Thoracostomy Tube

See Tube thoracostomy

  INDICATIONS
  • Pneumothorax
  • Hemothorax
  • Hemopneumothorax
 
 CONTRAINDICATIONS
  •  Relative:
    • Adhesions/blebs
    • Recurrent pneumothorax
    • Need for open thoracotomy
    • Bleeding diathesis

Tube Size Selection: 
Condition Tube Size
Tension Pneumothorax
 
24-28 Fr
OR Needle thoracostomy
Open Pneumothorax 28 Fr
Hemothorax 32 Fr
Flail Chest 36 Fr (at least)
Malignant Effusion 8-18 Fr
Parapneumonic effusion Most Pt: 10-14 Fr (small cath for pt comfort)
Viscous fluid or loculated on CT: 16-24 Fr
Empyema Stage 1 Empyema: 28 Fr or larger
Stage 2 Empyema: chest tube warranted but may fail --> Thoracic surgery consult
Stage 3 Empyema: Chest tube drainage will almost assuredly result in treatment failure.
  • Insertion Point 
    • Adult:
      • 4th-6th intercostal space at mid/ ant axillary line
      • Direct tube superiorly & anteriorly
    • Child:
      • Level of nipples at mid/ ant axillary line

 TECHNIQUE
  • Head of bed is elevated 30-60 degree.
  • Arm should be secured over patient's head.
  • Local anesthesia and procedural sedation should be used.
  • 2- to 4-cm incision is made at fourth or fifth intercostal space, midaxillary line (see image).
  • Blunt dissection is performed with long closed Kelly clamp above rib to avoid nerve/vessel damage (see image).
  • Place finger through hole and feel for lung to confirm you've entered the pleural space. This key step increases the likelihood that the tube will enter the pleural space. (See image)
  • Use finger to guide tip of Kelly-clamped chest tube into pleural space.
  • Insert chest tube posteriorly and toward lung apex (see image).
  • Connect to regulated suction (typically beginning at 20 cm H2O).
  • Secure with sutures (0 or 1-0 silk), gauze, and tape.
  • Confirm placement with CXR.
 COMPLICATIONS
  • Diaphragm, spleen, lung, cardiac, vascular, or liver injury
  • Subcutaneous placement of chest tub
 INTERPRETATION OF RESULTS 
  • Air return (rush) confirms pneumothorax.
  • Blood return confirms hemothorax, as long as the blood is coming from the pleural space.
  • An air leak is either due to significant air movement from the lung into the pleural space or a leak in the tubing. Temporarily clamp the tube near to the chest if the leak persists, it is in the tubing not the patient


(A) Site of thoracostomy tube insertion.
(B) Blunt dissection with Kelly clamp.
(C) Finger confirmation of hole into pleura.
(D) Insertion of thoracostomy tube.



(1)
Identify the insertion site, which is usually at the fifth intercostal space in the anterior axillary line (just lateral to the nipple in males) and immediately behind the lateral edge of the pectoralis major muscle.

(2) Connect the suction system to a wall suction outlet, and adjust the suction as needed until a small, steady stream of bubbles is produced in the water column

(3)
Using a 10-mL syringe and 25-gauge needle, raise a skin wheal at the incision area with 1% lidocaine with epinephrine, and liberally infiltrate the subcutaneous tissue and intercostal muscles

(4) Make a 2- to 3-cm transverse incision through the skin and the subcutaneous tissues overlying the interspace, and extend the incision by blunt dissection with a Kelly clamp through the fascia toward the superior aspect of the rib above

(5) Insert an index finger to verify that the pleural space has been entered, and check for adhesions, masses, or the diaphragm


(6)
Advance the chest tube through the hole into the pleural space using your finger as a guide until the last side hole is 2.5 to 5 cm inside the chest wall


(7) Suture the tube in place with 1-0 or 2-0 silk or other nonabsorbable sutures

(8) Place a second suture in a horizontal mattress or purse-string stitch around the tube at the skin incision site
 



(9) Place petroleum gauze around the tube where it meets the skin, and tape the gauze and tube in place along with the tubing connections.
(10) The chest tube is generally removed when there has been air or fluid drainage or less than 100 mL/24 hour for more than 24 hours
(11) For chest tube removal, place gauze over the insertion site, and remove the tube with a swift motion


(12) Apply petroleum gauze or antibiotic ointment on gauze, and tape securely

 

NOTE
- Don't advance a chest tube after it's been placed -- it's better to place another tube than risk introducing bacteria into the chest.
- Don't clamp a chest tube except to look for an air leak--clamping a chest tube exposes the patient to the risk of tension pneumothorax
- Typically, operative treatment of bleeding is required in patients with initial chest tube blood loss of >1500 mL or >200-300 mL/hour thereafter.