MANAGEMENT OF CHEST TUBES:

Pneumothorax

Dr. Carmine Simone

Thoracic Surgery Toronto East General Hospital

Chest tube insertion

•  Chest tube insertion is an essential skill for the general surgeon in Ontario

Pneumothorax

•  Indications for chest tube insertion: –  Small, asymptomatic pneumothorax can be treated

expectantly –  Moderate size, >25%

•  3 intercostal spaces off apex, off lateral wall, off diaphragm

–  Tension pneumothorax –  Significant bullous disease in contralateral lung –  Persistent symptoms –  Progression of pneumothorax

Pneumothorax

Pneumothorax

Pneumothorax

•  Before inserting chest tube: –  Ensure proper imaging – MAY NEED A CT SCAN –  Patient (SDM) aware –  Proper equipment and location

•  Risks of chest tube insertion: –  Bleeding –  Lung injury –  Pain –  Infection

Pneumothorax

When do you need to admit a patient with a chest tube?

Pneumothorax

When do you need suction versus underwater seal?

Pneumothorax

•  Tube selection: –  Interventional radiology is needed only when image

guidance is required –  Small bore chest tubes need not be inserted only by IR –  Smallest tube possible to get the job done –  Rarely need greater than 28 Fr chest tube for

pneumothorax

Pneumothorax

•  Tube management: –  Monitoring

•  Daily CXR •  Nature and volume of drainage and air leak

–  Tubes should never be clamped (usually) –  Functional status of tube (oscillation) –  Maintenace of patency

•  Milking and stripping •  Irrigation not recommended

–  Check dressing daily and daily changes needed –  Airtightness of system

Pneumothorax

•  Patient management: –  Pain management

•  Narcotics and stool sofeteners •  NSAIDS

–  Mobilization –  Dressing changes, minimize adhesive tape

Pneumothorax

Bullae

Pneumothorax

Pneumothorax

Pneumothorax

•  Contraindications for chest tube insertion: –  Giant bulla –  Previous thoracic surgery, pleurisy, pleurodesis,

hemothorax –  INR > 1.8, PTT > 45, platelets < 100 –  Therapeutic doses of heparin, coumadin, not prophylaxis –  Therapeutic doses of antiplatelet therapies

Pneumothorax

•  Indications for surgery: –  Persistent air leak > 7 days –  Large BPF

–  Bilateral pneumothorax –  Failure to re-expand lung with air leak –  Significant contralateral bullous disease –  Contralateral pneumonectomy –  Specialized occupation (airline pilot, scuba diver) –  Isolation from medical care –  Recurrence

THANK YOU