Chest Tube Insertion

E. J. Mayeaux, Jr, MD, DABFP, FAAFP and Sean Troxclair, MD
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Subject: Chest Tube Insertion

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Introduction

Chest tube insertion is a common therapeutic procedure used to provide evacuation of abnormal collections of air or fluid from the pleural space. Chest tube insertion is often required in a setting of trauma and can be a medical emergency. Chest trauma is a common cause of emergency department visits and may result in pneumothorax, hemothorax, or secondary infection. Patients with chest trauma should be assessed for signs of respiratory insufficiency, such as restlessness, agitation, altered or absent breath sounds, or respiratory distress. In severe cases, patients may exhibit cyanosis, deviated trachea, and paradoxical chest wall segment motion or shock. Coagulation studies and a chest radiograph should be available. In addition, tube thoracostomy may be indicated for pleural effusions associated with malignancy or infection. In these situations, drainage is imperative to allow for lung re-expansion. 
Sedation may be used if the patient is not in severe respiratory distress because of the procedural discomfort. Placement requires universal precautions for body fluids, and use good sterile technique, including a face mask and sterile gown whenever possible. Selection of the proper chest tube size is important. An 18- to 24-Fr chest tube typically is used for a pure pneumothorax. For a hemothorax, empyema, or other fluid accumulation, a 28- to 40-Fr catheter is more commonly employed. 
The classic technique for chest tube insertion has remained the same for many years. Some practitioners opt to perform a percutaneous tube thoracostomy with the Seldinger approach. The patient positioning and preparation is the same as the conventional method. An introducer needle is used to place a guidewire into the pleural space. Then serial dilators are passed over the guidewire to create an adequately dilated tract. The chest tube is then passed. A disadvantage to this technique is that the chest cavity cannot be digitally explored for adhesions; however, with careful consideration of the location of the guidewire, this can be performed after the last dilation. Some advantages to this technique are that an improved hemostatic barrier exists, which may be especially advantageous to pneumothoraces and patients prone to bleeding complications. This technique can take longer than traditional techniques and may not be optimal in emergency situations. There are references in literature indicating that when used for empyema, the percutaneous drains are more likely to become obstructed and stop draining. Thus far, this is only observational data, and no large-scale studies are available. 
Re-expansion pulmonary edema is a potentially life-threatening complication of chest tube placement. It usually occurs after rapid re-expansion in patients with a pneumothorax but may follow evacuation of large pleural effusions. It is related to the rapidity of lung re-expansion and to the severity and duration of lung collapse. Patients typically present soon after lung re-expansion and may range from simple radiographic changes to complete cardiopulmonary collapse. Treatment is supportive, mainly consisting of supplemental oxygen and, if necessary, mechanical ventilation. It is usually self-limited and may be prevented by limiting initial drainage to 1 to 1.5 L in the first 24 hours. 
The chest tube may be removed if the lung remains fully expanded on a chest radiograph performed on a water seal or after the tube is clamped for 4 to 6 hours. Traditionally, experts recommended that a chest tube be removed when the patient reached full inspiration, often with a concomitant Valsalva maneuver. The theory is that this is the point when intrathoracic pressure and lung volume are maximal. The involuntary reflex while the tube is removed is a quick inspiratory effort because of the pleural pain. In theory, this could allow air to reaccumulate just as the tube is being removed, necessitating reinsertion of another tube. However, research indicates that discontinuation of chest tubes at the end of inspiration or at the end of expiration has a similar rate of pneumothorax after removal and that both methods are equally safe. With all other things being equal, the end-inspiration timing remains the preferred technique. 

Equipment

Kits, thoracostomy trays, and suction-drainage system are available from Arrow Medical Products Ltd., 2400 Bernville Road, Reading, PA 19605. Phone: 1-800-233-3187. Web site: http://www.arrowintl.com/products/critical_care/
Many kits and supplies from various companies (including Baxter and American Hospital Supply) can be obtained from Cardinal Health, Inc., 7000 Cardinal Place, Dublin, OH 43017 (phone: 1-800-234-8701); Allegiance Healthcare Corp., McGraw Park, IL 60085 (phone: 847-689-8410; Web site: www.cardinal.com/allegiance), and Owens and Minor, 4800 Cox Road, Glen Allen, VA 23060-6292 (phone: 804-747-9794; fax: 804-270-7281). 
Chest tubes that are equipped with an intraluminal trocar are not recommended, because they are associated with a higher incidence of intrathoracic complications. 

Indications

  • Pneumothorax (especially if it is large or progressive or if the patient is symptomatic)

  • Tension pneumothorax

  • Penetrating chest trauma

  • Hemothorax

  • Chylothorax

  • Empyema

  • Drainage of recurrent pleural effusion

  • Prevention of hydrothorax after cardiothoracic surgery

  • Bronchopleural fistula

Contraindications (Relative)

  • Anticoagulation or a bleeding dyscrasia

  • Systemic anticoagulation

  • Small, stable pneumothorax (may spontaneously resolve)

  • Empyema caused by acid-fast organisms

  • Loculated fluid accumulation

The Procedure

Classic Technique

Step 1
Identify the insertion site, which is usually at the fourth or fifth intercostal space in the anterior axillary or midaxillary line (just lateral to the nipple in males) immediately behind the lateral edge of the pectoralis major muscle. Direct the tube as high and anteriorly as possible for a pneumothorax. For a hemothorax, the tube is usually inserted at the level of the nipple and directed posteriorly and laterally. Elevate the head of the bed 30 to 60 degrees, and place (and restrain) the arm on the affected side over the patient’s head. 
  • PITFALL: Do not direct the tube toward the mediastinum because contralateral pneumothorax may result.

