What is the best way to secure a chest drain? A scoping review

Abstract

Each year, around 30,000 intercostal chest drains (ICDs) are inserted in the UK, with complications like displacement being a common concern. Various fixation techniques have been proposed to secure ICDs, but there is no consensus on a gold standard. A scoping review was conducted to identify publications describing ICD fixation methods and frequency with which they become dislodged. Three databases were reviewed: MEDLINE from 1946 to 17th October 2024 through the Ovid^® website portal, PubMed^®, and the Cochrane Central Register of Controlled Trials (CENTRAL). Appropriate search terms and synonyms were applied with Boolean operators and from 5275 identified records 63 were included for review. Nine ICD fixation principles were identified to classify fixation methods: kinking; Poisson-effect (“Roman Sandal”); suture “through” the tube; tube fixation points (cuffs or wings); friction/adhesion (from ties or dressings); external coiling/locking/flattening; internal balloons; internal coiling (pigtails); subcutaneous tunnelling. Many fixation methods combined more than one principle. Although no definitive conclusions on the best fixation method can be drawn from this review, trends suggest that incorporating sutures or using combined techniques, such as sutures paired with dressings, cable ties or balloon catheters, may enhance ICD security. In laboratory conditions, the highest pull force was associated with the modified Jo’berg knot. Further robust studies are needed to compare the effectiveness of different fixation methods superior in terms of displacement rate, but also taking into account pain, skin integrity, wound leakage/infection, or ease of use.

Keywords

thoracostomy intercostal drain chest tube sutures fixation devices surgical occlusive dressings

Introduction

A working, well-positioned, intercostal chest drain (ICD) can be precious, particularly in mechanically ventilated, intensive care unit (ICU) patients. ICDs are used to allow drainage of air, blood, pus, or effusion fluid from the pleural space, and they are commonplace in the ICU in the management of trauma, infection and after surgery. Estimates of how often ICDs become partially or completely dislodged vary between 6% and 42% and incidence reportedly increases in ICDs in situ for greater than 24 h.^1–5 ICD dislodgement may result in additional radiological investigations and exposure, need for nursing and medical review, re-positioning or re-insertion. As an estimated 30,000 ICDs are inserted every year in the UK, preventing dislodgement is an important consideration.^6,7

Furthermore, ICD insertion is associated with significant risk of complications, including misplacement and visceral damage, making them the subject of alerts and guidelines.^8,9 Minimising the need for re-insertion has obvious safety implications, as well as being economically advantageous and kinder to the patient.

Many different techniques of ICD fixation have been described but there is no agreed gold standard, and it is unclear if any specific fixation technique is superior at reducing the risk of displacement. Many descriptions of fixation techniques are brief and ambiguous.^7,8,10,11 Advanced Trauma Life Support^® course (ATLS^®) and British Thoracic Society (BTS) guidelines both recommend using sutures, but do not recommend a method of suturing.^7,12

The aim of this work is to identify the range of published ICD fixation techniques and evaluate whether any have been demonstrated to be more secure.

Methods

We performed a structured search of MEDLINE, PubMed^® and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1946 to 17th October 2024 seeking publications describing fixation techniques or a comparison of the frequency of complications associated with different methods of fixation. Controlled trials (whether randomised or not), observational studies, laboratory studies, editorials, and items of correspondence were all considered for inclusion.

The search was performed and reported according to principles outlined by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline.¹³ The aims and methodology were agreed a priori but not pre-published in the international prospective register of systematic reviews (PROSPERO) which does not accept scoping reviews. In keeping with similar reviews, ethical approval was deemed unnecessary.

English language articles referring to temporary drains placed transcutaneously into the pleural cavity in either adult or paediatric practice were considered, including those placed using Seldinger or blunt dissection techniques, and those placed during surgery. All designs and sizes of ICD were included, and for the purposes of this review, any reference to “small bore” drains was interpreted as a drain size of less than 18 Fr (French gauge) which has a 6 mm outer diameter. Laboratory studies, including live animal, cadaveric, or simulation models, were included if deemed relevant to human practice.

