Chest Tube

Aka: Chest Tube, Thoracostomy, Tube Thoracostomy, Pleural Drain Insertion

1. See Also
   1. Needle Decompression of Thorax
2. Indications
   1. Tension Pneumothorax (following immediate Needle Decompression of Thorax)
   2. Simple Pneumothorax
   3. Open Pneumothorax
   4. Massive Hemothorax
3. Precautions
   1. Tension Pneumothorax requires immediate Needle Decompression of Thorax
      1. Chest Tube placement is only after the Needle Decompression of Thorax has been completed
   2. Indications for operative management in Traumatic hemothorax
      1. Chest Tube output >1500-2000 cc total or
      2. Chest Tube output 150-200 cc/hour for several hours
4. Equipment
   1. Tube size
      1. French tube size is diameter of tube in millimeters multiplied by 3 (e.g. 36 French = 12 mm diameter)
      2. Spontaneous uncomplicated Pneumothorax: 14 to 22 French (small bore)
      3. Complicated Pneumothorax or Hemothorax (trauma): 36 or 40 French (large bore)
   2. Chest Tube Suction Apparatus or pleur-evac
   3. Cell salvage device (e.g. Cell-Saver) for Hemothorax blood recovery
5. Preparation
   1. Personal Protection Equipment
   2. Betadine prep and drape
   3. Lidocaine 1% local anesthetic to skin and rib
   4. Chest Tube
      1. Clamp 1: Holds insertion end of Chest Tube
      2. Clamp 2: Clamps off the other end of tube, so chest contents does not spill from tube
6. Technique
   1. Image
      1. 
   2. Insertion Site
      1. Level of 5th intercostal space, over 6th rib
         1. Men: Nipple line
         2. Women: Xiphoid process level or inframammary fold
      2. Insert anterior to mid-axillary line
   3. Insertion length or tube
      1. Estimate distance from the 6th intercostal space to the Shoulder
      2. Note the marker position on the Chest Tube that covers that distance (deepest insertion point)
      3. Last hole on Chest Tube must be in chest or it will need to be replaced
      4. Tube distance marks are measured from the last hole position to the tip
   4. Insertion Procedure
      1. Incise horizontally 3 cm parallel and over the top of the 6th rib
      2. Bluntly dissect through subcutaneous tissue over rib with clamp
      3. Carefully puncture parietal pleura with clamp tip
         1. Firmly grasp Chest Tube several centimeters from insertion site
         2. Hand acts as a stopper to prevent clamp being forced too deep on puncture of the pleural space
      4. Insert finger into incision and make 360 degree sweep
         1. Check for organs, adhesions and enlarge path
      5. Insert Chest Tube tip with clamp
         1. Firmly grasp tube and hold in place while withdrawing clamp
         2. Insert at least 12 cm to ensure all Chest Tube holes are in chest
            1. May need to insert 16 cm or more in very large patients
            2. Smaller patients may only allow 10 cm of insertion
      6. Clinical signs of proper tube placement
         1. Look for tube condensation indicating good placement (unclamp proximal tube end)
         2. Rotate tube - should turn freely if not kinked
   5. Procedure Completion
      1. Suture tube in place
      2. Attach Chest Tube to suction
         1. Underwater seal apparatus and suction (-20 cm H2O)
         2. Pleur-evac
      3. Chest XRay
         1. Verify position and function of tube
   6. Suction
      1. Keep Chest Tube clamped until suction applied
         1. Can place to passive water seal initially
      2. Suction can be delayed initially in most cases to allow for securing the tube
         1. Exceptions include a large Bronchopleural Fistula which requires immediate suction
      3. Hemothorax will often drain without wall suction (blood is forced out with respirations)
      4. Pneumothorax requires suction until no air leak remains (Pleurovac contains no bubbles with respiration)
      5. Do not apply a Heimlich Valve in cases of trauma (use only for simple Spontaneous Pneumothorax in a patient going home)
      6. References
         1. Majoewsky (2012) EM:RAPC3 2(1): 1-2
7. Resources
   1. Chest Tube Insertion (NEJM) - Part 1
      1. http://www.youtube.com/watch?v=hQlt57AyQmg
   2. Chest Tube Insertion (NEJM) - Part 2
      1. http://www.youtube.com/watch?v=ZRoJzkY7SMA
   3. Regions Trauma Professional's Blog (Michael McGonigal, MD) - Chest Tube insertion
      1. http://www.youtube.com/watch?v=qyJkh-ghl70