Ref: EM:RAP Productions. (2016, August 2). Chest tube placement [Video]. YouTube. https://www.youtube.com/watch?v=IdmMR8JxmFo

Indications

• drainage of air/fluid from pleural space
• pleural lavage (e.g. rewarming in severe hypothermia)

Anatomy of “Triangle of safety”:

• anterior to mid axillary line, posterior to pectoral groove, above 5th intercostal space
• To avoid injury to Internal mammary artery, muscle or breast tissue, diaphragm, liver, spleen, kidneys.
• awareness of the intercostal bundle sitting on the inferior aspect of the ribs

Equipment

• sterile clothing (gloves, gown, hat, mask, facial shield)
• chlorhexidine sterile drapes
• lignocaine 1%
• 22G long needle
• scalpel
• curved forceps
• chest drain (>24 French for blood) or seldinger set
• suture material
• underwater seal drain
• dressing

Selection of Chest tube of Appropriate Size

• Spontaneous uncomplicated pneumothorax: 16 to 22 Fr (small bore)
• Unstable patient, bronchopleural fistula or Mechanical ventilation: 24 to 28 Fr
• Complicated pneumothorax or hemothorax (trauma): 32 Fr (large bore) Some recommend 36-40 Fr in hemothorax
• Pediatric: 4 X ET-tube size
  • ET-tube size = age/4 + 4
• For Seldinger technique of insertion: 12- 14 Fr
• Note:1 mm = 3 Fr

Procedure for chest tube insertion

• Consent
• Premedication: Opioid IV analgesia/or IV Midazolam
• Patient position:
  • Backrest lifted to 45 degrees with arms abducted and hands resting behind the head (This lowers the diaphragm and decreases the risk of injury to the diaphragm, spleen, or liver) OR
  • Upright position leaning over pillow or table OR
  • Lateral decubitus
• Painting and draping
• Local Anesthesia injection
• Incision and dissection:
  • With the scalpel, create a 1.5 to 2cm incision through the skin at the marked incision site
  • With a curved artery forceps, dissect the subcutaneous tissues until the intercostal muscle layer is reached
  • Staying on top of the rib to avoid the neurovascular bundle running along the inferior rib margin, guide the blunt dissecting instrument upwards, towards the insertion site. This will create a diagonal path for the chest tube which is thought to provide a better seal against air leaks
  • If using a larger calibre chest tube (24-Fr or greater), use your index finger to explore the tract created by the instrument, this will ensure that the tract will be large enough to accommodate the larger tube
  • Once you have reached the parietal pleura, push the clamp gently through the parietal pleura, you should feel a “give”, or a release of resistance. Alternatively, you may use your finger to advance into the parietal space. Often, pleural fluid may trickle out through the tract
  • Once you have gained access to the pleural space, use your index finger to make sure the lung is not adherent to the pleural wall as this would impede the passage of the tube. If possible, leave your finger in the tract as a guide for the tube. (BEWARE OF FRACTURED RIBS)
• Chest tube insertion:
  • Clamp the free end of the tube
  • Using your finger as a guide, pass the tube into the pleural space. This allows you to feel the tube entering the pleural space and avoid subcutaneous dissection with the tube.
  • Never force a tube into the pleural space
  • Direction of tube: To drain air (anterior and superior towards apex) and To drain fluid (posterior and inferior towards base). However, successful drainage can still be achieved when the drain is not placed in an ideal position.
• Securing the drain:
  • Use suture to secure the chest drain.
  • Purse string sutures are not recommended due to poor cosmetic results and increased risk of skin necrosis
• Dressing: Apply several pieces of sterile gauze cut in a “Y-cut” fashion around the tube with the Y-cuts at 90^oangles to each other. Apply adequate dressing.
• Connect to drainage chamber: Connect to drainage chamber and secure with tapes
• Unclamp the free end of the tube
• Rise in fluid level indicates effusion and bubbling indicates pneumothorax
• To avoid re-expansion pulmonary edema when evacuating chronic large pulmonary effusions, avoid collection of 1.5 L or more within a 30 minute period
• Confirming correct placement of tube:
  • A CXR must be done to ensure the correct placement of the tube.
  • The radiopaque stripe should be visible, with an interruption (indicating the placement of the proximal drainage hole), this hole must be within the pleural space. If the interruption lies outside the pleural space, the tube must be removed and replaced altogether.

Characteristics of Collection chamber

1. One bottle system:
   • distal end of the tube must be at least 2 cm under water (the seal) in the underwater-seal bottle
   • another vent tube is open to atmosphere
   • pleural pressure greater than +2 cm water will force air or fluid from the pleural space into the bottle while negative pressure in the pleural space will suck fluid up the tube
   • As long as the underwater-seal bottle is well below the patient (about 100 cm), the hydrostatic pressure of the fluid column in the tube will counterbalance the negative pleural pressure and prevent water from being sucked into the pleural space
   • A disadvantage of this single bottle system is that, as liquid content (blood, pus, effusion fluid) is expelled from the pleural space and collects in the underwater-seal bottle, the seal tube becomes immersed deeper under water and the pressure required to force more contents into the bottle increases thus impeding the clearance of the pleural collection
2. Two bottle system:

• Separate chamber for water-seal system and collection chamber
• Advantage: Amount and rate of drainage can be measured and also the water-seal system remains fixed

3. Heimlich valve:

• It is a mechanical one way valve that allow air to escape from the chest and prevent air from entering chest (doesn’t require water to operate and is not position sensitive)

COMPLICATIONS

Insertion

• pain
• damage to local structures
• pulmonary injury and bronchopleural fistula
• bleeding
• insertion into a vascular structure (pulmonary artery or left ventricle)
• infection

Use

• tube blockage
• tube displacement
• dislodgement
• infection
• misuse of drainage system leading to introduction of air or fluid into pleural cavity

Removal

• recurrence of underlying condition
• wound dehiscence
• scarring