Studies describing drainage systems connecting two body cavities, methods of wound closure rather than drain fixation, or long-term (or outpatient) ICDs were excluded.

The following search terms were used with the appropriate Boolean operators and wildcards to identify articles relating to ICDs: “thoracostomy,” “intercostal,” “pleural,” “chest”; “Seldinger,” “surgical,” “Wayne,” “Fuhrman,” “pigtail”, “tube,” “drain,” “catheter.”

Terms (including wildcards) used to identify different fixation techniques (when combined with the above terms) were: “fixation,” “securement,” “anchor,” “suture,” “stitch,” “adhesive,” “dressing,” “balloon,” “cuff,” “pigtail.”

After de-duplication, titles and abstracts of returned articles were independently screened by two investigators (MB and CW) according to the above a priori eligibility criteria. Where the inclusion of an articles was not clear, it was reviewed and discussed jointly by MB and CW to arrive at a consensus decision. This was required where articles only partially fulfilled the inclusion criteria, for example those that used Foley catheters as chest drains.

For studies deemed eligible for inclusion, the following data were extracted: authors, publication date, journal, title, country of origin, fixation technique, type and frequency of complications (where described), population and clinical setting.

Results

A total of 4531 records were identified by database searching and underwent title and abstract screening, with 159 articles selected for full-text review and 63 included in the final analysis (Figure 1). Of these, 30 were descriptions of techniques with no associated analysis.^14–43 There were 33 studies which examined or compared the efficacy of fixation techniques,^2,3,44–74 including 10 laboratory studies, including both simulations and alive and cadaveric animal models^44–53; and 23 human clinical studies,^2,3,54–74 of which five involved children.^{65–67,69,73}

Figure 1.

Flow diagram of literature search for intercostal chest drain fixation methods.

Fixation techniques

Thirty articles described one or more ICD fixation techniques (Table 1).^14–43 From these articles, nine common principles were identified as a means of classifying methods used to secure ICDs: kinking; Poisson-effect (“Roman Sandal”); suture “through” the tube; tube fixation points (cuffs or wings); friction/adhesion (from ties or dressings); external coiling/locking/flattening; internal balloons; internal coiling (pigtails); subcutaneous tunnelling (Table 2). Several ICD fixation techniques combined several of these principles, and some articles reported using equipment designed for other purposes, such as cable ties and urinary catheters, for ICD fixation.^18,31,47,60

Table 1.

Published descriptions of one or more novel techniques for intercostal chest drain fixation.

