Small Caliber Chest Tube

1. See Also
   1. Pneumothorax
   2. Needle Decompression of Thorax
   3. Chest Tube
2. Indications
   1. Primary Spontaneous Pneumonthorax
3. Contraindications
   1. Hemothorax
   2. Hemopneumothorax
   3. Traumatic Pneumothorax
      1. Outside of Hemothorax (and hemopneumothorax), Small Caliber Chest Tubes appear safe in uncomplicated Traumatic Pneumothorax
      2. Kulvatunyou (2014) Br J Surg 101(2): 17-22 [PubMed]
4. Preparation
   1. Obtain small-calibre pigtail catheter Thoracostomy kit (typically 8 Fr catheter)
      1. 
   2. Elevate head of the bed to 30 degrees
   3. Conscious Sedation
5. Efficacy
   1. Small Caliber Chest Tubes are as effective and significantly less painful than standard Chest Tubes in Pneumothorax
      1. Kulvatunyou (2014) Br J Surg 101(2): 17-22 [PubMed]
   2. Small Caliber Chest Tubes are effective even in large spontaneous pneumothoraces
      1. Voisin (2014) Ann Emerg Med 64(3): 222-8 +PMID:24439715 [PubMed]
6. Technique
   1. Identify entry site options
      1. Mid-clavicular line at the second intercostal space (over the third rib): Preferred site
         1. Same site as for Needle Thoracostomy (in Tension Pneumothorax decompression)
         2. Find the first palpable rib inferior to clavicle (2nd rib) and insert at the next inferior intercostal space
      2. Mid-Axillary line at the fifth intercostal space (over the fifth rib)
         1. Same site as for standard Tube Thoracostomy (as for Traumatic Pneumothorax)
   2. Select, mark and prepare the entry site
      1. Examiner puts on gown, glove and mask
      2. Mark the entry site (either option above)
      3. Chlorhexidine applied to skin (for 30 seconds)
      4. Drape (found in the catheter sets)
      5. Local Anesthetic
         1. Inject Lidocaine 1% with Epinephrine
         2. Raise a skin wheel then inject along the insertion site tract down to the pleura
      6. Nick the skin with #11 or similar blade
         1. Incision should be the same size as the tube
   3. Mini-tube or Pigtail (small-calibre, typically 8 French) Chest Tube insertion
      1. Prepare the catheter
         1. Insert trochar into pigtail catheter (the curly tip will straighten)
      2. No-Drop Technique (older, common method, non-seldinger technique)
         1. Insert the catheter (8 french) with small trochar
            1. Insert at the entry site, perpendicular to the skin, and immediately above the rib
            2. On breaching pleura, hear and feel pop as well as air rush
         2. Redirect needle, aiming toward patients head
            1. Insert the trochar needle another 1-2 cm
            2. Thread the catheter over the top of the trochar needle and into the chest
            3. Insert the catheter until all tube holes are well within chest
            4. Withdraw the trochar
      3. Drop Technique (Seldinger technique)
         1. Similar technique to Central Line Placement
         2. Select the kit's large bore needle (typically 16-18 gauge, large enough to accept the guidewire)
            1. Insert the needle at selected site, always over the top of the rib, perpendicular to skin surface
            2. On breaching pleura, hear and feel pop as well as air rush (or aspirate with syringe)
         3. Insert guidewire partially into chest, far enough that it will dislodge, but not so far as to misdirect the catheter
            1. Hold the guidewire firmly at one point throughout this process
            2. Remove introducer needle
            3. Insert dilator with twisting motion to form a tract for catheter insertion
               1. Perform this dilator insertion in and out several times to full thickness through pleura
               2. Skin and soft tissue should pucker out when withdrawing the dilator
         4. Insert the pigtail catheter (with trochar) over the guidewire
            1. Catheter is inserted into chest an adequate distance until all catheter holes are well within chest
            2. Remove the guidewire and trochar
   4. Secure the tube and attach apparatus
      1. Cover the Thoracostomy tube end to prevent increasing the Pneumothorax
      2. Place vaseline impregnated gauze (with slit cut) over chest wall entry site
      3. Place gauze pad under the Chest Tube to prevent kinking
      4. Suture the Thoracostomy tube in place in two places along it's course
      5. Consider reducing the Pneumothorax with aspiration (optional)
         1. Attach a three way stop cock to the Thoracostomy tube
         2. Attach a 20-30 cc syringe to the stopcock
         3. Continue to remove air by repeating the following steps until no further air can be aspirated from the pleural space
            1. Turn the stopcock to allow air to pass between the syringe and the Thoracostomy tube
            2. Aspirate air into the syringe
            3. Turn the stopcock toward the open side port and force all the air from the syringe through the open port
      6. Attach the Heimlich Valve
      7. Secure each tube connection with tape
      8. Secure the Heimlich Valve with foam tape
         1. Apply one strip to chest
         2. Apply one strip to enclose Heimlich Valve and attach to the chest tape
      9. Obtain a Chest XRay to confirm placement
7. Disposition
   1. Observe after Chest Tube placement for 1-2 hours
   2. Repeat Chest XRay to confirm re-expansion
   3. Patient without signs of leak and otherwise stable and asymptomatic may be discharged
      1. Follow-up and recheck in 24-48 hours
   4. Pneumothorax present for a longer period of time should be admitted and observed
      1. Risk of reexpansion Pulmonary Edema risk
8. Resources
   1. Pigtail Catheter Insertion Video (emcrit, Dr. Weingart)
      1. https://emcrit.org/emcrit/pigtail-video/
   2. Pigtail Catheter Insertion Video (Dr. Sacchetti)
      1. http://www.youtube.com/watch?v=xsB9MkuCQE4
   3. Pigtail Catheter Insertion Video (essentialmedicalskills.com)
      1. http://www.youtube.com/watch?v=jk19A8v7TtA
9. References
   1. Arora and Menchine in Herbert (2014) EM:Rap 14(5): 11
   2. Spangler and Inaba in Herbert (2017) EM:Rap 17(4): 4-5