Abstract
- Strict antiseptic precautions and personal protective equipment should be used during the procedure. A single dose of prophylactic antibiotics with Cefazolin should be administered before the procedure. There is no need for further prophylaxis.
- Chest tubes can be inserted with an open or percutaneous dilational technique.
- The site of insertion is the same for open or percutaneous insertion and for hemothorax or pneumothorax, at the fourth or fifth intercostal space, at the level of the nipple in males.
- Autotransfusion should be considered in all cases with large hemothoraces.
General Principles
Strict antiseptic precautions and personal protective equipment should be used during the procedure. A single dose of prophylactic antibiotics with Cefazolin should be administered before the procedure. There is no need for further prophylaxis.
Chest tubes can be inserted with an open or percutaneous dilational technique.
The site of insertion is the same for open or percutaneous insertion and for hemothorax or pneumothorax, at the fourth or fifth intercostal space, at the level of the nipple in males.
Autotransfusion should be considered in all cases with large hemothoraces.
Positioning
The patient should be placed in the supine position with the arm abducted at 90° and elbow fully extended or flexed at 90° cephalad (Figures 3.1a and 3.1b). Adduction and internal rotation of the arm is a suboptimal position and should not be used (Figures 3.1c and 3.1d).
Figure 3.1 The patient should be placed in the supine position with the arm abducted at 90° and elbow fully extended (a) or flexed cephalad at 90° (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 (d).
Site of Tube Insertion
Fourth or fifth intercostal space, midaxillary line. The external landmark is at or slightly above the nipple level in males. Insertion at this site is optimal due to the relatively thin chest wall and distance from the diaphragm, which during expiration can easily reach the sixth intercostal space.
Open Technique
Usual thoracostomy tube sizes for adults are 28–32 Fr. There is no advantage to using larger tubes. For pediatric cases, refer to the Broselow tape (Figures 3.2a and 3.2b).
After local anesthetic is injected in the skin, soft tissue, and along the periosteum, a 1.5–2.0 cm incision is made through the skin and subcutaneous fat (Figure 3.3).
Figure 3.3 A 1.5–2.0 cm incision is made through the skin and subcutaneous fat, in the fourth or fifth intercostal space at the midaxillary.
A Kelly forceps is used to enter the pleural cavity. Dissection should be kept close to the upper edge of the rib to avoid injury to the intercostal vessels. The Kelly forceps is inserted into the pleural cavity in a controlled manner to avoid injury to the intrathoracic organs (Figures 3.4a and 3.4b).
