Tube Thoracostomy

To evacuate abnormal collections of air or fluid from the pleural space in the following conditions:

Pneumothorax

Hemothorax

Chylothorax

Empyema

Recurrent pleural effusion

Prevention of hydrothorax after cardiothoracic surgery

CONTRAINDICATIONS

None for unstable injured patients

Relative Contraindications

Anatomic abnormalities—pleural adhesions, emphysematous blebs, or scarring

Coagulopathy

LANDMARKS

The fourth or fifth intercostal space at the mid- to anterior axillary line, but multiple sites are possible (FIGURE 14.1)

Intercostal nerve and vessels are located along the inferior margin of each rib; therefore, the tube should pass immediately over the superior surface of the lower rib

SUPPLIES

Antiseptic solution, drapes, and towel clips

1% Lidocaine, 20 mL

25- and 22-gauge needles and 10-mL syringe

No. 10 scalpel blade with handle, Kelly clamps (two), and forceps

Thoracostomy tube selection

Trauma: No. 36–40 French

Nontraumatic: No. 24–32 French

Children: No. 20–24 French

Infants: No. 18 French

Pleur-evac (collection bottle, underwater seal, suction control)

Connecting tubing

Gauze pads, adhesive tape, 4˝ × 4˝ pads, Xeroform gauze dressing

2, 1, or 0 suture (not 2-0 or 1-0), needle driver, and suture scissors

General Basic Steps

Analgesia

Incision

Blunt dissection

Verification

Insertion

Securing the tube

Confirmation

FIGURE 14.1 Possible sites for chest tube placement. (From Connors KM, Terndrup TE. Tube thoracostomy and needle decompression of the chest. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Lippincott Williams & Wilkins; 1997:399.)

TECHNIQUE

Preparation

Oxygen and continuous pulse oximetry monitoring

If the patient is stable, administer parenteral analgesics or procedural sedation

Elevate the head of the bed to 30 to 60 degrees

Arm on the affected side is placed over the patient’s head

Sterilize the area where the tube will be inserted with povidone–iodine or chlorhexidine solution

Drape the area with sterile towels

Assemble the suction-drain system according to manufacturer’s recommendations; adjust the suction until a steady stream of bubbles is produced in the water column

Analgesia

Produce local anesthesia using up to 5 mg/kg of 1% lidocaine with epinephrine (1:100,000)

Inject the subcutaneous area with a small-bore (25-gauge) needle

Generously infiltrate the muscle, periosteum, and parietal pleura in the area of the tube’s eventual passage using a larger-bore needle

Incision

Using a no. 10 scalpel blade, make at least a 3- to 4-cm transverse incision through the skin and subcutaneous tissue

One method is to make the incision at an intercostal space lower than the thoracic wall entry site so that the tube may be “tunneled” up over the next rib

Blunt Dissection

Use a large Kelly clamp or scissor (this often takes considerable force)

Track is created over the rib by pushing forward with the closed points and then spreading and pulling back with the points spread

Push through the muscle and parietal pleura with the closed points of the clamp until the pleural cavity is entered

A palpable pop is felt when the pleura is penetrated, and a rush of air or fluid should occur at this point

Verification

Once the pleura is penetrated, insert a gloved finger into the chest wall track to verify that the pleura has been entered and that no solid organs are present

The finger can be left in place to serve as a guide for tube insertion

Insertion

It is recommended that the tube be held in a large curved clamp with the tip of the tube protruding from the jaws

Pass the tube over, under, or beside the finger into the pleural space

The tube is advanced superiorly, medially, and posteriorly until pain is felt or resistance is met; then it is pulled back 2 to 3 cm

Ensure that all the holes in the chest tube are within the pleural space

Securing the Tube (numerous methods are acceptable)

Close the remainder of the incision using a large 0 or 1 silk or nylon suture, keeping the ends long

Suture ends are wrapped and tied repeatedly around the chest tube, then knotted securely. The sutures are tied tightly enough to indent the chest tube slightly to avoid slippage.

A horizontal mattress (or purse-string) suture is placed approximately 1 cm across the incision on either side of the tube, essentially encircling the tube. This suture helps secure the tube and eventually facilitates closing the incision when the chest tube is removed.

Place occlusive dressing of petroleum-impregnated gauze where the tube enters the skin; then cover with two or more gauze pads

Wide cloth adhesive tape can be used to hold the tube more securely in place

Confirmation

Indicators for correct placement are as follows:

Condensation on the inside of the tube

Audible air movement with respirations

Free flow of blood or fluid

Ability to rotate the tube freely after insertion

Attach tube to previously assembled water seal or suction

Observing bubbles in the water seal chamber when the patient coughs is a good way to check for system patency

Obtain a chest radiograph

COMPLICATIONS

Hemothorax

Pulmonary edema

Bronchopleural fistula

Empyema

Subcutaneous emphysema

Infection

Contralateral pneumothorax

Subdiaphragmatic placement of the tube

Localized hemorrhage

SAFETY/QUALITY TIPS

Procedural

The more urgent the chest tube, the less local anesthesia and the more systemic sedation/analgesia, for purposes of speed. In a chest tube required for emergent hemodynamic stabilization, it is reasonable to skip local anesthesia completely and place the chest tube after, for example, a dissociating dose of ketamine.

The more urgent the chest tube, the larger the size of the initial skin incision, for purposes of speed

Do not use the trocar that comes with many chest tubes. Trocar use is associated with solid organ injury.

We recommend inserting the chest tube over a finger that remains in the thorax, to minimize the likelihood of a misdirected chest tube. When a chest tube is advanced blindly through a track, subcutaneous placement is a common complication.

Clamp both ends of the tube during insertion to avoid being contaminated by fluid

Gently but assertively advance the chest tube completely into the pleural space

Avoid causing a contralateral pneumothorax by not directing the tube toward the mediastinum

Cognitive

Tube thoracostomy for unstable patients, as well as tube thoracostomy for stable patients without complicated lung disease (e.g., primary spontaneous pneumothorax), is well within the domain of emergency medicine. Caution and consultation are advised in placing chest tubes on stable patients with complicated lung disease.

Primary spontaneous pneumothorax can and often should be managed with less invasive strategies such as placement of a pigtail catheter, needle aspiration, or, in some cases, observation alone

Stable patients (especially older patients or patients with underlying lung disease) thought to have pneumothorax may benefit from computed tomography imaging, as blebs can mimic the appearance of pneumothorax on plain film

For a pneumothorax, direct the tube superiorly and anteriorly. For hemothorax, direct the tube posteriorly.

If there is no lung reexpansion after chest tube placement, consider the following: (1) the tube may not be in the pleural cavity; (2) the most proximal hole is outside the chest cavity; and (3) there is a large air leak from the tracheobronchial tree.