Chest Tube Insertion and Care
Ulises Torres
Robert A. Lancy
Chest tube insertion involves placement of a sterile tube into the pleural space to evacuate air or fluid into a closed collection system to restore negative intrathoracic pressure, promote lung expansion, and prevent potentially lethal levels of pressure from developing in the thorax. In order to avoid all the potential life-threatening complications that can result from the insertion of a chest tube, a clear concept of physiopathology and anatomy has to be established, followed by a visualization of the different steps in order to proceed with a safe practice [1].
Pleural Anatomy and Physiology
The pleural space is a potential space that separates the visceral and parietal pleura with a thin layer of lubricating fluid. Although up to 500 mL per day may enter the pleural space, 0.1 to 0.2 mL per kg surrounds each lung in the pleural space at any given time. These two layers are lined by an extensive lymphatic network that ultimately drains into the thoracic duct via the mediastinal and intercostal lymph nodes. These lymphatics prevent the accumulation of this pleural fluid. It is estimated that this mechanism allows clearance of up to 20 mL per hour per hemithorax of pleural fluid in a 70-kg human. The elastic recoil of the chest wall and lung creates a subatmospheric pressure in the space, between -5 and -10 cm H2O, which binds the lung to the chest wall [2,3].
Drainage of the pleural space is necessary when the normal physiologic processes are disrupted by increased fluid entry into the space due to alterations in hydrostatic pressures (e.g., congestive heart failure) or oncotic pressures or by changes in the parietal pleura itself (e.g., inflammatory diseases). A derangement in lymphatic drainage, as with lymphatic obstruction by malignancy, may also result in excess fluid accumulation and disruption of the pleural and lung parenchymal anatomy, creating accumulation of air and/or blood.
Chest Tube Placement
Indications
The indications for closed intercostal drainage include a variety of disease processes in the hospital setting (Table 8.1). The procedure may be performed to palliate a chronic disease process or to relieve an acute, life-threatening process. Chest tubes also may provide a vehicle for pharmacologic interventions, as when used with antibiotic therapy for treatment of an empyema or instillation of sclerosing agents to prevent recurrence of malignant effusions.
Pneumothorax
Accumulation of air in the pleural space is the most common indication for chest tube placement. Symptoms include tachypnea, dyspnea, and pleuritic pain, although some patients (in particular, those with a small spontaneous pneumothorax) may be asymptomatic. Physical findings include diminished breath sounds and hyperresonance to percussion on the affected side.
Diagnosis is often confirmed by chest radiography. The size of a pneumothorax may be estimated, but this is at best a rough approximation of a three-dimensional space using a two-dimensional view. Although the gold standard for the identification of a pneumothorax (independent of location within the thorax) is a computed tomography (CT) scan of the chest, ultrasound (US) identification has been shown to have the same sensitivity as that of a CT scan. Furthermore, US estimates of the extension of the pneumothorax correlate well with CT scan [4]. The sensitivity of detecting a pneumothorax with US ranges from 86% to 89%, compared to a range of 28% to 75% with a supine chest X-ray [4,5,6].
The decision to insert a chest tube for a pneumothorax is based on the patient’s overall clinical status and may be aided by serial chest radiographs. Tube decompression is indicated in those who are symptomatic, who have a large or expanding
pneumothorax, who are being mechanically ventilated (the latter of whom may present acutely with deteriorating oxygenation and an increase in airway pressures, necessitating immediate decompression), or in patients where there is no capability for serial chest radiographs or the absence of trained personnel (off-hour shifts and geographic location) for the emergency placement of a chest tube [3].
pneumothorax, who are being mechanically ventilated (the latter of whom may present acutely with deteriorating oxygenation and an increase in airway pressures, necessitating immediate decompression), or in patients where there is no capability for serial chest radiographs or the absence of trained personnel (off-hour shifts and geographic location) for the emergency placement of a chest tube [3].
Table 8.1 Indications for Chest Tube Insertion | |
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A small, stable, asymptomatic pneumothorax can be followed with serial chest radiographs. Reexpansion occurs at the rate of approximately 1.25% of lung volume per day [7].
Persistent leaking of air into the pleural space with no route of escape will ultimately collapse the affected lung, flatten the diaphragm, and eventually produce contralateral shift of the mediastinum. Compression of the contralateral lung and compromise of venous return result in progressive hypoxemia and hypotension. Emergency decompression with a 14- or 16-gauge catheter in the midclavicular line of the second intercostal space may be lifesaving while preparations for chest tube insertion are being made.
