Patients with symptomatic pneumothoraces, large-volume pleural effusions, infected effusions and symptomatic malignant effusions require chest drain insertion. For the most part, pneumothoraces are drained either as an emergency if under tension or because of trauma, on the ward or in Accident and Emergency departments. This is performed safely by clinicians using the safe triangle defined by anatomical landmarks. Occasionally, pneumothoraces may be small or loculated in patients with underlying lung disease such as cystic fibrosis or interstitial lung disease and drain insertion needs then to be performed under CT guidance to prevent underlying lung injury during insertion.

As with pleural aspiration, chest drains should be inserted under ultrasound guidance to avoid inadvertently puncturing lung or solid organs. For a substantial number of years there has been debate on whether large- or small-bore drains should be used in patients with infected pleural effusions. It would now appear that small-bore drains are at least as efficacious as large-bore drains. Both infected and malignant effusions may be uni- or multilocular and, or multiseptated. In these circumstances drain insertion alone may be insufficient to provide adequate drainage and the use of fibrinolytic therapy may be required.

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