Chest tube: Difference between revisions
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{{Adult top}} [[chest tube (peds)]] | |||
==Indications== | ==Indications== | ||
*[[Hemothorax]] | |||
*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 | |||
*[[Spontaneous pneumothorax]] (some) | |||
*Chylothorax | |||
==Relative Indications== | ===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== | ==Contraindications== | ||
*No absolute contraindications when performed for emergent indication. | |||
===Relative contraindications=== | |||
*Overlying skin infection | |||
*Coagulopathy | |||
*Multiple pleural adhesions | |||
==Equipment Needed== | ==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== | ==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 | ||
# Angle the clamp to go above and over the rib | #**Place 1-3 intercostal spaces higher in [[Pregnancy|pregnant]] patients (esp those in 3rd trimester) due to elevated diaphragm. | ||
# Open the clamp and pull it out with the clamp still open | #Clean with betadine and drape | ||
# Clamp the end of | #Confirm rib space and anesthetize with up to 5mg/kg of lido with or with out epinephrine | ||
# Once in the space, remove the clamp | #*Must anesthetize skin, soft tissue, muscle, periosteum, and pleural space | ||
# Attach | #Incise along upper border of the lower rib of the intercostal space | ||
# Secure | #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== | ==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 | ||
http://www.trauma.org/archive/thoracic/CHESTdrain.html | *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:Procedures]] | ||
[[Category:Trauma]] | [[Category:Trauma]] | ||
[[Category: | [[Category:Pulmonary]] |
Latest revision as of 21:04, 1 May 2024
This page is for adult patients. For pediatric patients, see: chest tube (peds)
Indications
- Hemothorax
- 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
- Spontaneous pneumothorax (some)
- Chylothorax
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
- 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 pregnant patients (esp those in 3rd trimester) due to elevated diaphragm.
- Insertion site = mid- to ant axillary line at 4th/5th intercostal space
- 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
- Aim superoanterior for pneumothorax; aim posteriorly for hemothorax
- 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
Adult Chest Tube Sizes
Chest Tube Size | Type of Patient | Underlying Causes |
Small (8-14 Fr) |
|
|
Medium (20-28 Fr) |
|
|
Large (36-40 Fr) |
|
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
External Links
- Chest Tube LITFL
- Trauma.org Chest Tubes
- OnePagerICU: Chest Tube Checklist
- Merk Manual - How To Do Surgical Tube Thoracostomy