Hemothorax
Accumulation of blood in the pleural space can be classified as spontaneous, iatrogenic, or traumatic. Attempted thoracentesis or tube placement may result in injury to the intercostal or internal mammary arteries or to the pulmonary parenchyma. Up to a third of patients with traumatic rib fractures may have an accompanying pneumothorax or hemothorax [8]. Pulmonary parenchymal bleeding from chest trauma is often self-limited due to the low pressure of the pulmonary vascular system. However, systemic sources (intercostal, internal mammary or subclavian arteries, aorta, or heart) may persist and become life threatening.
Indications for open thoracotomy in the setting of traumatic hemothorax include initial blood loss greater than 1,500 mL or continued blood loss exceeding 500 mL over the first hour, 200 mL per hour after 2 to 4 hours, or 100 mL per hour after 6 to 8 hours, or in an unstable patient who does not respond to volume resuscitation [9,10,11]. Placement of large-bore [36 to 40 French (Fr)] drainage tubes encourages evacuation of blood and helps determine the need for immediate thoracotomy.
Spontaneous pneumothoraces may result from necrotizing pulmonary infections, pulmonary arteriovenous malformations, pulmonary infarctions, primary and metastatic malignancies of the lung and pleura, and tearing of adhesions between the visceral and parietal pleurae.
Empyema
Empyemas are pyogenic infections of the pleural space that may result from numerous clinical conditions, including necrotizing pneumonia, septic pulmonary emboli, spread of intra-abdominal infections, or inadequate drainage of a traumatic hemothorax. Pyothorax as a complication of pneumonia is less common now than in the preantibiotic era, with the common organisms now being Staphylococcus aureus and anaerobic and gram-negative microbes.
Definitive management includes evacuation of the collection and antibiotic therapy. Large-bore drainage tubes (36 to 40 Fr) are used, and success is evidenced by resolving fever and leukocytosis, improving clinical status, and eventual resolving drainage. The tube can then be removed slowly over several days, allowing a fibrous tract to form. If no improvement is seen, rib resection and open drainage may be indicated. Chronic empyema may require decortication or, in more debilitated patients, open-flap drainage (Eloesser procedure). Fibrinolytic enzymes (urokinase or streptokinase) can also be instilled through the tube to facilitate drainage of persistent purulent collections or for hemothorax or malignant effusions [12,13,14].
Chylothorax
A collection of lymphatic fluid in the pleural space is termed chylothorax. Because of the immunologic properties of lymph, the collection is almost always sterile. As much as 1,500 mL per day may accumulate and may result in hemodynamic compromise or adverse metabolic sequelae as a result of loss of protein, fat, and fat-soluble vitamins. The diagnosis is confirmed by a fluid triglyceride level greater than 110 mg per dL or a cholesterol–triglyceride ratio of less than 1 [15,16]. Primary causes of chylothorax include trauma, surgery, malignancy, and congenital abnormalities [17].
Treatment involves tube drainage along with aggressive maintenance of volume and nutrition. With central parenteral nutrition and intestinal rest (to limit flow through the thoracic duct), approximately 50% will resolve without surgery [18]. Open thoracotomy may be necessary to ligate the duct and close the fistula; in the cases when the abdominal lymphatics are patent, percutaneous catheterization and embolization of the thoracic duct can be perform with good results [19].
Pleural Effusion
Management of a pleural effusion often begins with thoracentesis to identify the collection as either a transudative or
exudative process. Treatment of transudative pleural effusions is aimed at controlling the underlying cause (e.g., congestive heart failure, nephrotic syndrome, and cirrhosis). Tube thoracostomy may be helpful in controlling a temporary ventilatory or compliance-related issue, but it is not usually the solution. Exudative pleural effusions, however, often require tube drainage.
exudative process. Treatment of transudative pleural effusions is aimed at controlling the underlying cause (e.g., congestive heart failure, nephrotic syndrome, and cirrhosis). Tube thoracostomy may be helpful in controlling a temporary ventilatory or compliance-related issue, but it is not usually the solution. Exudative pleural effusions, however, often require tube drainage.
Sometimes it is necessary to perform chemical pleurodesis in order to develop apposition of pleural surfaces. Agents that can be used include bleomycin, doxycycline, and talc [20,21,22].
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