Tube ThoracostomyDR ELLAHI BAKHSH

PGR PULMONOLOGY

FATIMA JINNAH CHEST & GENERAL HOSPITAL QUETTA

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REFERENCES

BTS Guidelines for the Insertion of a Chest Drain 2014

Clinical Respiratory Medicine Stephen G . Spiro

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Background

In normal situation the pressure between the pleura of the lung is below the

atmospheric pressure.

When air or fluid enters the intra pleural space, the pressure is altered and this can

cause collapse of a portion of the lung.

Even with adequate oxygenation patient with collapse portion of the lung will not

have adequate oxygen - carbon dioxide exchange.

The only treatment for this altered condition is to restore the negative pressure to the

intra plural space .

This is accomplished through the insertion of chest tube

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Definition

Tube thoracostomy is the insertion of a tube (chest tube) into the

pleural cavity to drain air, blood, bile, pus, or other fluids.

Whether the accumulation of air or fluid is the result of rapid traumatic filling with air or blood or an insidious malignant exudative

fluid, placement of a chest tube allows for continuous, large volume

drainage until the underlying pathology can be more formally

addressed.

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Anatomy

Plural fluid separate parietal and visceral plural surfaces

Amount of plural fluid secretion is 0.3 ml/kg or 25ml/ 24 hours

Natural tendency of lung to recoil v/s adherence of pleura

Negative intra plural pressure keeps the lung expanded

During inspiration: -8cmH2O

During Expiration: -4cmH2O

Air Fluid or Blood in plural cavity create disruption of negative

intra-plural pressure that leads to Lung Collapse

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Indication for the Chest Tube Insertion

Pneumothorax

in any ventilated patient

tension pneumothorax after initial relief

persistent or recurrent pneumothorax after simple aspiration

large secondary spontaneous pneumothorax in patients over 50 years

Malignant pleural effusion

Empyema and complicated parapneumonic pleural effusion

Traumatic haemo pneumothorax

Postoperative—for example, thoracotomy, oesophagectomy, cardiac surgery

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Contra-indications

The need for Emergent Thoracotomy is an Absolute Contraindication to Tube Thoracostomy

Relative contraindications include the following

Coagulopathy

Pulmonary bullae

Pulmonary, pleural, or thoracic adhesions

Loculated pleural effusion or empyema

Skin infection over the chest tube insertion site

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Pre Drainage Risk assement

Risk of haemorrhage:

any coagulopathy or platelet defect should be corrected prior to chest drain insertion.

Following differential diagnosis requires careful radiological assessment.

pneumothorax and bullous disease .

lung collapse and a pleural effusion .

Contraindication to chest drain insertion.

Lung densely adherent to the chest wall throughout the hemithorax .

The drainage of a post pneumonectomy space should only be carried out by or after

consultation with a cardiothoracic surgeon

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Chest Drainage System

Chest tube types :

Thoracotomy chest tube.

Trocar chest tube .

malecot catheter .

Selection of chest tube.

At present, the most common tube used for chest drainage is a Silastic tube with multiple

side holes.

It usually has a linear radiopaque stripe running through the most proximal hole (allowing its

location to be identified on chest radiographs)

and markings to indicate distance in centimeters from the most proximal hole These tubes

range in size (gauge) 8 French up to 40 French .

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Chest Tube Types11

Chest Tube Types12

Chest Drainage System

According to patient age According to disease condition

Infants and young children (8F-12F) Pneumothorax ( 8F-14F )

Children and young adults (16F-20F)Malignant effusion (10F -14F )

Pleurodoesis

Most adults (24F-32F) Empyemas ( 24F-28F )

Large adult (36F-40F) Hemothorax ( 28F-32F )

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Equipments

Sterile Gloves and Gown

Skin Antiseptic Solution

Sterile Drapes

Gauze Swabs

Syringes and Needles

Local Anesthetics

Scalpel

Sutures

Dressing

Curved Kelly Clamps

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Drainage Canisters 15

ONE BOTTLE SYSTEM

Simplest set up .

First tube submerged in 2cm water creates a

water seal.

Second tube connected to wall suction.

Excessive accumulation of fluid can cause

decreased function of the unit.

Drainage canisters16

TWO BOTTLE SYSTEM

Separate bottle for collecting drainage and for water

seal .

Air from the pleural space travels through the

collecting bottle to the water seal bottle and exists

into the atmosphere .

Separate bottle for drainage means more fluid can

be collected before a new bottle is needed .

Drainage canisters17

THREE BOTTLE SYSTEM

Separate bottle

For Collecting drainage.

For water seal.

For suction control .

Level of fluid in the suction control bottle

determines the amount of suction provided.

Rarely used due to bulkiness

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CONSENT AND PREMEDICATION

Prior to commencing chest tube insertion the procedure should be explained fully to

the patient and consent recorded in accordance with National Guidelines.

Unless there are contraindications to its use, premedication (benzodiazepine or

opioid) should be given to reduce patient distress.

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I understand my need for a chest tube. I understand the need for this surgery and grant permission to the surgeon to proceed on my behalf. if condition may not improve, and it may worsen. No absolute guarantee can be made.

