Chest tube thoracostomy or chest tube insertion is the insertion of a tube called chest tube into the pleural cavity and less commonly in mediastinum. A chest tube is also called chest drain, thoracic catheter, or intercostal drain. It is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. Air or fluid in the pleural cavity are most common indications of chest tube thoracostomy.
Indications of Chest Tube Thoracostomy
Indications are as follows
- Air or fluid in the lung
- Penetrating chest wall injurywho are intubated or about to be intubated
- Considered for those about to undergo air transport who are at risk for pneumothorax
- Pulmonary bullae
- Pulmonary, pleural, or thoracic adhesions
- Loculated pleural effusion or empyema
- Skin infection over the chest tube insertion site
Chest Tube and Chest Tube Drainage System
Chest tubes come in sizes [ as measured by their external diameter] from 6 Fr to 40 Fr. Following sizes are often used
- Adult male = 28–32 Fr
- Adult female = 28 Fr
- Child = 18 Fr
- Newborn = 12–14 Fr
Chest tubes are also provided in right angle, trocar, flared, and tapered configurations for different drainage needs. Chest tube have an end hole (proximal, toward the patient) and a series of side holes. The number of side holes is generally 6 on most chest tubes. The length of tube that has side holes is the effective drainage length.
A chest drainage system is typically used to collect chest drainage. Most commonly, drainage systems use three chambers based on the three-bottle system. The first chamber allows fluid that is drained from the chest to be collected. The second chamber functions as a “water seal”. The water seal allows gas to escape, but not reenter the chest [This is essential to prevent outside air to enter pleural space. The third chamber is the suction control chamber. The height of the water in this chamber regulates the negative pressure applied to the system and prevents increase the negative pressure of the system.
Newer systems are smaller and more ambulatory so the patient can be sent home for drainage if indicated.
Recently digital or electronic chest drainage systems use onboard motor is used as vacuum source along with an integrated suction control canister and water seal.
These systems monitor the patient and allow clinicians to mobilize patients early, and can also lead to a reduction in complications.
Chest Tube Thoracostomy Procedure
- Place the patient in supine or elevated to at a 45 degrees with the affected side arm behind the patient’s head [abduct and externally rotate]
- Assemble the drainage system. The appearance of bubbles in the water chamber is a sign that the chest tube drainage device is functioning properly.
- Mark the site. The fifth intercostals space in the midaxillary line on the affected side is the usual site for chest tube insertion but may be varied according to the patient. The skin incision given over a rib below the intended insertion level, between the midaxillary and anterior axillary lines. A safe area is the triangle bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, a line superior to the horizontal level of the nipple, and an apex below the axilla.
- After part preparation, administer local anesthetic solution into the skin overlying the initial skin incision, into the periosteum, intercostal muscle, and the pleura.
- Make a skin incision approximately 4 cm long overlying the chosen rib.
- Use blunt dissection with a hemostat/Kelly clamp and make a tract in the subcutaneous tissue. Keep close to the upper border of the rib to minimize the injury to intercoastal vessel and nerve.
- Further pass through the intercostal muscles and parietal pleura to enter into the pleural space. This usually required some force and twisting motion of the tip of the closed hemostat.
- A rush of air or fluid occur on entering the pleural space.
- In cases of high-pressure empyema or pleural effusion, removal of 50-200 mL of fluid to prevent high-pressure spraying of the accumulated fluid once the pleural space is entered with the surgical instrument.
- Enlarge the tract with hemostat/Kelly clamp and insert finger to to feel for lung tissue and possible adhesions.
- Rotate the finger to break the adhesions. [ Adhesions which cannot be broken may necessitate require placement of the chest tube in a different site, preferably under fluoroscopy.
- Measure the length between the skin incision and the apex of the lung to estimate tube length inside
- Grasp the proximal (fenestrated) end of the chest tube with the large Kelly clamp and introduce it through the tract and into the thoracic cavity as shown.
- Release the Kelly clamp and continue to advance the chest tube posteriorly and superiorly. Make sure that all of the fenestrated holes in the chest tube are inside the thoracic cavity.
- Connect the chest tube to the drainage device Release the cross clamp that is on the chest tube after the chest tube is connected to the drainage device.
- Check for a respiration-related swing in the fluid level of the water seal device to confirm correct intrathoracic placement.
- Secure the chest tube to the skin with stitches.
- Improper placement
- Too far into the chest
- Placed into the abdominal space
- Local – Usually responds to direct pressure
- Hemothorax (lung vs intercostal artery injury) – Might require thoracotomy if it does not resolve spontaneously
- Hemoperitoneum (liver or spleen injury) requires emergent laparotomy.
- Visceral Injury lung, stomach or diaphragm
- Tube dislodgement is a possible complication
- Infection – Empyema may occur.
- Re-expansion pulmonary edema
- Tube clogging
- Thrombus formation inside the chest tube
- Employ larger diameter tubes
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