Chest Tube

See Also

Indications

Tension Pneumothorax (following immediate Needle Decompression of Thorax)
Simple Pneumothorax
Open Pneumothorax
Massive Hemothorax
Penetrating Chest Trauma

Contraindications
Relative

Underlying pleural adhesions
Underlying Emphysematous blebs
Coagulopathy

Precautions

Tension Pneumothorax requires immediate Needle Decompression of Thorax
1. Chest Tube placement is only after the Needle Decompression of Thorax has been completed
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
Do not choose an insertion site too low
1. Ideal insertion site is at the 4th or 5th intercostal space (mid or anterior axillary line)
  1. Err on the side of higher instead of lower
2. Diaphragm reaches the 7th intercostal space on expiration
3. Peritoneal Chest Tube placement occurs in 1% of cases
4. Emergency department doctors were below the 5th intercostal space in 64% of cases
  1. Below the 7th intercostal space 21% of cases (below the 8th in 9% of cases)
  2. Placement was more accurate in women than men
5. British Thoracic Society recommends staying within the "triangle of safety", with apex at axilla
  1. Anterior to latissimus dorsi Muscle
  2. Lateral to pectoralis major Muscle
  3. Superior to horizontal nipple line (men) or xiphoid process (women)
6. References
  1. Arora and Menchine in Herbert (2015) EM:Rap 15(2): 13
  2. Carter (2014) Emerg Med Australas 26(5): 450-4 +PMID:25212066 [PubMed]

Preparation
Equipment

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: 16 to 22 French (small bore)
3. Unstable patient, Bronchopleural Fistula or Mechanical Ventilation: 24 to 28 French
4. Complicated Pneumothorax or Hemothorax (Trauma): 28 to 32 French (large bore)
  1. Older recommendations were for 36-40 French Chest Tube in Hemothorax
  2. Recent evidence supports smaller Chest Tubes even for Hemothorax (28 French is most common)
    1. Similar complication rates (e.g. empyemea, retained Hemothorax) regardless of tube size
    2. 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
2. Filtered blood (and treated with citrate phosphate dextrose)
3. Contraindicated if pleural contamination, thoracic infection or malignancy, DIC, Sickle Cell Anemia
4. Minimum volume of Hemothorax collection is 700 ml
5. Blood may be re-transfused in Massive Hemothorax for up to 6 hours after collection (prefer <4 hours)
6. Spares utilization of allogenic blood and Platelet Transfusion
7. Replaces blood cells, Platelets and Fresh Frozen Plasma (FFP)
  1. Hemoglobin is less concentrated than packed RBC (9 g/dl compared with 13 g/dl in pRBC)
8. Inadequately filtered blood may introduce Leukocytes, Cytokines, small particular aggregates
9. Similar safety to allogenic transfusion
10. References

Preparation

Personal Protection Equipment
Povidone Iodine (Betadine) or Chlorhexidine (Hibiclens) prep and drape a wide area
Expose surrounding landmarks (axilla, clavicle, Sternum, costal margin)
Anesthetic
1. Lidocaine 1% with Epinephrine local Anesthetic to skin and down to rib (fan injection)
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
Optimize procedure conditions (esp. in obese patients, in whom landmarks are difficult)
1. Adequate lighting
2. Leave a wide prepped area free of draping to allow visualization of landmarks (chest, axilla)
3. Use a longer incision in obese patients
4. Consider Procedural Sedation (e.g. Ketamine)
5. Patient positioning
  1. Hold Breast tissue away from surgical field via assistant or tape
  2. Consider arm abducted to 90 degrees and secured to Mayo stand
  3. Consider towel roll under the Shoulder to reposition axillary fat
6. References
  1. Spangler and Inaba in Herbert (2016) EM:Rap 16(9): 7

