Tu b e t h o r ac ost omy i s t h e i n sertion o f a t u b e ( ch est t u b e) i n to t h e p l e ur al c a v ity t o d r a in a i r, b l o od, b i le, p u s, o r o t h er f l u ids.

W h e th er t h e a c c u mu lation i s t h e r e sult o f r a p id t ra umatic f i lling o r i nsidious m a lig na nt s e e pa ge, p l a cemen t o f a c h e st t u b e a llow s f o r c o n tin u ou s, l a r ge v o lu me d r a in ag e u n t il t h e u n d erlyin g p a t h ology c a n b e m o r e f o r mally a d d r essed . T h e l i st o f s p e c ific t r e a table e t iologies i s e x t ensive b u t w i th ou t i n t erv ention , p a t ien ts a r e a t g r e at r i sk f o r m a jor m o r bidit y o r m o r tality.

INDICATION

Pneumothorax Open or closed Simple or tension Hemothorax Hemopneumothorax Hydrothorax Chylothorax Empyema Pleural effusion Patients with penetrating chest wall injury who are intubated or about to be intubated Considered for those about to undergo air transport who are at risk for pneumothorax

CONTRAINDICATION

The need for emergent thoracotomy is an absolute contraindication to tube thoracostomy. Relative contraindications include the following:

Coagulopathy Pulmonary bullae Pulmonary, pleural, or thoracic adhesions

Loculated pleural effusion or empyema

Skin infection over the chest tube insertion site

ANESTHESIA

Systemic analgesia should be used in all conscious patients, unless contraindicated. Contraindications to use of systemic analgesia can include unstable vital signs and patient in extremis. Procedural sedation and analgesia should be considered, unless contraindicated. For more information, Local anesthesia

EQUIPMENTS

Chest tube drainage device with water seal (autotransfuser unit is an option) Suction source and tubing

Large curved Mayo scissors Large straight suture scissors Silk or nylon suture, 0 or 1 -0

Sterile gloves

Needle driver
Vaseline gauze Gauze squares, 4 x 4 in (10) Sterile adhesive tape, 4 in wide Chest tube of appropriate size

Preparatory solution

Sterile drapes

Surgical marker

Lidocaine 1% with epinephrine

Syringes, 10-20 mL (2) Needle, 25 gauge (ga), 5/8 in

Man - 28-32F Woman - 28F Child - 12-28F Infant - 12-16F Neonate - 10-12F

Needle, 23 ga, 1.5 in; or 27 ga, 1.5 in; for instilling local anesthesia Blade, No. 10, on a handle Large and medium Kelly clamps

Chest Drainage Apparatus

A chest-drainage system consists of a chest tube attached to a valve mechanism designed to allow air or fluid to drain out of, but not into, the chest cavity. The chest tube is a large-bore catheter. Water-seal drainage system may be with or without suction.

One-way valve

one-way valve is unidirectional. Meaning that the valve is OPEN only when the pressure within the chest exceeds atmospheric pressure so air and fluid are removed from the chest.

Absence of fluctuation can indicate:

Loss of patency in the chest tube Re-expansion of the lung.

One-bottle system
One-bottle system: Water seal and collection of drainage occurs in the same bottle. Used for simple pneumothorax.

Two-bottle system

Water seal and collection of drainage are in separate bottles. The 1 st bottle, which is directly attached to a patient, serves as the collection container for fluid. The 2 nd bottle serves as the water seal container, as in the one-bottle system.

Water-seal drainage system

This system uses three chambers or three bottles. With or without suction.

Most common type in use.

Water-seal drainage system

Three-bottle system: The collection chamber The water-seal chamber The suction chamber (1st), the collection chamber: The collection chamber is where the chest tube from the patient connects to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. (2nd), the water-seal chamber: This chamber provides a water-seal, which establishes 2cm of water pressure. If + pressure in the pleural space is > 2cm, air or fluid will be expelled into the drainage system. (3rd), the suction chamber: Controlled to provide (-) pressure to the chest. The chamber is filled with various levels of water to achieve the desired level of suction. Bubbling in the suction control chamber indicates there is suction. It does not indicate an air leak.

POSITIONING

The patient should be positioned supine or at a 45 angle. (Elevating the patient lessens the risk of diaphragm elevation and consequent misplacement of the chest tube into the abdominal space.)

