Procedure
Chest Tube
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Chest Tube
, Thoracostomy, Tube Thoracostomy, Pleural Drain Insertion
See Also
Needle Decompression of Thorax
Small Calibre Chest Tube
(
Heimlich Valve
,
Pigtail Chest Catheter
)
Indications
Tension Pneumothorax
(following immediate
Needle Decompression of Thorax
)
Simple Pneumothorax
Open Pneumothorax
Massive Hemothorax
Precautions
Tension Pneumothorax
requires immediate
Needle Decompression of Thorax
Chest Tube placement is only after the
Needle Decompression of Thorax
has been completed
Indications for operative management in
Traumatic hemothorax
Chest Tube output >1500-2000 cc total or
Chest Tube output 150-200 cc/hour for several hours
Do not choose an insertion site too low
Ideal insertion site is at the 4th or 5th intercostal space (mid or anterior axillary line)
Err on the side of higher instead of lower
Diaphragm reaches the 7th intercostal space on expiration
Peritoneal Chest Tube placement occurs in 1% of cases
Emergency department doctors were below the 5th intercostal space in 64% of cases
Below the 7th intercostal space 21% of cases (below the 8th in 9% of cases)
Placement was more accurate in women than men
British Thoracic Society recommends staying within the "triangle of safety", with apex at axilla
Anterior to latissimus dorsi muscle
Lateral to pectoralis major muscle
Superior to horizontal nipple line (men) or xiphoid process (women)
References
Arora and Menchine in Herbert (2015) EM:Rap 15(2): 13
Carter (2014) Emerg Med Australas 26(5): 450-4 +PMID:25212066 [PubMed]
Preparation
Equipment
Tube size
French tube size is diameter of tube in millimeters multiplied by 3 (e.g. 36 French = 12 mm diameter)
Spontaneous uncomplicated
Pneumothorax
: 16 to 22 French (small bore)
Unstable patient,
Bronchopleural Fistula
or
Mechanical Ventilation
: 24 to 28 French
Complicated
Pneumothorax
or
Hemothorax
(
Trauma
): 28 to 32 French (large bore)
Older recommendations were for 36-40 French Chest Tube in
Hemothorax
Recent evidence supports smaller Chest Tubes even for
Hemothorax
(28 French is most common)
Similar complication rates (e.g. empyemea, retained
Hemothorax
) regardless of tube size
Inaba (2012) J Trauma Acute Care Surg 72(2): 422-7 [PubMed]
Chest Tube Suction Apparatus or pleur-evac
Cell salvage device (
Autotransfusion
blood bag, cell-saver) for
Hemothorax
blood recovery
Filtered blood (and treated with citrate phosphate dextrose)
Blood may be re-transfused in
Massive Hemothorax
for up to 6 hours after collection
Replaces blood cells, platelets and
Fresh Frozen Plasma
(FFP)
Hemoglobin
is less concentrated than packed RBC (9 g/dl compared with 13 g/dl in
pRBC
)
Spares utilization of allogenic blood and
Platelet Transfusion
Similar safety to allogenic transfusion
Rhee (2015) J Trauma Acute Care Surg 78(4): 729-34 +PMID:25807402 [PubMed]
Preparation
Personal Protection Equipment
Betadine or Hibiclens prep and drape a wide area
Expose surrounding landmarks (axilla, clavicle,
Sternum
, costal margin)
Lidocaine
1% local
Anesthetic
to skin and rib
Chest Tube
Clamp 1: Holds insertion end of Chest Tube
Clamp 2: Clamps off the other end of tube, so chest contents does not spill from tube
Optimize procedure conditions (esp. in obese patients, in whom landmarks are difficult)
Adequate lighting
Leave a wide prepped area free of draping to allow visualization of landmarks (chest, axilla)
Use a longer incision in obese patients
Consider
Procedural Sedation
(e.g.
