CHEST TUBE INSERTION AND MANAGEMENT

WHAT YOU DRAIN?

• AIR PNEUMOTHORAX• BLOOD HEMOTHORAX• SERUM PLEURAL EFFUSION• LYMPH CHYLOTHORAX• PUS EMPYEMA• COMBINATIONS HYDRO PNX PYOPNX HEMOPNX

Abnormal collections leads to positive pleural pressure

Partial or complete collapse of lungs

hypoxemia

Tube 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 COMPROMISESEVERE RESPIRATORY COMPROMISEEG: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 30⁰ – 45⁰ INVOLVED SIDE ELEVATED BY (ROTATION)SUPPORT OF PILLOWS 30⁰ - 45⁰ 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 drainagecreates 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 CLAMPINGSHOULD 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

THANK YOU