Authors	Year	Country of origin	Fixation technique	Relevant comments	Population
Anonymous¹⁴	1996	Unclear	Adhesive dressing around drain and over skin with occlusive petroleum gauze followed by pre-slit sterile gauze and tape creating an air-tight seal	Generic adhesive bandages and dressings – not specific for drains	Trauma, surgery or spontaneous pneumothorax
David Papa Akuetteh et al.¹⁵	2020	China	Applying a two-way wrapping technique to the re-stickable silicone adhesive dressing with an absorption pad	Dressing designed for drains	Thoracic surgical patients
Bar-Maor¹⁶	1994	USA	Sutures to skin followed by suture around ICD under tension		Trauma
Barnung et al.¹⁷	2014	Denmark	Clamp to device and skin	iTClamp™ is a temporary wound closure device	Prehospital trauma
Ben-Nun¹⁸	2008	Israel	Intrapleural balloonSuture to skin and drain+/− Heimlich valve	Foley urinary catheter used	Patients with pleural effusion (general and thoracic surgical patients)
Boyle¹⁹	1999	UK	External cuff on drainSuture to skin and around cuff	Cuff fashioned from tubing	Trauma
Carignan et al.²⁰	2000	Canada	Catheter-securement device	Statlock™ dressing	No specific setting
Frank²¹	1983	USA	Sutures to skin and around the ICD in opposite direction leaving indentation		No specific setting
Fuhrman et al.²²	1986	USA	Modified pigtail inserted with modified Seldinger technique.Luer-locked to a negative pressure, closed pleural drainage system	Demonstrated in children and neonates	Infants and children with pleural effusion/ pleural collection of hyperalimentation fluid/pneumothoraces
Inzirillo et al.²³	2012	Italy	Alpha-shaped sutures around the woundSame sutures used to cross around the ICD in a Roman Sandal fit	Single suture for tube fixation and drain hole closure	Thoracic surgical patients
Jetty et al.²⁴	2000	Canada	Sutures to skin and through drain		Thoracic surgical patients (pneumonectomy)
Jung et al.²⁵	1991	USA	“Unique” pigtail design	Unable to access all of article	Neonates with pneumothoraces
Kamiyoshihara et al.²⁶	2008	Japan	Tunnelling, stapler and dressing	Tunnel made during thoracoscopy	Thoracic surgical patients
Kao et al.²⁷	2017	Taiwan	Three pre-embedded continuous subcuticular sutures applied to wound leaving an opening for ICD insertion before tightening post insertion	Combined thoracoscopy wound closure and drain fixation	Thoracic surgical patients (uniportal VATS)
Kesavan et al.²⁸	2011	UK	Intrapleural balloon and external balloon		Paediatric patients with pneumothoraces
Lawless et al.²⁹	1989	USA	Modified pigtail inserted with Seldinger technique.Christmas tree adaptor is used to connect the catheter and the drainage system	May be the same as Fuhrman et al. as Fuhrman is co-author²³	Neonates and children with pneumothorax or pneumomediastinum during mechanical ventilation
Maritz et al.³⁰	2014	UK	Horizontal mattress sutures placed with a simple knot placed distally halfway along the free ends. Wrap the thread around the ICD the same way up to the knot level. Pass the free ends through the loop of the horizontal mattress suture. Pull and wrap the free ends around the ICD in opposite direction before placing another knot for securement.	Description of the “Jo’burg knot”	No specific setting
Melamed et al.³¹	2007	Israel	Locking cable tie around tube; suture to skin and cable tie		Prehospital trauma
Plani³²	2004	South Africa	Vertical mattress suture placed to skin as the anchoring suture. A first throw of the suture is placed while a knot is tied 15 cm from the wound edge. ICD is wrapped around by the suture until the knot level before the knot is passed underneath the suture loop. The ends are then again tied around the ICD. Additional vertical mattress sutures could be placed on the sides for extra security.	Description of the “Jo’burg knot”	No specific setting
Perez et al.³³	2020	Italy	Catheter-securement device and cyanoacrylate glue and dressing	SecurAcath™ central venous access securement device	Premature neonates with pleural effusion
Rashid et al.³⁴	1998	Sweden	Two stitches placed on either side of wound with the free edges secured around the ICD.One horizontal mattress stitch placed in the middle of the wound wrapping several times around the ICD.	Combined wound closure and drain fixation	Patients requiring closed tube thoracostomy
Seaman³⁵	1959	USA	Horizontal mattress sutures to skin and loop around the ICD. Friction knot and double bow knot then tied. Narrow adhesive tape is placed in a spiral fashion over the suture onto the ICD.		Patients requiring a chest catheter
Simon et al.³⁶	1982	USA	Modified horizontal mattress stitch applied to skin and wrapped around ICD		Patients underwent closed tube thoracostomy
Son et al.³⁷	2015	South Korea	Subcutaneous suture and knot are placed. An anchor suture is then placed through the knot and fixating the ICD wrapping around it.		Thoracic surgical patients (single incision VATS lobectomy)
Spinoza et al.³⁸	2010	UK	Braided sleeve with anchoring points for suturing		No specific setting
Sun et al.³⁹	2021	China	Sutures to muscles on both sides of incision and tie a knot around ICD. A subcutaneous suture is placed continuously from the front side to the backside.		Thoracic surgical patients (uniportal VATS patients)
Tinckler⁴⁰	1976	UK	Intrapleural balloon and movable external collar		No specific setting
Weber et al.⁴¹	2005	USA	Adhesive dressing to skin and sutures to drain	Statlock™ dressing – for newer versions sutures not required	Infant with chylothorax
Yang et al.⁴²	2018	USA	Adhesive dressing to skin with additional sutures to drain	Statlock™ urinary catheter dressing	No specific setting
Zhang⁴³	2016	China	Sutures to skin and sailor’s knot around the ICD. Additional surgical knots are used to lock the sailor’s knot		Thoracic surgical patients

ICD: intercostal chest drain; UK: United Kingdom; USA: United States of America; VATS: video-assisted thoracoscopic surgery.

