Abstract
Traditionally, a tube thoracostomy is placed using the open technique; however, percutaneous techniques, and those using serial dilation, are also acceptable. Care should be taken with trocar techniques due to the high incidence of iatrogenic injuries.
General Principles
Tube thoracostomy to treat pneumothorax or hemothorax should be placed in the fourth or fifth intercostal space at the midaxillary line.
Full personal protective equipment should be used, and the procedure should be performed using standard sterile precautions when possible.
A single dose of prophylactic antibiotics, such as cefazolin, should be administered – ideally before the procedure. There is no need for further antibiotic prophylaxis.
Consider autotransfusion in cases with large hemothoraces.
Traditionally, a tube thoracostomy is placed using the open technique; however, percutaneous techniques, and those using serial dilation, are also acceptable. Care should be taken with trocar techniques due to the high incidence of iatrogenic injuries.
Positioning
The patient should be placed in the supine position with the arm abducted at 90 degrees and elbow fully extended or flexed at 90 degrees cephalad. Adduction and internal rotation of the arm should be avoided, because in this position the latissimus dorsi muscle moves toward the mid-axillary line and might interfere with the tube placement (Figure 19.1 AC).
Figure 19.1 A–C The patient should be placed in the supine position with the arm abducted at 90 degrees and elbow fully extended (A) or flexed cephalad at 90 degrees (B). Adduction and internal rotation of the arm is a suboptimal position and should not be used (C). The insertion site should be in the fourth or fifth intercostal space at the midaxillary line, at or slightly above the nipple level.
Site of Tube Insertion
The tube is inserted in the fourth or fifth intercostal space, mid-axillary line. The external landmark is at or slightly above the level of the nipple in males or in the inframammary crease in females. At this site, the chest wall is thin, containing only skin and intercostal muscles, and is also at a safe distance from the diaphragm, which during expiration can easily reach the sixth intercostal space.
Open Technique
A 28-F chest tube is usually sufficient in adults. Larger tubes are more difficult and more painful to insert and are no more effective at draining hemothoraces than the smaller tubes. In pediatric patients, tube size is based on the Broselow tape.
When possible, premedication with systemic analgesia is preferred. Local anesthesia is then injected into the skin, soft tissue, and underlying periosteum.
A 1.5–2.0 cm transverse incision is made through the skin and subcutaneous fat. Subcutaneous tunneling for the tube placement is not necessary because it makes the procedure painful and does not reduce the risk of empyema or air leak (Figure 19.2).
A Kelly forceps is used to dissect the intercostal muscles and enter the pleural cavity. The dissection should be kept close to the upper border of the rib to avoid injury to the intercostal vessels, which are located at the inferior border of the rib (Figure 19.3 A,B).
If the patient has no previous history of chest trauma or infection, there is no need for routine finger exploration of the pleural cavity. This maneuver is reserved only for cases with suspected pleural adhesions. In these cases, the index finger is inserted in the pleural cavity and swept 360 degrees, to evaluate for adhesions and avoid intraparenchymal placement of the tube (Figures 19.4).
The tube is then inserted into the thoracic cavity, exerting gentle pressure. A clamp may be placed at the fenestrated end of the tube to help guide the tube into the chest. During insertion, a clamp should be placed on the distal end of the tube to protect the operator from blood spillage. The tube is advanced in a posterior and superior direction to guide the tip toward the apex of the pleural cavity. A gentle turn may be introduced while advancing the tube, but avoid a corkscrew motion, as this can result in iatrogenic damage to the lung parenchyma. If resistance is encountered, draw back the tube. In a normal weight adult, the tube should be inserted 8–10 cm (Figure 19.5, Figure 19.6).
The end of the tube is connected to a collection system at –20 cm H2O. In most systems, the suction level is adjusted on the collection system and does not require titration of the wall suction unit.
The chest tube is then sutured in place. If the skin incision is large relative to the tube size, the excess incision can be reapproximated using interrupted sutures or staples (Figure 19.7 AC).
An occlusive dressing is placed around the entry site, and the tube is further secured to the thoracic wall with adhesive tape.
If the clinical condition allows, the patient is encouraged to sit up, take deep breaths, and cough to facilitate lung re-expansion and blood drainage.
Figure 19.2 1.5–2.0 cm incision is made through the skin and subcutaneous fat, at the fourth or fifth intercostal space midaxillary line.
Figure 19.3 A,B Kelly forceps are used to enter the pleural cavity just over the top of the rib. Spreading of the subcutaneous fat and tissue as the Kelly is withdrawn from the pleural cavity.
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