Technique

Image
Insertion Site
1. See precautions above
2. Insert anterior to mid-axillary line
3. Level of 5th intercostal space, over 6th rib
  1. Men: Nipple line
  2. Women: Xiphoid process level or inframammary fold
4. Triangle of safety
  1. Apex: Axilla
  2. Posterior boundary: Latissimus dorsi Muscle (anterior edge)
  3. Anterior boundary: Pectoralis major Muscle (lateral edge)
  4. Inferior boundary: Nipple line in men or xiphoid process in women (as above)
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
Insertion Procedure
1. Incise horizontally 3 cm parallel and over the top of the 6th rib (incision should follow the course of the rib)
  1. Consider a wider incision in patients with a larger chest wall (to ensure successful placement)
2. Consider injecting additional local Anesthetic into the subcutaneous tissue above the intended rib entry site
3. Bluntly dissect through subcutaneous tissue over rib with clamp
4. Carefully puncture parietal pleura with clamp tip
  1. Firmly grasp Chest Tube several centimeters from insertion site
  2. Hand acts as a stopper
    1. Prevents clamp from being forced too deep on puncture of the pleural space
5. Insert finger into incision and make 360 degree sweep
  1. Check for organs, adhesions and enlarge path
6. Insert Chest Tube tip with clamp
  1. Once the pleura is opened, any potential emergency related to Tension Pneumothorax is resolved
    1. The tube insertion can be delayed if the provider needs to return to airway management
    2. Take time to ensure the Chest Tube is properly inserted
  2. Firmly grasp tube and hold in place while withdrawing clamp
  3. Finger adjacent to the tube can confirm the Chest Tube direction is toward the apex
  4. 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
  5. Insertion direction
    1. The tube typically can not be directed once it leaves the clamp
    2. Ideally, direct toward apex for for Pneumothorax, posterior-laterally for Hemothorax
    3. Avoid inserting toward hilum or mediastinum
7. 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
Procedure Completion
1. Close skin around the Chest Tube entry
2. Suture tube in place (0 or 1 non-Absorbable Suture, e.g. silk ties)
3. Cover tube entry with petroleum-impregnated gauze
4. Tape tube in place (Rubber tape)
5. Attach Chest Tube to suction
  1. Underwater seal apparatus and suction (-20 to 30 cm H2O)
  2. Pleur-evac
6. Chest XRay
  1. Verify position and function of tube
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)
  1. See Hemothorax
  2. See Autotransfusion protocol in Massive Hemothorax (esp. >2000 ml)
4. Pneumothorax requires suction until no air leak remains
  1. Pleurovac contains no bubbles with respiration
5. Do not apply a Heimlich Valve in cases of Trauma
  1. Use only for simple Spontaneous Pneumothorax in a patient going home
6. References
  1. Majoewsky (2012) EM:RAPC3 2(1): 1-2
Testing for persistent air leak
1. Ask patient to cough while observing Chest Tube output
  1. Water seal chamber OR
  2. Heimlich Valve immersed in water
2. Air bubbling through water on coughing suggests persistent leak
  1. Continue to leave in Chest Tube until no persistent air leak is found
  2. Consider other causes of air leak (e.g. leaky vacuum tubing, Chest Tube hole not fully in chest)
Chest Tube removal timing
1. At least 24 hours after air leaks have stopped AND
2. Chest Tube drainage <200 ml per 24 hours AND
3. Serous drainage AND
4. Not intubated on Ventilator or other form of Positive Pressure Ventilation (e.g. Bipap, CPaP)

Complications

Typical complications (similar to any invasive procedure)
1. Infection
  1. Empyema
  2. Chest wall Cellulitis
  3. Necrotizing Fasciitis
2. Bleeding
  1. Intercostal Vessel or intrathoracic vessel disruption
3. Scarring
Chest Tube specific complications
1. Chest Tube malposition (most common)
2. Tension Pneumothorax (if Chest Tube becomes obstructed)
3. Blocked Chest Tube drain
4. Chest Tube dislodgement
5. Reexpansion Pulmonary Edema
6. Subcutaneous Emphysema
7. Chylothorax
8. Persistent air leak
  1. Common concern when there is a persistent communication between Bronchioles and pleural space
  2. Consider other causes of air leak (e.g. leaky vacuum tubing, Chest Tube hole not fully in chest)
Organ injury
1. See precautions above
2. Lung injury
3. Nerve injury
4. Great Vessel injury
5. Liver injury (right)
6. Spleen or Stomach injury (left)

Resources

Chest Tube Insertion (NEJM) - Part 1
1. http://www.youtube.com/watch?v=hQlt57AyQmg
Chest Tube Insertion (NEJM) - Part 2
1. http://www.youtube.com/watch?v=ZRoJzkY7SMA
Regions Trauma Professional's Blog (Michael McGonigal, MD) - Chest Tube insertion
1. http://www.youtube.com/watch?v=qyJkh-ghl70

References

Swadron and Inaba in Herbert (2019) EM:Rap 19(6): 15
Swanson (2019) Crit Dec Emerg Med 33(3): 12-3