Chest tube insertion


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Chest tube insertion

  3. 3. Content Definition Indication Contraindication Equipment  Preparation Anesthesia Positioning Technique Complication
  4. 4. TUBE THORACOSTOMY  Tube thoracostomy is the insertion of a tube (chest tube) into the pleural cavity to drain air blood bile pus or other fluid  But the tube can also be used to instill medications for pleurodesis.
  5. 5. INDICATION  Pneumothorax Spontaneous pneumothorax Traumatic Pneumothorax Iatrogenic pneumothorax, most commonly due to central line placement Tension pneumothorax Bronchopleural fistula, postoperative or due to mechanical ventilation
  6. 6.  Hemothorax Chest trauma (blunt or penetrating) Postoperative following thoracic or upper abdominal surgery
  7. 7. Cont’d  Pleural effusion Sterile effusion Infected effusion (i.e., empyema, Para pneumonic effusion) Chylothorax Malignant effusion Other effusion  Hemopneumothorax  Considered for those about to undergo air transport who are at risk for pneumothorax
  8. 8. • Patients with penetrating chest wall injury who are intubated or about to be intubated
  9. 9. Cont’d • Pleurodesis – Chest tube insertion to facilitate the instillation of sclerosing agents into the pleural space is indicated for the treatment of refractory effusion
  10. 10. 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.
  11. 11. Cont’d  Blind insertion of a chest tube is dangerous in a patient with pleural adhesions from infection, previous pleurodesis, or prior pulmonary surgery; so guidance by ultrasound or CT scan without contrast is preferred.
  12. 12. PREPARATION    The proper equipment should be gathered and The patient assessed to determine the optimal chest tube size and Location of placement.
  13. 13. ANTIBIOTIC PROPHYLAXIS  The need for prophylactic antibiotics prior to the placement of thoracostomy tubes depends upon the clinical circumstances. Prophylactic antibiotics are not warranted for chest tubes placed in the setting of spontaneous pneumothorax or other non- traumatic indications Prophylactic antibiotics are warranted for chest tubes placed in the setting of Trauma, particularly in patients with penetrating injury.
  14. 14. CONT’D • The optimal duration of antibiotic therapy is uncertain; a single dose may be administered, or in cases of penetrating injury, antibiotic therapy may be continued for up to 24 hours. • There is no evidence of benefit for continuation of antibiotics for longer than 24 hours.
  15. 15. EQUIPMENT • Chest tube drainage device with water seal (autotransfuser unit is an option) • • • • Suction source and tubing Sterile gloves Preparatory solution Sterile drapes
  16. 16. CONT’D • • • • • Surgical marker Lidocaine 1% with epinephrine Syringes, 10-20 mL (2) Needle, 25 gauge (ga), 5/8 in Needle, 23 ga, 1.5 in; or 27 ga, 1.5 in; for instilling local anesthesia • Blade, No. 10, on a handle
  17. 17. CONT’D • • • • • • • • • Large and medium Kelly clamps Large curved Mayo scissors Large straight suture scissors Silk or nylon suture, 0 or 1-0 Needle driver Vaseline gauze Gauze squares, 4 x 4 in (10) Sterile adhesive tape, 4 in wide Chest tube of appropriate size Man - 28-32F Woman - 28F Child - 12-28F Infant - 12-16F Neonate - 10-12F
  18. 18. POSTIONING • 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.
  19. 19. CONT’D • 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.
  20. 20. TUBE SELECTION • A chest tube's internal diameter (d) and the viscosity (μ) of the fluid determine volume of fluid flow. • Chest tubes are available in a range of French sizes from 14 to 40 Fr. • A 28 Fr tube will drain about 15 L/min for air but about thirty times less for liquids. • Compared with a transudate or sterile exudate, the drainage of more viscous fluids (eg, pus or blood) requires a larger bore chest tube to obtain the same flow rate.
  21. 21. • Chest tubes can be straight or angled . • Angled chest tubes are used often in the surgical setting to assure placement in the posterior cost phrenic sulcus.
  22. 22. • PNEUMOTHORAX Spontaneous and iatrogenic =16-24 Fr. In patients who develop pneumothorax during mechanical ventilation = 28 Fr In patients with severe underlying lung disease who have a pneumothorax (iatrogenic or spontaneous) = 28 Fr For traumatic pneumothorax = 36-40 Fr It is important to distinguish between air leaks that are due to an alveolar-pleural fistula and those due to a bronchopleural fistula.
