chest tube insertion and management

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CHEST TUBE INSERTION AND MANAGEMENT

Author: amith-sreedharan

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CHEST TUBE INSERTION AND MANAGEMENT

WHAT YOU DRAIN? AIR BLOOD SERUM LYMPH PUS COMBINATIONS PNEUMOTHORAX HEMOTHORAX PLEURAL EFFUSION CHYLOTHORAX EMPYEMA HYDRO PNX PYOPNX HEMOPNX

Abnormal collections leads to positive pleural pressure Partial or complete collapse of lungs

hypoxemiaTube thoracostomy is the insertion of a chest tube to drain air or fluid Re- establishes a negative pleural pressure and allows lung to expand

INDICATIONS ABSOLUTE INDICATION: ACUTE RESPIRATORY COMPROMISE SEVERE RESPIRATORY COMPROMISE EG:TENSION PNEUMTHORAX LARGE SYMPTOMATIC PNX HEMOTHORAX EMPYEMA CHYLOTHRAX MALIGNANT PLEF POST OPERATIVE SURGICAL VIOLATION OF PLEURAL SPACE

CONTRAINDICATIONS PLEURAL SYMPHYSIS INEXPERIENCED PERSONNEL

TECHNIQUE COMPREHENSIVE HISTORY PHYSICAL EXAMINATION CXR CT EXPLANATION TO THE PT ABOUT INDICATION RISK POST PROCEDURE CARE

TUBE SELECTION SILASTIC TUBE WITH MULTIPLE HOLES AT SIDE SIZE IS UPTO 40 FRENCH GAUGE(FR) RADIO OPAQUE STRIPE MARKINGS IN CMS SIZE SELECTION SMALL: BETTER TOLERATED DONE UNDER LA DRAWBACK: PRONE TO KINKING CLOG WITH THICK FLUID AS IN EMPYEMA COMMONLY USED: 28 32 Fr SIMPLE PNX:24 Fr

INSERTION SITE 4TH OR 5TH ICSpace ANTERIOR TO MCL BEYOND THE LATERAL EDGE OF PECTORALIS MUSCLE AND BREAST TISSUE POSTERIOR PLACEMENT IS PROBLEMATIC IN SUPINE PTS. PLACEMENT ANTERIORLY: 2ND 3RD ICS. MORE PAINFUL,DISFIGURING POSITIONING: SUPINE SEMI-FOWLER THORAX & HEAD ELEVATED 30 45 INVOLVED SIDE ELEVATED BY (ROTATION)SUPPORT OF PILLOWS 30 - 45 PT S ARM ABOVE HEAD OPERATOR SHOULD STAND AT PT S BACK.

INSTRUMENT REQUIREMENT STERILE GLOVES STERILE GOWN STERILE DRAPE SYRINGE NEEDLE 18G,21G XYLOCAINE : 1% SCALPEL WITH BLADE NEEDLE DRIVER O SILK STITCH CUTTING NEEDLE CLAMP (KELLY) CHEST TUBE UNDER WATER SEAL CHEST DRAINAGE GAUZE & DRESSING MATERIAL SALINE

CXR SHOULD BE ON DISPLAY PT S IDENTITY CONFIRMED CORRECT SIDE CONFIRMED CHEST WALL IS CLEANED ITH ANTISEPTIC SOLN DRAPE APPLIED OPERATIVE FIELD 20cm 20 cm SKIN INFILTRATED WITH 1% LIGNOCAINE AT THE CHOSEN SITE WITH 21 G NEEDLE GENEROUS INFILTRATION WITH LARGE BORE NEEDLE (18 G) OF SUBCUTANEOUS TISSUE PARIETAL PLEURA THROUGHLY ANAESTHETISED 2 cm TRANSVERSE INCICION WITH SCALPEL OBESE (> 2 cm) INCISION IN THE LOWER INTERSPACE TUNNELLING SUPERIOR BORDER OF LOWER RIB O SILK STITCH PLACED AT POSTERIOR MARGIN OF INCISION (SECURING STITCH) CURVED KELLY CLAMP IS USED TO DISSECT A TRACK ITHIN SUBCUTANEOUS AND INTERCOSTAL TISSUES TUNNELLING F THE TRACK IS DONE OVER THE SUPERIOR BORDER OF THE LOWER RIB DISSECT ALONG ONE TRACK CONTROLLED ADVANCEMENT WITH INCREMENTAL SPREADING

ENTRY INTO PLEURAL CAVITY EGRESS OF AIR OR FLUID DECREASE IN RESISTANCE TO THE CLAMP MOVING FORWARD EXTRA XYLOCAINE FOR PARIETAL PLEURA WITHDRAW CLAMP IN OPEN POSITION. INSERT INDEX FINGER EXCLUDE ADHESION PLEURAL NODULARITY CONFIRM PLEURAL SPACE EXCLUDE SUBDIAPHRAGMATIC PLACEMENT INSERT TUBE FIRST POSTERIORLY AND THEN (USE KELLY CLAMP)TO GUIDE CEPHALAD(DRAINS BOTH AIR & FLUID) SUTURE,UNDERWATER SEAL,DRESSING CXR FOR CONFIRMATION OF PLACEMENT

CHEST TUBE MANAGEMENT GENERAL PRINCIPLES SPECIFIC SITUATIONS

General principles Monitoring for nature of (fluid,air,both) drain. Quantity and volume of fluid and the rate of evacuation (hourly). Air leak Suction: promotes drainage creates negative intrapleural pressure -20 cm H20. Suction is applied to underwater seal drainage device and not directly to chest tube.

Do not apply suction ICT after pneumonectomy Emphysema with prominent air leak Eg:LVRS Oscillation or tidaling of fluid level in water seal or in the tubing synchronous with the pt s respiratory cycle Patent Lung not fully expanded The dependant loop of the tube is to be intermittently drained to prevent increased resistance to proper drainage of air

AIR LEAK Airleak in tube or junction of ICT with underwater seal Unexpected finding Not in cycle with respiration Place a clamp near insertion site and then shift clamp distally

CHEST TUBE CLAMPING SHOULD BE AVOIDED Trouble shoot when a leak in the tubing system is suspected Clamped proximally while changing tubing or underwater seal device Prevent REPE To confirm expansion of lung Clamp for 1- 2 hrs CXR repeated Lung expanded No increased subcutaneous emphysema No increased chest pain No increased SOB Routine use of clamp is unnecessary

CHEST TUBE REMOVAL Air leak stopped Drainage < 300 ml / 24 hrs CXR shows expanded lungs In positive pressure ventilation the ICT is in place until extubation or risk of barotrauma minimised End inspiration and breath holding after cutting drain stitch holding the tube in place If purse string suture is given then it is tied down to ensure wound closure Drawback:increased pain,removal of stitch again after 7 days

Subcutaneous emphysema Prolonged airleak > 1 week Use of heimlich valve(passive drainage system) Blockage or obstruction Fibrinous debris Frank clot Method:milking or stripping fogarty embolectomy catheter retrograde insertion

FAILURE OF RE EXPANSION Incorrect placement of tube Intrapleural : CXR PA & LATERAL CT All holes in pleural sac Extrapleural : no oscillation Fibrinous peel overlying visceral pleura decortication Endobronchial block - bronchoscopy

REPE Large intrapleural fluid collection Rapid increase in blood flow and pulmonary capillary pressure leading to fluid shift across the capillary and alveolar membranes Intractable cough after tube insertion Acute drainage of 800 1500 ml fluid Clamp tube

PLEURODESIS Long term indwelling pleural drain