Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010

TLDR

Pleural aspiration and chest drain insertion are common across specialties, yet reports of serious complications—especially with large‑bore drains—have raised safety concerns and highlighted the need for improved training. The guideline seeks to enhance procedural safety by incorporating NPSA recommendations and providing detailed techniques for pleural aspiration, Seldinger chest drain insertion, and ultrasound guidance. It recommends that all operators receive appropriate training and initial supervision by an experienced trainer before performing invasive pleural procedures. The guideline reports that many complications stem from inadequate training or supervision, with most UK NHS trusts lacking formal training policies and clinicians exhibiting wide variation in knowledge and skills.

Abstract

In hospital practice, pleural aspiration (thoracocentesis) and chest drain insertion may be required in many different clinical settings for a variety of indications. Doctors in most specialities will be exposed to patients requiring pleural drainage and need to be aware of safe techniques. There have been many reports of the dangers of large-bore chest drains and it had been anticipated that, with the previous guidelines, better training and the advent of small-bore Seldinger technique chest drains, there would have been an improvement. Unfortunately the descriptions of serious complications continue, and in 2008 the National Patient Safety Agency (NPSA) issued a report making recommendations for safer practice.1 These updated guidelines take into consideration the recommendations from this report and describe the technique of pleural aspiration and Seldinger chest drain insertion and ultrasound guidance. Much of this guideline consists of descriptions of how to do these procedures but, where possible, advice is given when evidence is available. Before undertaking an invasive pleural procedure, all operators should be appropriately trained and have been initially supervised by an experienced trainer. Many of the complications described in the NPSA report were the result of inadequate training or supervision. A recent survey of UK NHS Trusts showed that the majority did not have a formal training policy for chest drain insertion in 2008.2 Studies of clinical practice have shown that there is a wide variation in the knowledge and skills of doctors inserting chest drains. In a published study3 where doctors were asked to indicate where they would insert a chest drain, 45% indicated they would insert the drain outside of the safety triangle, …