Table 2.

Classification system of intercostal chest drain fixation principles.

Different techniques may combine more than one principle.

In practice combinations of the above principles are used, particularly when fixing the drain to the skin. For example, studies describe securing balloon and pigtail catheters with additional sutures.^2,3

One balloon device involves a “port” which penetrates the chest and has a balloon attached. A drain can then be inserted through the port, but it is not clear how the drain is held by the port.⁴⁶

Laboratory studies

Table 3 summarises laboratory and simulation-based studies of ICD fixation techniques.^47–54 There was no standardised assessment of the efficacy of different techniques. Some studies compared the absolute risk of displacement, while others measured the length of tubing displaced by force, or the time until complete displacement. Experimental methods involved either a continuously increasing force, repeated pulling events using a predetermined force, or subjective estimates of force. Different fixation techniques withstood peak pull forces (i.e. the force required to dislodge an ICD) ranging from 19 to 180 N (Table 4). For comparison, a previous ergonomics paper has suggested that the average peak pull strength of a sample of young men in a standing position was approximately 150 N.⁷⁶

Table 3.

Laboratory studies (including animal or simulation models) analysing different types of intercostal chest drain fixation methods.

Authors	Year	Country of origin	Fixation method	Variety of methods	Details of research
Authors	Year	Country of origin	Fixation method	Variety of methods	Study design	Relevant outcome(s)
Ablett et al.⁴⁴	2017	UK	Sutures to skin and drain.	8	Porcine cadaveric crossover.	Length of ICD dislodged after 50 N applied for 10 s.
Domanska et al.⁴⁵	2023	Ireland	Comparison of techniques of tape fixation using “Sleek”^® tape.	6	Laboratory model comparative analysis.	Maximum pull force (N) and cycles to failure with repeated 30 N pull force.
Eisenkraft et al.⁴⁶	2021	Israel	Port with intrapleural balloon with external fixation disc through which drains are inserted.	1	Live porcine observational study.	Ease of use; evidence of displacement up to 58.8 N traction force.
Heskin et al.⁴⁷	2018	Ireland	Sutures to skin; sutures to drain +/− cable tie, +/− adhesive dressing.	5	Survey of techniques used (n = 138 responses) and laboratory model research comparative analysis.	Repeated cycles of increasing force up to 30 N. Number of cycles until failure/displacement in mm.
Homma et al.⁴⁸	2020	Japan	Dressings to skin and tube.	8	Survey of techniques used and Laboratory model research comparative analysis.	Peak and total resistance force (N) and energy (J).
Howes et al.⁴⁹	2015	UK (military study conducted in Afghanistan)	Sutures to skin; sutures to drain +/− adhesive “flag” dressing.	7	Observational study. Mannikin simulation comparing techniques.Partially blinded assessment.	Time to complete insertion; displacement by “moderate” manual force.
Mckee et al.⁵⁰	2018	Canada	iTClamp™ versus sutures; both to skin and drain.	2	Human cadaveric comparative analysis.	Insertion time; displacement events after 5 lb pull force (22.2 N) applied.
Ringel et al.⁵¹	2021	Israel	Sutures, ties, dressings and fixation devices.	14	Porcine cadaveric comparative analysis.	Breaking force and failure point.
Song et al.⁵²	2008	USA	Sutures to skin and drain.	2	Canine cadaveric comparative analysis.	Force required for failure and displacement; point of failure.
Tokur et al.⁵³	2016	Turkey	Intrapleural balloon with external cuff and lock versus standard drain.	2	Live porcine comparative analysis	Speed of insertion; evidence of iatrogenic insertion injury.

ICD: intercostal chest drain; J: joules; N: newtons; lb: pounds; UK: United Kingdom; USA: United States of America; mm: millimetres.

Table 4.

Comparison of the peak pull forces at which failure occurs with ICD fixation methods.