The arm on the affected side should be abducted and externally rotated, simulating a position in which the palm of the hand is behind the patient's head.
A soft restraint or silk tape can be used to secure the arm in this location. If a restraint is used, make sure that good blood flow to the hand is present.

TECHNIQUES

Obtain informed consent from the patient or patients representative. Assemble the drainage system and connect it to the suction source. The appearance of bubbles in the water chamber is a sign that the chest tube drainage device is functioning properly. Position the patient as described above. Identify the patient using two identifiers ( eg, name and date of birth). If possible, match the patient's identifiers at his or her bed side with the identifiers present on a chest x-ray or CT scan that was recently performed (preferably, one performed at the patient's bed side). Clearly mark the site of chest tube insertion (right or left). Identify the fifth intercostal and the midaxillary line.

The skin incision is made in between the midaxillary and anterior axillary lines over a rib that is below the intercostal level selected for chest tube insertion. A surgical marker can be used to better delineate the anatomy.

Shave excessive hair and apply a preparatory solution to a wide area of the chest wall

Skin preparation and marking.

We a r s t e r i l e g l o v e s , g o w n , h a i r c o v e r, a n d g o g g l e s o r f a c e shield, and apply sterile drapes to the area. Administer analgesia. Administer a systemic analgesic (unless contraindicated). Use the 25-ga needle to inject 5 mL of the local anesthetic solution into the skin overlying the initial skin incision,

Use the longer needle (23 or, preferably, 27 ga) to infiltrate about 5 mL of the anesthetic solution to a wide area of subcutaneous tissue superior to the expected initial incision. Redirect the needle to the expected course of the chest tube (following the upper border of the rib below the fifth intercostal space), and inject approximately 10 mL of the anesthetic solution into the periosteum (if bone is encountered), intercostal muscle, and the pleura. Aspiration of air, blood, pus, or a combination thereof into the syringe confirms that the needle entered the pleural cavity.

U s e t h e N o . 11 o r 1 0 b l a d e t o m a k e a s k i n i n c i s i o n approximately 4 cm long overlying the rib that is b e l o w t h e d e s i r e d i n t e r c o s t a l l e v e l o f e n t r y. T h e skin incision should be in the same direction as the rib itself

Use a hemostat or a medium Kelly clamp to bluntly dissect a tract in the subcutaneous tissue by intermittently advancing the closed instrument and opening it

Blunt dissection down to the intercostal muscle.

Further blunt dissection down to the intercostal muscle.

P a l p ate t h e t r a ct w i t h a f i n ger a s s h o w n , a n d m a k e s u re t h a t t h e t r a ct e n d s a t t h e u p p er b o r der o f t h e r i b a b o ve t h e s k i n i n cision .

Palpation of the selected intercostal space and the superior margin of its inferior rib.

Adding more local anesthetic to the intercostal muscles and pleura at this time is recommended. Use a closed large Kelly clamp to pass through the intercostal muscles and parietal pleura and enter into the pleural space,

A closed and locked Kelly clamp is used to enter the chest wall into the pleural cavity. Make sure to guide the clamp over the upper margin of the rib.

This maneuver requires some force and twisting motion of the tip of the closed Kelly clamp. This motion should be done in a controlled manner so the instrument does not enter too far into the chest, which could injure the lung or diaphragm. Upon entry into the pleural space, a rush of air or fluid should occur.

T h e K e l ly c l amp s h o u ld b e o p en ed ( w hile s t ill i n side t he p l eural s p a ce) a n d t he n w i thdrawn s o t ha t i ts j a w s e n l arge t h e d i ssect ed t r a c t t h r ou gh a l l l a yer s o f t h e c h e st w a l l a s s h o w n . T h i s f a c ilita tes p a ssage o f t h e c h e st t u b e w h e n i t i s i n serted

Once the Kelly clamp enters the pleural cavity, the clamp should be opened to further enlarge the opening.

Use a sterile, gloved finger to appreciate the size of the tract and to feel for lung tissue and possible a d h e s i o n s , a s s h o w n i n t h e i m a g e b e l o w. R o t a t e the finger 360 to appreciate the presence of dense adhesions that cannot be broken and require placement of the chest tube in a different site, preferably under fluoroscopy

A finger is used to palpate the tract and feel for adhesions before insertion of the chest tube.

