View source for Chest tube

{{AdultPage|chest tube (peds)}}
==Indications==
*[[Hemothorax]]<ref>Anderson D, et al. Comprehensive Review of Chest Tube Management: A Review. JAMA Surg. 2022 Mar 1;157(3):269-274. PMID 35080596</ref>
*Abscess 
*[[Empyema]]
*[[Traumatic pneumothorax]] (some) 
**Indication for thoracotomy in OR: >1200ml (20ml/kg) drainage immediately after insertion or continous 150-200 mL/hr for 2-4 hours or persistent 7ml/kg/hr at any time<ref>Porcel JM. Chest Tube Drainage of the Pleural Space: A Concise Review for Pulmonologists. Tuberc Respir Dis (Seoul). 2018 Apr;81(2):106-115. PMID 29372629</ref>
*[[Spontaneous pneumothorax]] (some)
*Chylothorax

===Relative Indications===
*[[Thoracic trauma|Penetrating thoracic]] injury and need for positive pressure ventilation 
*Profound hypoxia/hypotension in patient with penetrating chest injury 
*Profound hypoxia/hypotension and signs of hemothorax

==Contraindications==
*No absolute contraindications when performed for emergent indication.

===Relative contraindications===
*Overlying skin infection 
*Coagulopathy 
*Multiple pleural adhesions

==Equipment Needed==
*Chest tube 
**14-28F for pneumothorax 
**32-40F for hemothorax 
*Scalpel 
*Kelly Clamp 
*Sterile drapes 
*Silk sutures 
*Syringes and needles for anesthesia 
*[[Lidocaine]] 
*Betadine 
*Sterile gown/gloves 
*Face shield 
*Pleur-evac

==Procedure==
[[File:Gray530.png|thumb|Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) directly '''under''' the ribs.]]
#Consider antibiotic (e.g. [[cefazolin]])
#If possible; Elevate HOB to 30-60 degrees to lower diaphragm-decreasing risk of injury to diaphragm/intra-abdominal organs 
#Expose insertion site by moving upper extremity above head on affected side 
#*Insertion site = mid- to ant axillary line at 4th/5th intercostal space 
#**~Nipple line in men, inframammary crease in women 
#**Place 1-3 intercostal spaces higher in [[Pregnancy|pregnant]] patients (esp those in 3rd trimester) due to elevated diaphragm.  
#Clean with betadine and drape 
#Confirm rib space and anesthetize with up to 5mg/kg of lido with or with out epinephrine 
#*Must anesthetize skin, soft tissue, muscle, periosteum, and pleural space 
#Incise along upper border of the lower rib of the intercostal space 
#Use curved clamp to bluntly dissect through the muscle until you reach the rib 
#Angle the clamp to go above and over the rib and push until enter the pleural space 
#Open the clamp and pull it out with the clamp still open to create a larger tract 
#Premeasure chest tube from skin incision to ipsi clavicle to avoid advancing chest tube too far 
#Clamp the prox end of the chest tube and pass it along the tract into the pleural cavity 
#*Ensure that inner tract/incision can fit your finger and tube
#*It helps to have your finger in the tract and pass the tube along your finger, particularly in obese patients 
#Once in the space, remove the clamp 
#Feed the chest tube until all the holes are inside the thoracic cavity 
#*Aim superoanterior for pneumothorax; aim posteriorly for hemothorax 
#**Controversial as to whether this is important 
#Rotate the tube 360 degrees 
#*Reduces likelihood of tube kinking 
#*If tube rotates easily, can help indicate correct location inside pleural cavity 
#Attach distal end of tube to the pleur-evac and place on suction (20-30cmH2O suction) 
#Secure tube with silk suture and cover with gauze and cloth tape 
#Obtain CXR position of tube 

{{Chest tube size table}}

===Drainage System and Suction===
*[[Spontaneous pneumothorax]]
**The least amount of suction (including none) needed to maintain full expansion of the lung is appropriate
**Starting with Heimlich valve (no suction) or -10 cm of water and increasing only as needed 
*Fluid drainage
**-20 cm of water
**Increased as indicated with the goal of achieving full lung expansion
*For thoracic trauma, few data are available 
**Start -20 cm of water

==Complications==
*Exsanguination (secondary to removing the tamponade effect of the hemothorax) 
**Clamp tube immediately; take patient to the OR for emergent thoracotomy 
*Air leak 
**Reason why you never clamp the tube once it is in place (could cause tension pneumothorax) 
*Failure 
*Infection 
**Give prophylactic antibiotics (e.g. [[Ancef]]) to decrease rate of empyema 
*Re-expansion pulmonary edema
*Damage to nerves/vessels/heart/lung/diaphragm/abdomen 
*Improper positioning of the tube 
*[[Tension pneumothorax]]

===Failure to drain===
*Improper connections or leaks in the external tubing / water seal system 
*Improper positioning of tube 
*Occlusion of bronchi or bronchioles by secretions or foreign body 
*Tear of one of the large bronchi 
*Large tear of the lung parenchyma
*Clotting of a smaller diameter chest tube or pigtail catheter by blood (may require low dose [[TPA]] to declot pigtails) 
*If [[pneumothorax]] persists or large air leak despite well-placed tube need emergent bronchoscopy

==See Also==
*[[Pneumothorax]] 
*[[Hemothorax]] 
*[[Chest Tube (Peds)]]

==External Links==
*[https://litfl.com/own-the-chest-tube/ Chest Tube LITFL]
*[http://www.trauma.org/archive/thoracic/CHESTdrain.html Trauma.org Chest Tubes]
*[https://static1.squarespace.com/static/5e6d5df1ff954d5b7b139463/t/5eaf854675670c5192253c5b/1588561222937/Checklist_chest_tube.pdf OnePagerICU: Chest Tube Checklist]
*[https://www.merckmanuals.com/professional/pulmonary-disorders/how-to-do-pulmonary-procedures/how-to-do-surgical-tube-thoracostomy?query=chest%20tube Merk Manual - How To Do Surgical Tube Thoracostomy]

==References==
<references/>

[[Category:Procedures]]
[[Category:Trauma]]
[[Category:Pulmonary]]