Material	Technique	Pull force to cause failure (Newtons)	Experimental model	Author
Suture	Purse string	70–88 N^a	Porcine cadaver	Ringel et al.⁵¹
	Multiple (four) friction sutures	83–103 N^b	Canine cadaver	Song et al.⁵²
	Poisson-effect	74–83 N^b 71–96 N^a	Porcine and canine cadaver	Song et al.⁵² Ringel et al.⁵¹
	Modified “Jo’burg” knot	129–180 N^a	Porcine cadaver	Ringel et al.⁵¹
Suture combined with locking cable tie		93–147 N^a,c	Porcine cadaver	Ringel et al.⁵¹
Port with intrapleural balloon		>58.8 N	Porcine/anesthetized	Eisenkraft et al.⁴⁶
Commercially designed Tube holder		20 N	Porcine cadaver	Ringel et al.⁵¹
Adhesive dressings		19–68 N25–52 N50 N	Polyethylene plateUnclear^d Porcine cadavers	Homma et al.⁴⁸ Domanska et al.⁴⁵ Ringel et al.⁵¹

Differences in drain material and size, suture material, and dressings may affect the reliability of comparisons.

Dependent on tube material (silicone > polyvinyl chloride).

Dependent on suture material (1 silk > 0 silk).

Dependent on number of passes through locking tie (2 > 1).

Domanska et al. did not use human or animal subjects. It is likely that a laboratory surface of some description was used.

Suturing techniques appeared to withstand the highest forces, with the modified “Jo’burg” technique being highly resistant to displacement, resisting forces up to 180 N (Newtons).⁵¹ The modified “Jo’burg” technique is a hybrid technique that combines elements of both pinching and Poisson effects (Figure 2).

Figure 2.

Modified Jo’burg knot suture fixation technique.

Although commonly used suturing techniques that rely on the Poisson-effect (“Roman Sandal”) appeared to perform well in laboratory studies, some studies suggested that it was prone to becoming loose with the wrappings slipping down the tube.^49,51 Heskin et al. found that the Poisson-effect was made more effective by the addition of cable ties or adhesive dressings to prevent slippage.⁴⁷ Combination techniques performed favourably in some studies, however the only force measurements were those from Ringel et al. involving cable tie and suture combination – these performed well (approximately 100–150 N), although not as well as the modified “Jo’burg” knot.⁵¹ Adhesive dressings did not perform as well in laboratory studies with displacement forces ranging from 19 to 68 N.^45,48,51

Studies in humans

There were 23 studies that identified that examined ICD fixation in humans (Table 5).^2,3,54–74 Four studies described combined techniques of wound closure and drain fixation in patients undergoing thoracoscopic surgery.^54,56,59,71 They were among several studies addressing skin discomfort or injury/healing as the outcomes of primary interest.^{57,58,60,62,74}

Table 5.

Human clinical studies analysing or comparing different types of intercostal chest drain fixation methods.

