The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Chest Tube Placement

by Todd Howell

Indications

• Pneumothorax as visualized by Chest Radiograph
  
• Hemothorax as visualized by Chest Radiograph
• Empyema
• Sucking Chest Wounds
  
• Hemopneumothorax
• Drainage of recurrent pleural effusion

Contraindications

• Multiple Pleural Adhesions
  
• Hemothorax resulting in large volume loss without adequate volume replacement available
  
• Any situation requiring an immediate open thoracostomy

Equipment

• Sterile Thoracostomy Tray (Containing: Prep razor, sterile towels, gauze pads, l0cc. syringe, 20cc. syringe, 25 ga. 5/8 inch needle, 23 ga. 1 1/2 inch needle, basin for prep solution, cup for anesthetic, large straight suture scissors, large curved Mayo scissors, large & medium Kelly clamps, needle driver, 1-0 & 0 silk sutures on cutting needles, #4 scalpel handle, #10 scalpel blades, hemostats)
  
• Local anesthetic (I% Xylocaine with Epinephrine)
  
• Prep solution (Betadine, etc.)
  
• Vaseline gauze
  
• Tape
• Chest tubes (28-36 French for Adults; 16, 20, or 24 French for Child)
  
• Clear sterile tubing for attachment of tube to suction device

Procedure

1. In emergent situations, the second intercostal space in the midclavicular line can be used as an insertion site for needle decompression, followed by immediate tube thoracostomy.
   
2. In most other situations, and especially for pneumothorax, a chest tube is ideally placed in the 4th or 5th intercostal space just slightly above the midaxillary line.
   
3. Once the locati cement has been chosen, the area must be cleaned and sterilized.
   
4. Using the prep razor and prep solution, remove any hair and then sterilize the area.
   
5. THIS IS NOW A STERILE FIELD AND STERILE TECHNIQUE MUST BE USED!
   
6. Fill a syringe with I % lidocaine anesthetic.
   
7. Using the 25ga. needle, administer the anesthetic subcutaneously over a wide area one intercostal space below the level of insertion @ 5-7 cc.
   
8. Next switch to the 23ga. needle and use it to administer anesthetic to the deeper tissues and parietal pleura @ 5-10 cc.
   
9. Clamp the chest tube at a point far enough back from the tip @ 5-10 cm distal to the last lateral hole to assure appropriate length of insertion.

• Blunt Insertion

  1. 2 to 4 cm transverse incision should be made directly over the rib one interspace below the one to be used for insertion.
     
  2. Using the large Kelly clamps insert them through the incision and advance them over the rib and through the intercostal space being careful to avoid hitting the neurovascular bundle underneath the upper rib.
     
  3. A tunnel is created by advancing the closed Kelly clamps, then opening them up and pulling them back towards the opening incision.
     
  4. Once the pleura is reached, the Kelly clamps should be advanced forward through the pleura into the pleural cavity.
     
  5. Penetration will be noted usually by a rush of air or fluid.
     
  6. A sterile, gloved finger should then be inserted into the opening and into the pleural cavity.
     
  7. Using a sweeping motion the area should be checked for adhesions as well as to make certain that the diaphragm is not present and damaged by tube insertion.
  8. KEEP YOUR FINGER IN THE HOLE.
     
  9. Grasp the chest tube with the curved clamps and using your fmger as a guide, insert the tube into the pleural cavity.
     
  10. Remove the large curved clamp from the tube, and your finger from the chest cavity.
      
  11. Advance the tube so that the most proximal hole on the chest tube is inside the chest cavity, directing the thoracostomy tube in a posterior-lateral position to avoid the hilar structures.

  
  

• Suturing a thoracostomy tube in place

  1. To secure the tube, some use a "utilitarian suture" tied at the skin WITH ONLY ONE THROW utilizing 0, l,or 2 silk .
     
  2. Both ends of this suture are then wrapped several times around the tube before being tied in a square knot.
     
  3. Later, when the knot is Cut, the suture can be unwound from the chest tube and there will be enough length to tie another knot to close the tract incision securely after the chest tube is removed.
     
  4. If a square knot (two throws) has been tied at the skin, the suture must be removed.
     
  5. Alternatively, a horizontal mattress suture is placed around the chest tube incision.
     
  6. This is then tied with one knot, then the ends are wrapped around the tube and can be used to close the incision once the tube is removed.

  
  

• Removal
  *There are two methods of air or fluid removal that are generally available:

  1. Water-seal system
     • The water-seal system involves connecting the chest tube to a water filled bottle that is placed on the floor (minimum 15cm. below the patient's chest).
       
     • Specifically, the chest tube is connected to another tube that terminates 3-4 cm. below the surface of some sterile water in a container.
       
     • The container is vented to the outside.
       
     • When the patient coughs or exhales the- intrapleural pressure is high enough to expel the air or fluid into the jar.
       
     • Pressures generated by normal inspiration are not sufficient to pull the fluid in the jar back into the lungs, provided that the jar remains on the floor.
  2. Pleurevac
     • The more commonly used method of air/fluid removal is capable of removing up to 20 Liters per minute.
       
     • This method involves connecting the chest tube to a vacuum device that is generally set to apply suction at 20cm. of water.
       
     • The pleurevac should be used when large volumes of air, fluid or blood need to be removed quickly.
       
     • AFTER CONNECTFNG THE CHEST TUBE TO A SUCTION DEVICE, REMOVE THE CLAMPS ATTACHED TO THE CHEST TUBE!

*A single dose of 1 gram Cefazolin may be given with no further need for antibiotic prophylaxis.

Complications

• Infection
  
• Bleeding
  
• Damage to organs or nerves
  
• Dislodgment of chest tube
  
• Incorrect tube placement
  
• Air leaks
• Blocked or kinked drainage/suction tubes
  
• Allergic reaction to prep materials or anesthetic
  
• Hypotension resulting from pulmonary reexpansion
  
• Edema resulting from pulmonary reexpansion
  
• Pulmonary atelectasis
  
• Increased blood loss during use of pleurevac

Interpretation of results

• Post procedure PA Chest X-ray taken during patient expiration to confirm tube placement and lung reexpansion.

Follow-up/Tube Removal

• A chest tube may be removed when there is no blood or air loss for 24 hours.
  
• Also since approximately 100cc. of pleural fluid is produced each day, a chest tube should only be removed if fluid loss is less than 100cc. in 24 hours.
  
• The outer gauze pads should be removed leaving the Vaseline gauze in place.
  
• Hold the tube in place while cutting the sutures used to secure it, maintaining long ends to close the thoracostomy site.
  
• Have the patient take a deep breath, then as they exhale REMOVE THE TUBE AS QUICKLY AS POSSIBLE, pulling the sutures closed immediately upon exit of the thoracostomy tube.
  
• Removal of the tube rapidly, decreases the amount of pain as well as improves the odds that air will not enter the chest cavity.
  
• Leave the Vaseline dressing in place over the site for at least 48 hours before changing it to allow the wound to heal.
  
• Make sure you order and check a PA chest X-ray to be sure a pneumothorax did not result from the removal of the tube.

Related Tests
See also Thoracentesis