and muscle fibres to gain access to pleural cavity. The procedure becomes even more difficult as the operator has significant time constraint on him or her.
To avoid the hurdles as mentioned above, we have devised an innovative technique of "Surgical Chest Drain Insertion" using "Railroad Technique" which we would like to share with the readers.

Case
A 55-year-old male with previous history of COPD (chronic obstructive pulmonary disease), arrived at Emergency Department, in the early hours, with sudden shortness of breath. Chest auscultation suggested no air entry on the right side, which was diagnosed as large right sided pneumothorax with the help of X-Ray chest. Patient was a known case of COPD (Chronic obstructive pulmonary disease) and an ex-smoker. Patient was diagnosed with COPD 10 years ago and left smoking 5 years after the diagnosis. He is prescribed steroids and antibiotics when he gets admitted with exacerbation of COPD, otherwise he takes regular nebulisations at home.

Indication and Procedure
A decision was made to place a surgical chest drain to treat pneumothorax. After the skin incision, blunt dissection of facia, subcutaneous fat and spreading of muscle fibres was done using blunt tip forceps until pleural space was accessed.
Thereafter we followed the track with little finger and swiped the finger 360˚ along parietal pleura. Thereafter alongside the finger, a "Gum Bougie" with "atraumatic end first" was slipped into the pleural cavity for about 10 centimeters at an angle of 30 Degree to skin. It was decided if the bougie does not glide in smoothly the procedure would be abandoned (Figure 1).
In our experience we could direct the tip of gum bougie towards the apex of thoracic cavity over which a 16 French surgical chest drain (Flexo Cath-Thoracic Drainage Catheter, By Romsons India) was gently advanced and the "gum bougie" was withdrawn and the chest drain was connected immediately to an

Conclusions
Very often surgical chest drain placement demands high level of expertise and promptness for its safe and right insertion.
Using the Railroad technique with the help of a gum bougie, as described above, the operators would experience that they are placing chest drains more easily as compared to using the conventional methods. They would also place chest drains more confidently in correct place and position.

Limitations and Future Perspective
Although the described technique was used successfully in first attempt and a couple of times thereafter, mainly in patients with pneumothorax, it would be worth using this technique (Chest drain insertion using a gum bougie) in patients who present with Pleural effusion, hemothorax and pyothorax as well.
It is also recommended to run a RCT (randomized control trial) to compare the advantages and disadvantages of this technique (Chest drain insertion using a gum bougie) with other "conventional techniques" of chest drain insertion. • Authors' contributions: All authors read and approved the final manuscript.

Declarations
SA performed the procedure, SB also scrubbed and helped during the procedure. PT supervised the procedure.