Authors	Year	Country of origin	Title	Fixation method	Details of research
Authors	Year	Country of origin	Title	Fixation method	Type of study	Setting and participants (n)	Relevant outcome(s)
Asciak et al.³	2018	UK	Chest drain fall-out rate according to suturing practices: a retrospective direct comparison	Sutures to skin and drain versus pigtail drain and dressing	Retrospective cohort case-control study	Respiratory/cardiothoracic wards (n = 369)	No. of displacementsTime to displacement
Chen et al.⁵⁴	2022	China	A new traceless technique for cosmetic closure of minimally invasive incision and chest tube fixation after uniportal video-assisted thoracoscopic surgery	Sutures to skin and drain	Retrospective cohort case-control study comparing techniques	Following uniportal thoracoscopic surgery (n = 258)	Length of stay; ICD “prolapse”; other complications
Cho et al.⁵⁵	2023	Republic of Korea	Double-pigtail drainage catheter: a new design for efficient pleural drainage	Double versus single pigtail; +/− suture	Retrospective observational cohort analysis	Hospital drainage of pleural effusions (n = 343; 382 procedures)	“Dysfunctional retraction”; blockage
Fu et al.⁵⁶	2019	China	Drainage tube hole suture improvement: Removal-free stitches	Sutures to skin and drain	Retrospective cohort case-control study of skin port closure and ICD fixation	Following uniportal thoracoscopic surgery (n = 102)	Scarring, hernia, and infection; tube bypassing or “dislocation”
Gross et al.⁵⁷	2016	USA	Comparison of three practices for dressing chest tube insertion sites: a randomised controlled trial	Dressings to skin. Unclear if other fixation also used.	Prospective randomised control trial of three different dressings	Cardiothoracic patients(n = 59)	Wound leakage; pain scores and skin integrity.
Jones⁵⁸	2013	USA	A randomised comparative effectiveness study comparing two chest tube dressing methods	Adhesive dressings. Unclear if other methods used	Randomised observational study	Cardiothoracic surgery (n = 79)	Skin irritation and damage
Kim⁵⁹	2017	Republic of Korea	Barbed suture material technique for wound closure and concomitant tube placement in uniportal VATS for pneumothorax	Sutures to skin and drain	Description of technique Non-randomised controlled trial	Following uniportal thoracoscopic surgery.(n = 31; 35 drains)	ICD complications
Lai et al.⁶⁰	2018	China	Is it safe and practical to use a Foley catheter as a chest tube for lung cancer patients after lobectomy? A prospective cohort study with 441 cases.	Intrapleural balloon versus chest drain – other fixation not recorded	Prospective non-randomised cohort study	Postoperative thoracoscopic cancer surgery (n = 441)	Pain scores and frequency of medical complications
Li et al.⁶¹	2021	China	The application of pigtail catheters in postoperative drainage of lung cancer	Pigtail + fixation device/suture versus silicone tubes + suture	Randomised control trial, unblinded	Thoracoscopic surgery patients (n = 1375)	Length of stay; pain; complications including slippage and obstruction
Mehta et al.⁶²	2016	India	The pigtail catheter for pleural drainage: a less invasive alternative to tube thoracostomy	Pigtail versus standard drain; fixation method unclear	Observational cohort analysis	Hospital drainage of pleural effusions (n = 92)	Pain; length of stay; complications including blockage and accidental removal
Mercer et al.²	2022	UK	A randomised controlled trial of intrapleural balloon intercostal chest drains to prevent drain displacement	Intrapleural balloon versus standard drain, both +/− suture and dressing	Randomised controlled trial, unblinded	Any hospital environment where small bore drain required. (n = 267)	Drain displacement rate, and time to displacement; pain; length of stay; requirement for X-ray; other adverse events
Miotto et al.⁶³	2022	Brazil	Early discharge for patients with benign pleural effusions using a Wayne catheter (pigtail) chest drain - analysis of safety, complications, and quality of life	Pigtail; fixation method unclear	Prospective observational cohort analysis	Outpatient drainage of pleural effusions (n = 47)	Pain; catheter “replacement”
Mortman et al.⁶⁴	2023	USA	Reintervention rate after pigtail catheter insertion compared to surgical chest tubes	Pigtail versus standard drain; fixation method unclear	Retrospective observational cohort analysis	Hospital patients requiring pleural drainage (n = 1032)	Length of stay; complications requiring re-intervention
Panza et al.⁶⁵	2020	UK, Italy	Pigtail catheters versus traditional chest drains for pneumothorax treatment in two NICUs	Fuhrman pigtail; fixation method unclear	Retrospective observational cohort analysis	Neonatal ICU pneumothoraces (n = 44)	Drain displacement, dysfunction
Petel et al.⁶⁶	2013	Canada	Percutaneous pigtail catheter versus tube thoracostomy for paediatric empyema: A comparison of outcomes Surgery.	Pigtail and dressing versus standard drain with sutures	Retrospective observational cohort analysis	Children with empyema (n = 43)	Drain displacement, occlusion or reintervention
Pierrepoint et al.⁶⁷	2002	UK	Pigtail catheter drain in the treatment of empyema thoracis	Pigtail versus standard drain; fixation method unclear	Retrospective observational cohort analysis	Children with empyema (n = 23)	Length of stay; drain replacement or adjustment
Rasihashemi et al.⁶⁸	2021	Iran	Comparison of the therapeutic effects of a pigtail catheter and chest tube in the treatment of spontaneous pneumothorax: a randomised clinical trial study	Pigtail versus standard drain; fixation method unclear	Randomised controlled trial	Adult hospital patients requiring a pleural drain (n = 42)	Length of stay; pain; complications including displacement or obstruction
Roberts et al.⁶⁹	1998	USA	Efficacy and complications of percutaneous pigtail catheters for thoracostomy in paediatric patients	Pigtail; suture; dressing	Retrospective observational cohort analysis	Paediatric ICU (n = 91; 133 procedures)	Complications including disconnection, displacement, or obstruction
Ross et al.⁷⁰	2016	UK	A pilot study of a dedicated ballooned intercostal drain	Intrapleural balloon; dressing	Observational trial	Inpatient pleural effusion drainage (n = 20)	Drain displacement
Shi et al.⁷¹	2023	China	Experience of a modified chest tube suture-fixation technique in uniportal thoracoscopic pulmonary resection	Sutures to skin and drain	Retrospective cohort case-control study of skin port closure and ICD fixation	Following uniportal thoracoscopic surgery (n = 116)	Scarring, pain score, time until tube removal
Vaidya et al.⁷²	2022	Nepal	Comparative study between the use of pigtail catheters and traditional chest tube drain in cases with pneumothorax	Pigtail and suture versus standard drain with unclear fixation	Prospective comparative study	Adults with pneumothorax (n = 76)	Length of stay; pain; complications including displacement
Wei YH et al.⁷³	2014	Taiwan	Pigtail catheters versus traditional chest tubes for pneumothoraces in premature infants treated in a neonatal intensive care unit	Pigtail versus standard drain with suture	Retrospective observational cohort analysis	Neonatal ICU pneumothoraces (n = 66; 86 procedures)	Length of stay; drain-free days; tube displacement/malfunction
Wood et al.⁷⁴	2019	USA	Comparative evaluation of chest tube insertion site dressings: a randomised controlled trial	Adhesive dressings. Unclear if other methods used.	Randomised observational study	Medical, surgical and cardiothoracic ICUs (n = 127 patients; 236 drains)	Skin integrity, pain, absorbency, air leak and displacement.