  23. 23. • TENSION PNEUMOTHORAX If immediately available, a standard thoracostomy tube (24 or 28 Fr, 36 Fr for trauma) should be placed. Otherwise needle thoracostomy should be performed, followed by chest tube placement as soon as possible.
  24. 24. • HEMOTHORAX Cause Closed chest trauma Secondary to Malignancy Anticoagulation Aneurysm rupture The goals of tube thoracostomy in acute hemothorax are Drainage of fresh blood, Measurement of the rate of bleeding, Evacuation of any coexisting pneumothorax, and Tamponade of the bleeding site by apposition of the pleural surfaces. Large-bore tubes (36 to 40 Fr) are required to reliably achieve these goals.
  25. 25. Malignant effusion A small-bore catheter (8 to 18 Fr) placed under ultrasound or CT guidance is usually adequate to drain a malignant pleural effusion or perform pleurodesis (depending on the viscosity of the sclerosant). • Chronic indwelling catheters (e.g., Pleurx®) are available for outpatient treatment of recurrent malignant effusion. These catheters come in a kit that includes disposable suction bottles and the appropriate tubing and connectors to access the catheter.
  26. 26. Parapneumonic effusion  We prefer initial image-guided placement of a small catheter (10 to 14 Fr), with or without intrapleural fibrinolytic agents.  However, if the fluid appears more viscous, a larger tube (16 to 24 Fr) should be used to minimize the risk of occlusion with fibrinous debris.  Unsuccessful drainage of an effusion using a small catheter indicates the presence of multiple loculations or very viscous material.
  27. 27. Empyema • For empyema, a 28 Fr or larger tube will likely be needed to manage the thicker drainage, particularly if there is debris draining with the pus. • Failure to achieve drainage with a single tube should prompt thoracic surgery consultation for drainage using video-assisted thoracoscopic surgery (VATS).
  28. 28. Insertion site  The chest tube insertion site depends upon the indication for tube placement. Fluid collects in the dependent portion of the chest cavity, while Air collects in the nondependent portion.  For evacuating pneumothorax, most clinicians insert the chest tube via an incision at the 4th or 5th intercostal space in the anterior axillary or midaxillary line  The second intercostal space in the midclavicular line has been suggested as an alternative site for tubesaxillary line .
  29. 29. SAFE TRIANGLE • 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.
  30. 30. Level of suction • The typical level of suction used in the clinical setting is -20 cm of water.
  31. 31. TECHNIQUES • Two techniques are most commonly used to place a chest tube. 1-The standard technique 2-The Seldinger technique Role of ultrasound or other imaging — Ultrasound or other imaging modalities (e.g., fluoroscopy, computed tomography) can be used to guide chest tube placement.
  32. 32. Technique ① Obtain informed consent from the patient or patient’s representative. ② 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. ③ Place the patient in the supine position with the ipsilateral arm abducted and the elbow flexed to position the hand comfortably over the patient’s head.
  33. 33. ④ 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.
  34. 34. CONT’d ⑤ Prepare the skin around the area of insertion, preferably with chlorhexidine or alternatively with 10 percent povidone-iodine solution. Wear sterile gloves, gown, hair cover, and goggles or face shield, and apply sterile drapes to the area
  35. 35. ⑥ Administer analgesia Using 1% lidocaine, anesthetize a 2 to 3 cm area of skin and subcutaneous tissue one intercostal space below the intercostal space that will be used to place the tube 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. inject approximately 10 mL of the anesthetic solution into the periosteum.
  36. 36. • Use the No. 11 or 10 blade to make a skin incision approximately 4 cm long overlying the rib that is below the desired intercostal level of entry. The skin incision should be in the same direction as the rib itself.
  37. 37. • 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
  38. 38. • Palpate the tract with a finger as shown, and make sure that the tract ends at the upper border of the rib above the skin incision.
  39. 39. • 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. • • • • 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.
  40. 40. • The Kelly clamp should be opened (while still inside the pleural space) and then withdrawn so that its jaws enlarge the dissected tract through all layers of the chest wall as shown. This facilitates passage of the chest tube when it is inserted.
  41. 41. • Use a sterile, gloved finger to appreciate the size of the tract and to feel for lung tissue and possible adhesions, as shown in the image below. Rotate the finger 360o 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 (ie, by interventional radiology).
  42. 42. 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.
  43. 43. CONT’D 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 as shown.
  44. 44. • 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.
  45. 45.  Connect the chest tube to the drainage device as shown (some prefer to cut the distal end of the chest tube to facilitate its connection to the drainage device tubing). Release the cross clamp that is on the chest tube only after the chest tube is connected to the drainage device.