Ketamine
)
Patient positioning
Hold
Breast
tissue away from surgical field via assistant or tape
Consider arm abducted to 90 degrees and secured to Mayo stand
Consider towel roll under the
Shoulder
to reposition axillary fat
References
Spangler and Inaba in Herbert (2016) EM:Rap 16(9): 7
Technique
Image
Insertion Site
See precautions above
Insert anterior to mid-axillary line
Level of 5th intercostal space, over 6th rib
Men: Nipple line
Women: Xiphoid process level or inframammary fold
Triangle of safety
Apex: Axilla
Posterior boundary: Latissimus dorsi muscle (anterior edge)
Anterior boundary: Pectoralis major muscle (lateral edge)
Inferior boundary: Nipple line in men or xiphoid process in women (as above)
Insertion length or tube
Estimate distance from the 6th intercostal space to the
Shoulder
Note the marker position on the Chest Tube that covers that distance (deepest insertion point)
Last hole on Chest Tube must be in chest or it will need to be replaced
Tube distance marks are measured from the last hole position to the tip
Insertion Procedure
Incise horizontally 3 cm parallel and over the top of the 6th rib (incision should follow the course of the rib)
Consider a wider incision in patients with a larger chest wall (to ensure successful placement)
Consider injecting additional local
Anesthetic
into the subcutaneous tissue above the intended rib entry site
Bluntly dissect through subcutaneous tissue over rib with clamp
Carefully puncture parietal pleura with clamp tip
Firmly grasp Chest Tube several centimeters from insertion site
Hand acts as a stopper
Prevents clamp from being forced too deep on puncture of the pleural space
Insert finger into incision and make 360 degree sweep
Check for organs, adhesions and enlarge path
Insert Chest Tube tip with clamp
Once the pleura is opened, any potential emergency related to
Tension Pneumothorax
is resolved
The tube insertion can be delayed if the provider needs to return to airway management
Take time to ensure the Chest Tube is properly inserted
Firmly grasp tube and hold in place while withdrawing clamp
Finger adjacent to the tube can confirm the Chest Tube direction is toward the apex
Insert at least 12 cm to ensure all Chest Tube holes are in chest
May need to insert 16 cm or more in very large patients
Smaller patients may only allow 10 cm of insertion
Insertion direction
The tube typically can not be directed once it leaves the clamp
Ideally, direct toward apex for for
Pneumothorax
, posterior-laterally for
Hemothorax
Avoid inserting toward hilum or mediastinum
Clinical signs of proper tube placement
Look for tube condensation indicating good placement (unclamp proximal tube end)
Rotate tube - should turn freely if not kinked
Procedure Completion
Close skin around the Chest Tube entry
Suture
tube in place (0 or 1 non-
Absorbable Suture
, e.g. silk ties)
Tape tube in place
Attach Chest Tube to suction
Underwater seal apparatus and suction (-20 to 30 cm H2O)
Pleur-evac
Chest XRay
Verify position and function of tube
Suction
Keep Chest Tube clamped until suction applied
Can place to passive water seal initially
Suction can be delayed initially in most cases to allow for securing the tube
Exceptions include a large
Bronchopleural Fistula
which requires immediate suction
Hemothorax
will often drain without wall suction (blood is forced out with respirations)
Pneumothorax
requires suction until no air leak remains
Pleurovac contains no bubbles with respiration
Do not apply a
Heimlich Valve
in cases of
Trauma
Use only for simple
Spontaneous Pneumothorax
in a patient going home
References
Majoewsky (2012) EM:RAPC3 2(1): 1-2
Testing for persistent air leak
Ask patient to cough while observing Chest Tube output
Water seal chamber OR
Heimlich Valve
immersed in water
Air bubbling through water on coughing suggests persistent leak
Continue to leave in Chest Tube until no persistent air leak is found
Consider other causes of air leak (e.g. leaky vacuum tubing, Chest Tube hole not fully in chest)
Chest Tube removal timing
At least 24 hours after air leaks have stopped AND
Chest Tube drainage <200 ml per 24 hours AND
Serous drainage AND
Not intubated on
Ventilator
or other form of
Positive Pressure Ventilation
(e.g. Bipap, CPaP)
Complications
Typical complications (similar to any invasive procedure)
Infection
Empyema
Chest
wall
Cellulitis
Necrotizing Fasciitis
Bleeding
Scarring
Chest Tube specific complications
Chest Tube malposition (most common)
Blocked Chest Tube drain
Chest Tube dislodgement
Reexpansion
Pulmonary Edema
Subcutaneous
Emphysema
Chylothorax
Persistent air leak
Common concern when there is a persistent communication between
Bronchi
oles and pleural space
Consider other causes of air leak (e.g. leaky vacuum tubing, Chest Tube hole not fully in chest)
Organ injury
See precautions above
Lung
injury
Nerve injury
Great Vessel
injury
Liver
injury (right)
Spleen
or
Stomach
injury (left)
Resources
Chest Tube Insertion (NEJM) - Part 1
http://www.youtube.com/watch?v=hQlt57AyQmg
Chest Tube Insertion (NEJM) - Part 2
http://www.youtube.com/watch?v=ZRoJzkY7SMA
Regions
Trauma
Professional's Blog (Michael McGonigal, MD) - Chest Tube insertion
http://www.youtube.com/watch?v=qyJkh-ghl70
References
Swadron and Inaba in Herbert (2019) EM:Rap 19(6): 15
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