ICD: intercostal chest drain; ICU: intensive care unit; NICU: neonatal intensive care unit; UK: United Kingdom; USA: United States of America; VATS: video-assisted thoracoscopic surgery.

A total of 13 studies involved pigtail ICDs.^{3,55,61–69,72,73} Five such studies were conducted on children (where body size often necessitates small diameter ICDs and where external methods of skin fixation other than dressings are challenging).^{65–67,69,73} Mortman et al. one of the largest retrospective studies, indicated a significantly higher incidence of displacement with pigtail drains compared with surgical ICDs.⁶⁴ Double pigtail drains may have a lower displacement rate compared with standard pigtails.⁵⁵

Mercer et al. investigated a custom-made ICD with an integral balloon and identified a lower incidence of drain displacement compared with standard 12Fr ICDs, but also a minor increase in adverse events including difficult or painful removal.² Two further studies also compared how well balloons secured tubes, but these involved the use of Foley urinary catheters as ICDs, a practice that would be considered off-label usage in many countries.^18,60

Discussion

In this scoping review we classified ICD fixation systems using nine principles and have reported a wide variety of laboratory and human studies assessing the comparative performance of fixation techniques that employ those principles. Unfortunately, between-study methodologic and reporting heterogeneity means definitive conclusions on the superiority of any one fixation technique cannot be offered. The type and size of the ICD tube, the suture material and size, the use of any dressings, and the experience of the health practitioner are also likely to play a part.^49,51,52 Given the paucity of definitive evidence, it is perhaps unsurprising that ATLS^® and BTS guidelines, arguably the most relevant, do not advocate any specific fixation technique.^3,12

