Chest tube

Indications

• Hemothorax
• Abscess
• Empyema
• Traumatic pneumothorax (some)
  • Indication for OR: >1200ml drainage immediately after insertion or continous 150-200 mL/hr for 2-4 hours
• Spontaneous pneumothorax (some)

Relative Indications

• Penetrating thoracic injury and need for positive pressure ventilation
• Profound hypoxia/hypotension in patient with penetrating chest injury
• Profound hypoxia/hypotension and signs of hemothorax

Contraindications

• No absolute contraindications when performed for emergent indication.

Relative contraindications

• Overlying skin infection
• Coagulopathy
• Multiple pleural adhesions

Equipment Needed

• Chest tube
  • 14-28F for pneumothorax
  • 32-40F for hemothorax
• Scalpel
• Kelly Clamp
• Sterile drapes
• Silk sutures
• Syringes and needles for anesthesia
• Lidocaine
• Betadine
• Sterile gown/gloves
• Face shield
• Pleur-evac

Procedure

1. Consider antibiotic (e.g. cefazolin)
2. If possible; Elevate HOB to 30-60 degrees to lower diaphragm-decreasing risk of injury to diaphragm/intra-abdominal organs
3. Expose insertion site by moving upper extremity above head on affected side
   • Insertion site = mid- to ant axillary line at 4th/5th intercostal space
     • ~Nipple line in men, inframammary crease in women
     • Place 1-3 intercostal spaces higher in pregnant patients (esp those in 3rd trimester) due to elevated diaphragm.
4. Clean with betadine and drape
5. Confirm rib space and anesthetize with up to 5mg/kg of lido with or with out epinephrine
   • Must anesthetize skin, soft tissue, muscle, periosteum, and pleural space
6. Incise along upper border of the lower rib of the intercostal space
7. Use curved clamp to bluntly dissect through the muscle until you reach the rib
8. Angle the clamp to go above and over the rib and push until enter the pleural space
9. Open the clamp and pull it out with the clamp still open to create a larger tract
10. Premeasure chest tube from skin incision to ipsi clavicle to avoid advancing chest tube too far
11. Clamp the prox end of the chest tube and pass it along the tract into the pleural cavity
    • Ensure that inner tract/incision can fit your finger and tube
    • It helps to have your finger in the tract and pass the tube along your finger, particularly in obese patients
12. Once in the space, remove the clamp
13. Feed the chest tube until all the holes are inside the thoracic cavity
    • Aim superoanterior for pneumothorax; aim posteriorly for hemothorax
      • Controversial as to whether this is important
14. Rotate the tube 360 degrees
    • Reduces likelihood of tube kinking
    • If tube rotates easily, can help indicate correct location inside pleural cavity
15. Attach distal end of tube to the pleur-evac and place on suction (20-30cmH2O suction)
16. Secure tube with silk suture and cover with gauze and cloth tape
17. Obtain CXR position of tube

Adult Chest Tube Sizes

Chest Tube Size	Type of Patient	Underlying Causes
Small (8-14 Fr)	Most spontaneous pneumothorax (primary and secondary) Most iatrogenic pneumothorax	Alveolar-pleural fistulae (small air leak) Iatrogenic air
Medium (20-28 Fr)	Pneumothorax on mechanical ventilation Non-traumatic tension pneumothorax Malignant effusion	Bronchial-pleural fistulae (large air leak) Malignant fluid
Large (36-40 Fr)	Traumatic pneumothorax Empyema	Bleeding (Hemothorax/hemopneumothorax) Thick pus

Drainage System and Suction

• Spontaneous pneumothorax
  • The least amount of suction (including none) needed to maintain full expansion of the lung is appropriate
  • Starting with Heimlich valve (no suction) or -10 cm of water and increasing only as needed
• Fluid drainage
  • -20 cm of water
  • Increased as indicated with the goal of achieving full lung expansion
• For thoracic trauma, few data are available
  • Start -20 cm of water

Complications

• Exsanguination (secondary to removing the tamponade effect of the hemothorax)
  • Clamp tube immediately; take patient to the OR for emergent thoracostomy
• Air leak
  • Reason why you never clamp the tube once it is in place (could cause tension pneumothorax)
• Failure
• Infection
  • Give prophylactic antibiotics (e.g. Ancef) to decrease rate of empyema
• Re-expansion pulmonary edema
• Damage to nerves/vessels/heart/lung/diaphragm/abdomen
• Improper positioning of the tube
• Tension pneumothorax

Failure to drain

• Improper connections or leaks in the external tubing / water seal system
• Improper positioning of tube
• Occlusion of bronchi or bronchioles by secretions or foreign body
• Tear of one of the large bronchi
• Large tear of the lung parenchyma
• Clotting of a smaller diameter chest tube or pigtail catheter by blood (may require low dose TPA to declot pigtails)
• If pneumothorax persists or large air leak despite well-placed tube need emergent bronchoscopy

See Also

• Pneumothorax
• Hemothorax
• Chest Tube (Peds)

External Links

• Chest Tube LITFL
• Trauma.org Chest Tubes

References

Authors

Jordan Swartz, Ross Donaldson, Tiffany Joe, Babak Missaghi, Marissa Camilon, Tianjiang Ye, Jesse Gentiluomo, Michael Holtz, Vincent Chan, Neil Young, Claire, Daniel Ostermayer