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==Indications==
==Indications==
#Hemothorax
*[[Hemothorax]]
#Abscess
*Abscess  
#Empyema
*[[Empyema]]
#[[Traumatic Pneumothorax]] (some)
*[[Traumatic pneumothorax]] (some)  
#[[Spontaneous Pneumothorax]] (some)
**Indication for OR: >1200ml drainage immediately after insertion or continous 150-200 mL/hr for 2-4 hours
*[[Spontaneous pneumothorax]] (some)
 
===Relative Indications===
*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


==Relative Indications==
==Contraindications==
#Penetrating thoracic injury and need for positive pressure ventilation
*No absolute contraindications when performed for emergent indication.
#Profound hypoxia/hypotension in pt with penetrating chest injury
#Profound hypoxia/hypotension and signs of hemothorax


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


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


#Sterile drapes
#Silk sutures
#Syringes and needles for anesthesia
#Lidocaine
#Betadine
#Sterile gown/gloves
#Face shield
#Pleur-evac
==Procedure==
==Procedure==
#Expose insertion site by moving upper extremity above head on affected side
#Consider antibiotic (e.g. [[cefazolin]])
##Insertion site = mid- to ant axillary line at 4th/5th intercostal space
#If possible; Elevate HOB to 30-60 degrees to lower diaphragm-decreasing risk of injury to diaphragm/intra-abdominal organs
###~Nipple line in men, inframammary crease in women
#Expose insertion site by moving upper extremity above head on affected side  
#Clean w/ betadine and drape
#*Insertion site = mid- to ant axillary line at 4th/5th intercostal space  
#Confirm rib space and anesthetize w/ up to 5mg/kg of lido w/ or w/o epi
#**~Nipple line in men, inframammary crease in women  
##Must anesthetize skin, soft tissue, muscle, periosteum, and pleural space
#**Place 1-3 intercostal spaces higher in pregnant patients (esp those in 3rd trimester) due to elevated diaphragm. 
#Incise along upper border of the lower rib of the intercostal space
#Clean with betadine and drape  
##Ensure that incision is large enough to fit your finger through
#Confirm rib space and anesthetize with up to 5mg/kg of lido with or with out epinephrine
#Use curved clamp to bluntly dissect through the muscle until you reach the rib
#*Must anesthetize skin, soft tissue, muscle, periosteum, and pleural space  
#Angle the clamp to go above and over the rib and push until enter the 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  
#Open the clamp and pull it out with the clamp still open to create a larger tract  
#Clamp the prox end of the chest tube and pass it along the tract into the pleural cavity
#Premeasure chest tube from skin incision to ipsi clavicle to avoid advancing chest tube too far
##It helps to have your finger in the tract and pass the tube along your finger
#Clamp the prox end of the chest tube and pass it along the tract into the pleural cavity  
#Once in the space, remove the clamp
#*Ensure that inner tract/incision can fit your finger and tube
#Feed the chest tube until all the holes are inside the thoracic cavity
#*It helps to have your finger in the tract and pass the tube along your finger, particularly in obese patients
##Aim superoanterior for ptx; aim posteriorly for hemothorax
#Once in the space, remove the clamp  
###Controversial as to whether this is important
#Feed the chest tube until all the holes are inside the thoracic cavity  
#Attach distal end of tube to the pleur-evac and place on suction (20-30cmH2O suction)
#*Aim superoanterior for pneumothorax; aim posteriorly for hemothorax  
#Secure tube with silk suture and cover with gauze and cloth tape
#**Controversial as to whether this is important  
#Obtain CXR position of tube
#Rotate the tube 360 degrees
#Give abx (e.g. cefazolin)
#*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==
==Complications==
#Exsanguination (2/2 removing the tamponade effect of the hemothorax)
*Exsanguination (secondary to removing the tamponade effect of the hemothorax)  
##Clamp tube immediately; take pt to the OR for emergent thoracostomy
**Clamp tube immediately; take patient to the OR for emergent thoracostomy  
#Air leak
*Air leak  
##Reason why you never clamp the tube once it's in place (could cause tension ptx)
**Reason why you never clamp the tube once it is in place (could cause tension pneumothorax)  
#Failure
*Failure  
#Infection
*Infection  
##Give prophylactic abx (decreases rate of empyema)
**Give prophylactic antibiotics (e.g. [[Ancef]]) to decrease rate of empyema  
#Damage to nerves/vessels/heart/lung/diaphragm/abdomen
*Re-expansion pulmonary edema
#Improper positioning of the tube
*Damage to nerves/vessels/heart/lung/diaphragm/abdomen  
#Tension pneumothorax  
*Improper positioning of the tube  
#Failure to drain  
*[[Tension pneumothorax]]
##Improper connections or leaks in the external tubing / water seal system
 
##Improper positioning of tube
===Failure to drain===
##Occlusion of bronchi or bronchioles by secretions or foreign body
*Improper connections or leaks in the external tubing / water seal system  
##Tear of one of the large bronchi
*Improper positioning of tube  
##Large tear of the lung parenchyma
*Occlusion of bronchi or bronchioles by secretions or foreign body  
##If ptx persists or large air leak despite well-placed tube need emergent bronchoscopy  
*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==
==See Also==
*[[Pneumothorax]]
*[[Pneumothorax]]  
*[[Hemothorax]]
*[[Hemothorax]]
*[[Chest Tube (Peds)]]
 
==External Links==
*[http://lifeinthefastlane.com/own-the-chest-tube/ Chest Tube LITFL]
*[http://www.trauma.org/archive/thoracic/CHESTdrain.html Trauma.org Chest Tubes]


==Source==
==References==
http://www.trauma.org/archive/thoracic/CHESTdrain.html
<references/>


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

Revision as of 20:51, 19 April 2017

Indications

Relative Indications

  • 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

  1. Consider antibiotic (e.g. cefazolin)
  2. If possible; Elevate HOB to 30-60 degrees to lower diaphragm-decreasing risk of injury to diaphragm/intra-abdominal organs
  3. 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 pregnant patients (esp those in 3rd trimester) due to elevated diaphragm.
  4. Clean with betadine and drape
  5. 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
  6. Incise along upper border of the lower rib of the intercostal space
  7. Use curved clamp to bluntly dissect through the muscle until you reach the rib
  8. Angle the clamp to go above and over the rib and push until enter the pleural space
  9. Open the clamp and pull it out with the clamp still open to create a larger tract
  10. Premeasure chest tube from skin incision to ipsi clavicle to avoid advancing chest tube too far
  11. 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
  12. Once in the space, remove the clamp
  13. 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
  14. Rotate the tube 360 degrees
    • Reduces likelihood of tube kinking
    • If tube rotates easily, can help indicate correct location inside pleural cavity
  15. Attach distal end of tube to the pleur-evac and place on suction (20-30cmH2O suction)
  16. Secure tube with silk suture and cover with gauze and cloth tape
  17. Obtain CXR position of tube

Adult Chest Tube Sizes

Chest Tube Size Type of Patient Underlying Causes
Small (8-14 Fr)
  • Alveolar-pleural fistulae (small air leak)
  • Iatrogenic air
Medium (20-28 Fr)
  • Trauma/bleeding (hemothorax/hemopneumothorax)
  • Bronchial-pleural fistulae (large air leak)
  • Malignant fluid
Large (36-40 Fr)
  • Thick pus

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 thoracostomy
  • 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

External Links

References

  1. ↑ Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
  2. ↑ Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.
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