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Chest tubes - what one needs to know?
- 1. Chest Tubes William Parker, MD Jayanth H.Keshavamurthy. MD
- 2. Fig. 2. Possible positions of needle thoracocentesis (NT): (A) False positiveâas needle decompresses sub-cutaneous emphysema. (B) False negativeâas needle does not reach pleural space. (C) Correct position of NT with decompression of tension pneumothorax. (D) False positiveâwith needle intrapulmonary in bulla or bronchial tree. If the tension pneumothorax is loculated due to pulmonary adhesions and missed by NT a false-negative result may occur with intra-pulmonary placement. (E) True negativeâwith needle in a major vessel or the heart. This may be mis-interpreted as a false positive for haemothorax. Only C will decompress a tension pneumothorax. A, B, D and E have all been associated with failure to decompress the pleural space and fatal outcomes.
- 3. Extrapleural placement of catheter-over-needle thoracocentesis. The catheter length is adequate but is extrapleural. There is no pneumothorax.
- 4. Incorrectly placed right catheter-over-needle thoracocentesis. The Pneumocathâą on the right (A) is in the mid-clavicular line but is extra-pleural within the right axilla. There is a ruptured left hemi diaphragm with associated mediastinal shift and a left intra-pleural Pneumocathâą (B). The patient is intubated.
- 5. False positive needle decompression of chest. Bilateral Pneumocathâą cannulae post-needle decompression of the chest can be seen on this chest CT. The associated Heimlich valves can be seen taped to the anterior chest wall. A right chest tube is visible. The right Pneumocathâą is intrapulmonary with associated haemorrhage (A). The left Pneumocathâą is intrapulmonary with the tip in the bronchial tree with an associated ongoing air leak creating a false positive finding (B).
- 6. Heimlich, not the maneuverâŠ
- 7. Incorrect identification of the mid-clavicular line may result in needle decompression that is too medial, with increased risk of vascular and cardiac injury. The recommended insertion point (A) in the second intercostal space in the midclavicular line is more lateral to the point commonly identified, which is half- way between the midline and the lateral chest wall (B)
- 8. Possible positions and complications of tube thoracostomy (TT): (A) Trauma to the intercostal neurovascular bundle. (B) Extrapleural placement. (C) Correct position in pleural space. (D) Intrafissural placement. (E) Intrapulmonary placement. (F) Mediastinal impingement or penetration. (G) Trans- diaphragmatic placement. (H) Infection.
- 9. False positive as chest tube decompresses sub-cutaneous emphysema. There is a left pneumothorax. The tube thoracostomy has been placed extrapleural in sub-cutaneous gas, creating a false positive with associated failure to decompress the pleural space.
- 10. The Real Chest Tube
- 11. These work for PTX
- 12. Intrapulmonary placement of tube thoracostomy. Poor Form
- 13. An autopsy photograph of a chest tube which has been inserted through the heartleading to death. The tube was inserted with the use of a trocar.. Poor Form Continued
- 14. Just asking for troubleâŠ
- 17. Our Patients Where is the tip of this chest tube?
- 32. Our Patients Does this patient need a chest tube? I mean, whatâs the deal here?
- 33. Our Patients Does this patient need a chest tube? I mean, whatâs the deal here?
- 45. How Big is it??? Quantification of pneumothorax size on chest radiographs using interpleural distances: regression analysis based on volume measurements from helical CT. Am J Roentgenol. 1995 Nov;165(5):1127-30 C D Collins, A Lopez, A Mathie, V Wood, J E Jackson and M E Roddie Guidelines for the Diagnosis and Treatment of Spontaneous Pneumothorax Arch Bronconeumol. 2008;44:437-48. - Vol. 44 Num.08 Juan J Rivas de Andrés, Marcelo F Jiménez López, Laureano Molins López-Rodó, Alfonso Pérez Trullén, Juan Torres Lanzas ACCP > 3 cm apical = large BTS > 2 cm apical = large PTX % = 4.2 + [4.7 x (A+B+C)] PTX > 20-25% should be drained Spontaneous reabsorption of pneumothoraces occurs at rates from 1.25% to 1.8% (50-75 mL) of the total volume of air in the pleural space per day and can be accelerated by as much as a factor of 4 by the administration of supplemental oxygen
- 46. Theory behind the O2 TX If a patient is hospitalized for observation, supplemental high flow (10 l/min) oxygen should be given where feasible. Inhalation of high concentrations of oxygen may reduce the total pressure of gases in pleural capillaries by reducing the partial pressure of nitrogen. This should increase the pressure gradient between the pleural capillaries and the pleural cavity, thereby increasing absorption of air from the pleural cavity. The rate of resolution/reabsorption of spontaneous pneumothoraces is 1.25â1.8% of the volume of hemithorax every 24 hours.In a group of 11 patients with pneumothoraces ranging in size from 16% to 100%, the mean rate of re-expansion was 1.8% per day and full re-expansion occurred at a mean of 3.2 weeks. A 15% pneumothorax would therefore take 8â12 days to resolve fully. The addition of high flow oxygen therapy has been shown to result in a fourfold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation. BTS GUIDELINES BTS guidelines for the management of spontaneous pneumothoraxThorax 2003;58:ii39-ii52 M Henry, T Arnold, J Harvey, on behalf of the BTS Pleural Disease Group, a subgroup of the BTS Standards of Care Committee
- 47. QUESTIONS?