Previously the risks of ICD insertion in patients on mechanical ventilation has been described [5] however we presented the above case due to frequent referral of patients on mechanical ventilation to us with harmful complications of tube thoracostomy. Prior to ICD insertion in a patient on mechanical ventilation, the PEEP must be turned off and the ventilator must be disconnected briefly during the introduction of the ICD. In ICD insertion deploying Seldinger technique the same steps need to be taken for introducing the guide wire as well as the chest tube. Any ICD breaching the lung parenchyma should be removed after insertion of another ICD in the pleural space.
We believe the BTS guidelines [1] require a new revision with the view to including the mechanical ventilation as a hazardous clinical setting in "pre-drainage risk assessment" section. Furthermore ICD insertion needs to be explained separately in self- and mechanical-ventilating patients along with considering the clinical settings as well as the specialty demands.
For instance efficient drainage of left-sided pleural effusion in a post-CABG (coronary artery bypass graft surgery) patient requires a tube thoracostomy below the triangle of safety; or fine bore ICD insertion under Seldinger technique for the treatment of pneumothorax is a well established procedure deployed by respiratory physicians while in thoracic surgery a large bore ICD with conventional insertion technique is favourable.
The royal college of surgeons has introduced S-DOPS (direct observation of procedural skills in surgery) via intercollegiate surgical curriculum programme (ISCP) [6]. We recommend a unified usage of surgical DOPS in all specialties to sign off junior doctors' competency in tube thoracostomy in self- and mechanical-ventilating patients.