Measure the length between the skin incision and the apex of the lung to estimate how far the chest tube should be inserted. If desired, place a clamp over the tube to mark the estimated length. Some prefer to clamp the tube at a distal point, memorizing the estimated length.

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
The proximal end of the chest tube is held with a Kelly clamp that is used to guide the chest tube through the tract. The distal end of the chest tube should always be clamped until it is connected to the drainage device.

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.

C o n n ec t t h e c h e st t u b e t o t h e d r ain a ge d e v ice a s s h o w n ( some p r efer t o c u t t h e d i stal e n d o f t h e c h e st t u b e t o f a cilitat e i t s c o n n ection t o t h e d ra in ag e d e v ice t u b in g). R e lea se t h e c r o ss c l amp t h a t i s o n t h e c h e st t u b e o n ly a f t er t h e c h e st t u b e i s c o n n ec ted t o t h e d r a ina ge d e vic e.

Connection of the chest tube to a drainage system.

Before securing the tube with stitches, look 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 using 0 or 1 -0 silk or nylon stitches,

A 0 or 1-0 silk or nylon suture is used to secure the chest tube to the skin.

Securing sutures: Two separate through-andthrough, simple, interrupted stitches on each side of the chest tube are recommended. This technique ensures tight closure of the skin incision and prevents routine patient movements from dislodging the chest tube. Each stitch should be tightly tied to the skin, then wrapped tightly around the chest tube several times to cause slight indentation, and then tied again. Sealing suture: A central vertical mattress stitch with ends left long and knotted together can be placed to allow for sealing of the tract once the chest tube is removed.

Place petrolatum (eg, Vaseline) gauze over the skin incision

C r e at e a n o cclu sive d r e ssin g t o p l ac e o v er t h e c he st t u b e b y t u rning r e g ular g a uze s q ua res ( 4 x 4 i n ) i n to Y- sh ap ed f e n est ra ted g a u ze s q u ar es a n d u s i ng 4 - in a d h esive t a p e t o s e c u r e t h e m t o t h e c h e st w a l l. M a k e s u r e t o p r o vid e e n o ug h p a d d ing b e t w een t h e c h e st t u b e a n d t he c he st w a l l.

Preparation of a Yshaped fenestrated drain gauze from regular gauze (4 x 4 in).

Apply support gauze dressing around the chest tube and secure it to the chest wall with 4-in adhesive tape.

Strap the emerging chest tube on to the lower trunk with a "mesentry" fold of adhesive tape, as this avoids kinking of the tube as it passes through the chest wall. It also helps reduce wound site pain and discomfort for the patient. All connections are then taped in their long axis to avoid disconnections.

Obtain a chest radiograph, like the one below, to ensure correct placement of the chest tube.

Chest tube in good position.

In cases of high-pressure empyema or pleural effusion, removal of 50 -200 mL of fluid using a s y r i n g e a n d a 1 4 - g a n e e d l e , a s s h o w n b e l o w, m i g h t prevent high-pressure spraying of the accumulated fluid once the pleural space is entered with the surgical instrument.

A needle and a syringe are used to decompress the pleural cavity in a case of tension empyema.

Since the intercostal vessels and nerve run on the inferior margin of each rib, incision and tunneling should be performed over the rib. Errors that are commonly observed but easily avoidable include inadequate volume of local anesthetic, failure to wait adequate time for anesthetic to take effect, and too small an incision.

A "safe triangle has been described as the preferred site of insertion. This 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

The safe triangle.

Small-bore drains are recommended, as they are more comfortable than larger-bore tubes, but no evidence indicates that either is therapeutically superior. Large-bore drains are recommended for drainage of acute hemothorax and to monitor further blood loss

COMPLICATIONS
Improper placement

Horizontal (over the diaphragm) Acceptable for hemothorax; should be repositioned for pneumothorax

The chest tube is angulated, overlying the diaphragm

Subcutaneous - Must be repositioned Placed too far into the chest (against the apical pleura) - Should be retracted Placed into the abdominal space - Should be removed

Bleeding

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 Organ penetration (usually requires surgical repair)
Stomach, colon, or diaphragm - Occurs as a result of unrecognized diaphragmatic hernia Lung - Occurs as a result of pleural adhesions or use of a thoracostomy tube trocar Liver or spleen

Tube dislodgement Empyema - Chest tube (foreign object) could introduce bacteria into the pleural space Retained pneumothorax or hemothorax - Might require insertion of a second chest tube Chest tubes