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Know how to thoracocentesis and thoracostomy tubes
- 1. Know-how… …thoracocentesis and thoracostomy tubes Matteo Rossanese DVM SPSA CertAVP MSc Dipl ECVS MRCVS ECVS and EBVS Specialist in Small Animal Veterinary Surgery
- 2. Pleural space • Tiny volume of fluid • Pleural effusion: abnormal collection of fluid in the thoracic cavity • Air or fluid in the pleural space: • Prevent lungs inflating • Large volume dyspnoea death
- 3. Clinical Examination • Restrictive breathing pattern • Rapid shallow respiration (progressing to dyspnoea) • “Mouth breathing”
- 4. Recognising air/fluid within the pleural space • Hyper-resonance on percussion • Absence of lung sounds • Dullness on percussion • Muffled heart and lung sounds
- 5. Thoracocentesis • Allow “one off” drainage of the pleural cavity • Used when we don’t anticipate ongoing requirement for drainage • Immediate patient stabilisation • Diagnostic and therapeutic
- 6. Thoracocentesis • Sternal recumbency • Supplemental oxygen • Analgesia/sedation (based on patient status) • Clip and aseptically prepared an area of skin (5-10cm2) • Centred on the lower 7-8° intercostal space • Sterile gloves / sterile technique
- 7. Equipment • 16-gauge to 20-gauge, 1.0 to 1.5 inch needle • Or over the needle intravenous cannula • Or butterfly cannula • Extension line • Three way tap • Syringe (50-60mls) • Kidney dish
- 8. Procedure • Place the needle/cannula through the mid to caudal intercostal space • Remember: intercostal vessels and nerves run caudal to the ribs • Avoid the caudal rib/cranial intercostal space to avoid these structures • Advance the needle/cannula through the chest wall • Needle directed caudally at an angle such that it will pass just underneath the internal surface of the ribs
- 9. Procedure
- 10. Procedure • Aspirate air and/or fluid • Measure the volume • Retain samples of fluid for analysis • Plain sterile tubes for C/S, EDTA for cytology • Bilateral pneumothorax/pleural effusion: • drainage of one side may be adequate • Take thoracic radiographs after drainage
- 11. Complications • Iatrogenic pneumothorax • Laceration of the pleura overlying the lungs • Creation of excessive negative pressure within the pleural space ripping the pleura • Laceration of the heart • Laceration of the major vessels • Laceration of the intercostal vessels or nerves
- 13. Thoracostomy tube placement • Tube through the thoracic wall into the pleural cavity • Close technique • Open technique (during surgery) • Relative short-term management (days) • When: • Severe dyspnoea • repeat thoracocentesis
- 14. Thoracostomy tube placement • Allows “long-term” access to pleural space: • For drainage of rapidly accumulating, large volume pleural fluid/pneumothorax • Which side? • based on clinical, radiographic and thoracic ultrasound findings • Which size? • Internal diameter approx half the intercostal space • Smaller is OK depending on nature of fluid (or air)
- 15. Patient preparation • IV access • Administer oxygen • Patient position? • Clip from caudal border of scapula to behind last rib • Surgically prep and drape patient • NOTE: treat as surgical procedure • Surgical scrub and wear sterile gloves
- 17. Equipment • Thoracostomy tube • Drain connector • Three-way stopcock • Two bungs • Clamp • 20-50mls syringe • N°11 blade
- 18. Location • Tube enters chest at 7-8th intercostal space • Midway up thorax
- 19. Preparation • Local anaesthetic: • Intercostal nerve block • Infiltrate along the proposed tunnel
- 20. Tube placement
- 21. Tube placement
- 25. Tube placement Finger trap suture
- 26. Wire-guided chest drains Low profile 14- or 12- gauge Modified Seldinger technique
- 28. Post placement • Empty pleural cavity • Radiographs thorax
- 29. Ready for recovery • Check tube location
- 30. Management • Bandage • Maintain “sterility” • Prevent patient interference • Analgesia • Close patient observation • Drain/record volume q4h
- 31. Complications • 20% • Tube disconnection • Obstruction • Kinking • Dislodgement • Air-leaks • Pneumothorax • Haemorrhage
- 32. Reducing complications • Aseptic technique • Avoid intercostal neuromuscular bundles • Use 7-8th intercostal space • Create subcutaneous tunnel • Pre-measure length required • Secure tube in place • Ensure connections are secure • Ensure correct position/patency • Reduce patient interference
- 33. When to remove it • ASAP !!! • Drain will cause pleural fluid production • (2-3mls/kg/days) • Generally, remove when: • no/minimal air aspirated • <2mls fluid/kg/day • Remove tube on expiration • Dress skin wound, antibiotic ointment and light dressing for 24h
- 34. Do you have any question? Drop us an email or leave a feedback at: info@vetspoke.com We will get back to you as soon as possible!