NAME OF PATIENT ________________________________________________________________

SIGNATURE ______________________________________________

WITNESS ________________________________________________

SURGEON ________________________________________________

RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ________________________________

SIGNATURE __________________________________________________

DATE _________________

23Consent accordance with National Guidelines

Patient Prepration

Explain the procedure

Informed Written Consent

Verify the Site of abnormality

Mark the site patients on patients' chest

Premedication

Monitor O2 saturation and supplemental O2

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Patients Position

Supine, Slightly rotated with arm on side of lesion behind patients

head to expose the axillary.

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Patients Position

Sit upright learning over an adjacent table with a pillow

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Patients Position

Lateral Decubitus Position

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Insertion Site

Triangle of Safety (Mid Axillary line 4th or 5th Intercostal Space)

Anterior Border of Latissimus Dorsi

Lateral Border of Pectoralis Major muscle

Line superior to Horizontal Level of nipple

Apex below Axilla

Mid Clavicular Line 2nd Intercostal Space

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Direction of Tube

Air

Anterior and Superior towards Apex

Fluid

Posterior and inferior Towards Base

Any Tube Position can be effective at draining Air or Fluid

An effectively functioning chest tube should not be repositioned

because of position in Chest x ray

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Strict Aseptic Measures30

Skin Preparations31

Towelling32

Anesthesia 33

Incision with Scalpel34

Muscle Splitting 35

Chest Tube Placement 36

Suturing 37

Dressing 38

Improper Chest Tube 39

40Improper Chest tube Placement

Post Procedural Notes 41

Reason for chest tube placementDrainage received (if any) colour, characteristics,

volume.

Patient Vital Signs in recovery room .Dressing type applied and connections securely

taped

Any Medication given. Vitals sign during Post-procedure

Location and size of Chest Tube insertion.Water level ordered and set for suction control

chamber

Patient's tolerance of procedure. Post insertion chest ray taken

Complications

Insertional

Pain

Placement out with Plural cavity ( S/C, Intra Abdominal, Solid Organ)

Puncture of Solid Organs ( Liver, Spleen, Heart, lung Esophagus)

Puncture of Intercostal arteries – Hemothorax

Insertion on Incorrect site

Sub Cutaneous Emphysema

Intercostal Neuroglia

Positional

Drain Failure ( Dislodgement, Knicked, Blocked)

Re-Expansion Pulmonary edema

Broncho-Plural Fistula

Pneumothorax

InfectiveWound Infection

Empyema

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Complications 43

Patient Care Respiration

Rate, regularity, Depth and ease

Breath Sounds

Deep Breath and Cough

Splintage of thoracic incision with pillow

Knowledge Level

Pain control

Vital Signs

Patient position and movements

Encourage movement

Gravity drainage v/s Suction

If Discontinued from suction tube should be opened to air

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Incentive Spirometer45

Post Procedure Patient Care

Chest Tube site and dressing

Dressing should be dry and intact

Palpate for Sub Cutaneous Emphysema

Regular inspection for leak and knink dependent loops

compression/collision

Monitor Volume , Rate , Color and Characteristics

Keep Drain below level of chest

High or Semi fowler’s position

Chest Tube should not be clamped during movement ambulation

or trips

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Post Procedure Patient Care

Clamp only to

Locate air leaks

Stimulate Tube removal

Replace a drain

Connect or disconnect an in line auto transmission bag

A bubbling chest tube should never be clamped

Drainage of large plural effusion should be controlled to prevent potential

complication of pulmonary edema

Incase of pneumothorax, Clamping of chest should usually be avoided,.

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Milking Method In Chest Tube Care

Post Procedure Patient Care

Water Seal

Water seal is filled to appropriate level

Water level moves on patients breaths

If there is no movement

Kinked clamped or lying on the tube

Dependent fluid filled loop

Lung tissue are blocking the holes

No more air leaking to plural space and lung has re expanded

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Post Procedure Patient Care

Suction

Check connection and tubing

Typical Suction level -15 to -20 cm H2O

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Bubbling Chest Tube Differentials

If tube is not inserted into plural space One or more of the holes in chest tube

will be outside the plural space

Air enters from atmosphere

In debilitated patients with poor tissue turgor negative pressure will cause air to

enter plural space around chest tube insertion site and leaks into the system

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How to differentiate air leaks

Measuring the level of PCO2 in the Air coming from the chest tube

Collected in the syringes – Blood gas Analyzer

PCO2 more the 20 mmhg ( Broncho-plural fistula )

If PCO2 is less then mmhg ( Atmospheric Air )

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Timing of chest tube removal

Depends upon indications

Pneumothorax

Bubbling movement has ceased

Lung fully expanded in Chest x ray

If controversial

duration of observation

Get Chest X ray 12-24 hours after last air leak

Plural Fluid Drainage

If volume is less than 100ml in 24 hours

If serous fluid

Lung re expanded and clinical status improved

No fresh or altered blood coming out of the chest tube

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Removing of the Chest Tube

Explain the procedure to the patient

Prevent the risk of diseased condition

End expiration v/s end inspiration

Instruct the patient and pull the tube

Occlude the insertion site

Tight the sutures and occlusive dressing

Chest x-ray after 12-24 hours after removal

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Removing of the Chest Tube 55

Heimlich Valve

Mechanical One way valve

Allow air to escape from chest

Prevent air from entering chest

Advantages

Doesn’t require water to operate

Not Position Sensitive

Early ambulation of patient

Disadvantage

Less patient assessment information

Can’t see change in intra plural pressure

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