The literature does, however, allow some conclusions to be drawn. Porcine cadaveric research suggests that the modified “Jo’burg” technique is very resistant to displacement, resisting forces up to 180 N.⁵¹ Our review also suggests that combining different methods of securement, for example combining adhesive dressing with sutures, or suturing pigtail, small bore Seldinger, and balloon drains, may be more successful at preventing dislodgement than single techniques alone.^2,3,47 In fact, BTS guidelines recommend that small bore or pigtail ICDs are sutured alongside any other fixation method, based in part on the results of Asciak et al.^3,7

Another BTS recommendation is that any adhesive dressings should involve a “mesentery” or “omental tag” (see Table 2, dressing or tape with uses a mesentery).¹⁰ The paper by Domanska et al. would seem to cast doubt on this suggestion as it found that a higher force was required to dislodge a drain with a “bridge” covering (see Table 2, external flattening using a dressing or tape (a “bridge”)) than those with a mesentery.⁴⁵ However, insofar as comparison between studies is possible, our scoping review finds that that adhesive dressings appear less effective than sutures in preventing ICD dislodgement (Table 4).

Some fixation techniques may have limited applicability. Although a large proportion of included studies involve pigtail drains, their use remains contentious for several indications.⁶⁴ Another example, tunnelling, is typically only feasible for large bore drains inserted during surgical wound closure. In contrast, certain techniques may provide added benefits in specific circumstances. For example, balloon-tipped urinary catheters have been deliberately used to tamponade bleeding intercostal vessels.⁷⁷ Some intraoperative techniques combine chest drain fixation with wound closure aiming for improved cosmetic results.

The re-purposing of medical equipment as ICDs, including central venous, Bonnano, and urinary catheters, was described in several papers that were excluded at the screening stage. Off-label use of equipment not designed for chest drainage is discouraged as it leaves health organisations and professionals liable in the event of adverse reactions.⁷⁸ In spite of this, we chose to include two references to Foley catheters in our review due to the size of the cohorts examined, and the potential requirement for non-standard approaches to ICDs in low-resource settings.^18,60

One of the strengths of this study is that it had very broad search criteria which meant a wide range of methodologies were reviewed. These included living and cadaveric, human and animal models. By way of contrast, a weakness of this study is that it was not possible to synthesise all of the available results into definitive recommendations on fixation technique. Only 15 studies compared frequency of dislodgement, but often this was as a secondary outcome with methodology that was poorly described and involved small numbers of participants.^{2,3,54–56,61,62,66–69,72–74} Another weakness of this study is that it has not been possible to identify the frequency with which different fixation techniques are encountered in the ICU setting or in other clinical scenarios. The largest audit of UK ICDs did not record which techniques were used, only that “accidental dislodgement of chest drains should be avoided by adequate fixation.”⁴

We also recognise that bland dislodgement rates are only one aspect of what might make one fixation method better or worse than any other. Consideration of insertion time, expertise required, cost, patient experience (including pain), skin integrity, and wound leakage (including subcutaneous emphysema and wound infection) should all be considered important. Many of these factors were outcome measures in several of the studies we reviewed.^{2,56–58,60–63,71,74} Future research should combine examinations of the security of different fixation methods with the other outcomes described above.

Conclusions

Despite the recognised problems associated with of ICD fixation failure, research in this field has been sporadic and inconsistent. This review has attempted to summarise existing research to inform current practice and future research needs. Individual expert practitioners with established ICD fixation techniques acceptable to their institution and patients should be reticent to alter practice based solely on this review of the literature. However, we can cautiously suggest that it was possible to identify certain trends. For example, the more secure ICD fixation techniques identified in this scoping review appear to be those involving sutures or sutures combined with cable ties or adhesive dressings. Of the suture techniques for which evidence was available, those which indented the chest drain were more successful than those that did not, whilst in a laboratory setting the highest identified pull force identified was associated with the modified Jo’berg knot.

Footnotes

ORCID iD

Martin Beed

Author contributions

Study design, planning, conduct: CW, MB, DWH. Writing, and revision of manuscript: all authors.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study/project is funded by the NIHR - i4i Product Development Awards (PDA) - Breakaway Chest Drain Valve (Reference: NIHR204562). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MB receives an annual honorarium for work with Quotient Sciences.

The other authors have no interests to declare.

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