Chest tube
(Redirected from Thoracostomy)
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