This presentation was prepared by a 4th year medical student of All saints university,Dominica doing surgery rotation in milton cato memorial hospital,St.Vincent.

1. LECTURE ON CHEST
TUBE INSERTION.
PREPARED BY:
MUSA, SAKINA K.

3. CONTENT.
• Definition.
• Indication.
• Contraindication.
• Equipment.
• Preparation (anesthesia, positioning).
• Technique.
• Complication.

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 fluids.
• But the tube can also be used to instill medications for pleurodesis.

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.

9. • Hemothorax.
• Chest trauma (blunt or penetrating).
• Postoperative following thoracic or upper abdominal surgery.

10. • Pleural effusion.
• Sterile effusion.
• Infected effusion(empyema, para pneumonic effusion).
• Chylothorax.
• Malignant effusion
• Other effusion.
• Hemopneumothorax.
• Considered for those about to undergo air transport who are at risk for
pneumothorax.
• Patients with penetrating chest wall injury who are intubated or about to be
intubated.

11. • Pleurodesis – Chest tube insertion to facilitate the instillation of
sclerosing agents into the pleural space is indicated for the
treatment of refractory effusion.

12. 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.
• 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.

13. PREPARATION.
• The proper equipment should be gathered and
• The patient assessed to determine the optimal chest tube size and
• Location of placement.

14. 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.

15. • 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 hrs.
• There is no evidence of benefit for continuation of antibiotics for longer than 24
hours.

17. • Surgical marker.
• Lidocaine 1% with epinephrine.
• Syringes, 10-20 mL (2)
• Needles 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 scalpel

21. TUBE SELECTION.
• A chest tube’s internal diameter (d) and the viscosity 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 15L/min for air but about thirty times less for
liquids.
• Compared with a transudate or sterile exudate, the drainage of more viscous
fluids (pus or blood) requires a larger bore chest tube to obtain the same
flow rate.

23. PNEUMOTHORAX.
Spontaneous and iatrogenic = 16 -24 Fr.
In patients who develop pneumothorax during mechanical ventilation = 28 Fr.
In patients who 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 broncho-pleural fistula.

24. TENSION PNEUMOTHORAX.
If immediately available, a standard thoracostomy tube (24 or 28 Fr for trauma)
should be placed.
Otherwise needle thoracostomy should be performed, followed by chest tube
placement as soon as possible.

25. 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
• 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.

26. PARAPNEUMONIC EFFUSION.
• We prefer initial image-guided placement of a small catheter (10 to 14 Fr)
with or without 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. MALIGNANT EFFUSION.
A small-bore catheter (8 to 18 Fr) placed under ultrasound or CT scan guidance
is usually adequate to drain a malignant pleural effusion or perform pleurodesis
( depending on the viscosity of the sclerosant).
Chronic indwelling catheters (eg. Pleurx) are available for outpatient treatment
of recurrent malignant effusion. These catheters come in a kit that includes
disposable suction bottles and appropriate tubing and connectors to access the
catheter.

29. INSERTION SITE.
• The chest tube insertion site depends upon the indication for tube
placement. Fluids 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 2nd intercostal space in the midclavicular line has been suggested as an
alternative site for tubesaxillary line.

31. LEVEL OF SUCTION.
The typical level of suction used in the clinical setting is -20cm of water.

32. TECHNIQUES.
• Two techniques are most commonly used to place a chest tube.
• The standard technique
• The seldinger technique
Role of ultrasound or other imaging – Ultrasound or other imaging modalities
(eg. Fluoroscopy, computed tomography) can be used to guide chest tube
placement.

42. • Use a sterile, gloved finger to appreciate the size of the tract and to feel for lung
tissue and possible adhesions.
• 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).
• 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.

51. Strap the emerging chest tube on to the lower trunk with a ‘mesentery’ 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.

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 from 1 to 1.5 liters by clamping the chest tube and
waiting 2 to 4 hrs before draining additional fluid, provided symptoms have
resolved.

56. • Patients with large effusion 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 re-expansion pulmonary edema.

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. 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. 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.

62. • 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 re-accumulation of
fluid.

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 removed.
• Bleeding;
• Local-usually responds to direct pressure.
• Hemothorax (lung vs intercostal artery injury) – might require thoracotomy if it does not resolve
spontaneously.

64. • 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.

65. FOLLOW UP AFTER PROCEDURE.

73. The emergency medicine physician needs
a combination of skills tempered with
patience and the ability to keep a cool
head under fire.