  46. 46. • Before securing the tube with stitches, look for a respiration-related swing in the fluid level of the water seal device to confirm correct intra thoracic placement. Secure the chest tube to the skin using 0 or 1-0 silk or nylon stitches, as depicted below.
  47. 47. CONT’D • Securing sutures: Two separate through-and-through, 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.
  48. 48. CONT’D • 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.
  49. 49. CONT’D • Place petrolatum (eg, Vaseline) gauze over the skin incision as shown.
  50. 50. • Create an occlusive dressing to place over the chest tube by turning regular gauze squares (4 x 4 in) into Y- shaped fenestrated gauze squares and using 4-in adhesive tape to secure them to the chest wall, as shown below. Make sure to provide enough padding between the chest tube and the chest wall.
  51. 51. • 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.
  52. 52. CONT’D  Obtain a chest radiograph, like the one below, to ensure correct placement of the chest tube.
  53. 53. Needle thoracostomy • large bore angiocatheter can be used in hemodynamically unstable patients for whom a suspicion of tension pneumothorax is high. • A 14 to 16 gauge intravenous needle/catheter attached to a 5 or 10 mL syringe is inserted along the superior margin of the second or third rib in the midclavicular line
  54. 54. Managing initial drainage • The amount of thoracostomy drainage should be assessed on a regular basis, hourly in the setting of trauma. Generally, an immediate drainage of 20 mL/kg or the accumulation of >3 mL/kg per hour of blood is an indication for thoracotomy to identify and manage thoracic vascular injury. • The rapid removal of large volumes of fluid from the pleural space can be associated with re- expansion pulmonary edema.
  55. 55. • So To minimize the likelihood of developing re-expansion pulmonary edema, if the patient develops coughing, chest pain, shortness of breath, or oxygen desaturation after chest tube placement, the chest tube should be clamped and no additional fluid should be removed. • We limit initial fluid drainage to 1 to 1.5 liters by clamping the chest tube and waiting two to four hours before draining additional fluid, provided symptoms have resolved.
  56. 56. • Patients with large effusions and mediastinal shift contralateral to the chest tube may tolerate a larger amount of initial fluid removal . Patients without mediastinal shift or with mediastinal shift ipsilateral to the chest tube may have a marked decrease in pleural pressure with a small amount of fluid removal and an increased risk of reexpansion pulmonary edema.
  57. 57. Removal • Criteria: Pneumothorax The lung is fully expanded
  58. 58. No visible air leak is present and air does not accumulate when suction is removed. If there is any question as to whether an air leak has resolved, a ―clamp trial‖ can be performed. The chest tube is clamped and a chest radiograph repeated at intervals (eg, 2 hours, 6 hours, 12 hours). If air does not re-accumulate, the tube can be removed. • Opinion is divided as to whether a chest tube placed for pneumothorax in a patient receiving mechanical ventilation should remain in place as long as the patient requires mechanical ventilation even when no air leak is present.
  59. 59. • Criteria: Effusion The lung is fully expanded Daily fluid output is less than about 100 to 300 mL/day. The threshold is individualized depending upon the indication for the insertion and patient factors (eg, body mass)
  60. 60. Removal technique • In preparation for removal obtain a petroleum gauze dressing and cut the sutures anchoring the chest tube to the skin If the sutures holding the skin together have loosened, tighten them prior to chest tube removal Have several strips of occlusive tape already dispensed to apply to the dressing once the tube has been removed. Prior to removing the tube, it should be explained to patients that they will need to inspire deeply and hold their breath during tube removal
  61. 61. CONT’D • Holding the dressing near the chest tube insertion site with the nondominant hand, ask the patient to inspire and hold his or her breath, then remove the tube quickly with the dominant hand while simultaneously covering the insertion site with the gauze dressing.
  62. 62. CONT’D • Tape the dressing into place, and obtain a chest radiograph immediately following chest tube removal, and 24 hours later to evaluate for recurrence of pneumothorax and/or reaccumulation of fluid.
  63. 63. COMPLICATIONS  Improper placement Horizontal (over the diaphragm) - Acceptable for hemothorax; should be repositioned for pneumothorax Subcutaneous - Must be repositioned Placed too far into the chest (against the apical pleura) Should be retracted Placed into the abdominal space - Should be remove  Bleeding Local - Usually responds to direct pressure Hemothorax (lung vs intercostal artery injury) - Might require thoracotomy if it does not resolve spontaneously
  64. 64. CONT’D  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
  66. 66. The emergency medicine physician needs a combination of skills tempered with patience and the ability to keep a cool head under fire.
  67. 67. THANK YOU