  • PITFALL: The diaphragm, liver, or spleen can be lacerated if the patient is not properly positioned or the tube is inserted too low.

Step 2
Assemble the suction-drain system according to manufacturer’s recommendations. Connect the suction system to a wall suction outlet. Adjust the suction as needed until a small, steady stream of bubbles is produced in the water column. 
  • Pearl: If a suction-drain system is not immediately available, place a Penrose drain at the end of the chest tube to act as a one-way valve until an appropriate system is available.

Step 3
Prep the skin with povidone-iodine or chlorhexidine solution and allow it to dry (see Appendix E). Drape the site with a fenestrated sheet. Using the 10-mL syringe and 25-gauge needle, raise a skin wheal at the incision area (in the interspace one rib below the interspace chosen for pleural insertion) with a 1% solution of lidocaine with epinephrine
  • Pearl: Prep a wide area so that an undraped area is not inadvertently exposed if the drape slides a little.

Step 4
Liberally infiltrate the subcutaneous tissue and intercostal muscles, including the tissue above the middle aspect of the inferior rib to the interspace where pleural entry will occur and down to the parietal pleura. Using the anesthetic needle and syringe, aspirate the pleural cavity, and check for the presence of fluid or air. If none is obtained, change the insertion site. 
  • PITFALL: Use <7 mL/kg of lidocaine with epinephrine to avoid toxicity.

  • PITFALL: Be careful to keep away from the inferior border of rib to avoid the intercostal vessels.

Step 5
Make a 2- to 3-cm transverse incision through the skin and the subcutaneous tissues overlying the interspace. Extend the incision by blunt dissection with a Kelly clamp through the fascia toward the superior aspect of the rib above. After the superior border of the rib is reached, close and turn the Kelly clamp, and push it through the parietal pleura with steady, firm, and even pressure. Open the clamp widely, close it, and then withdraw it. 
  • PITFALL: Be careful to prevent the tip of the clamp from penetrating the lung, especially if no chest radiograph was obtained or if the x-ray film does not clearly show that the lung is retracted from the chest wall.

  • PITFALL: Avoid being contaminated by the air or fluid that may rush out when the pleura is opened.

Step 6
Insert an index finger to verify that the pleural space, not the potential space between the pleura and chest wall, has been entered. Check for unanticipated findings, such as pleural adhesions, masses, or the diaphragm. 
Step 7
Grasp the chest tube so that the tip of the tube protrudes beyond the jaws of the clamp, and advance it through the hole into the pleural space using your finger as a guide. Direct the tip of the tube posteriorly for fluid drainage or anteriorly and superiorly for pneumothorax evacuation. Advance it until the last side hole is 2.5 to 5 cm (1 to 2 inches) inside the chest wall. Attach the tube to the previously assembled suction-drainage system. The chest tube should be inserted with the proximal hole at least 2 cm beyond the rib margin. Position of the chest tube with all drainage holes in the pleural space should be assessed by palpation. Confirm the correct location of the chest tube by the visualization of condensation within the tube with respiration or by drained pleural fluid seen within the tube. Ask the patient to cough, and observe whether bubbles form at the water-seal level. If the tube has not been properly inserted in the pleural space, no fluid will drain, and the level in the water column will not vary with respiration. 
  • Pearl: If a significant hemothorax is present, consider collecting the blood in a heparinized autotransfusion device so that it can be returned to the patient.

Step 8
Suture the tube in place with 1-0 or 2-0 silk or other nonabsorbent sutures. The two sutures are tied so as to pull the soft tissues snugly around the tube and provide an airtight seal. Tie the first suture across the incision, and then wind both suture ends around the tube, starting at the bottom and working toward the top. Tie the ends of the suture very tightly around the tube, and cut the ends. 
Step 9
Place a second suture in a horizontal mattress or purse-string stitch around the tube at the skin incision site. Pull the ends of this suture together, and tie a surgeon’s knot to close the skin around the tube. Wind the loose ends tightly around the tube, and finish the suture with a bow knot. The bow can be later undone and used to close the skin when the tube is removed. Alternatively some choose to only use the purse-string stitch to secure the chest tube. This usually involves wrapping the suture around the tube several more times than in the other method to ensure the tube does not slip from location. 
Step 10
Place petroleum gauze around the tube where it meets the skin. Make a straight cut into the center of two additional 4 × 4-inch sterile gauze pads, and place them around the tube from opposite directions. Tape the gauze and tube in place, and tape together the tubing connections. Obtain posteroanterior and lateral chest radiographs to check the position of the chest tube and the amount of residual air or fluid as soon as possible after the tube is inserted. 
  • Pearl: Silastic chest tubes contain a radiopaque strip with a gap that serves to mark the most proximal drainage hole.

  • PITFALL: A bedside, portable x-ray device is preferable to sending the patient to another location, because the suction usually must be removed and the tube may become displaced.

  • PITFALL: If the patient is sent to another location for radiographs, do not clamp the chest tube, because any continuing air leakage can collapse the lung or produce a tension pneumothorax. Keep a water-seal bottle 1 to 2 feet lower than the patient’s chest during transport. If a significant air leak develops, perform chest films.

Step 10
Step 10
Step 11
Use serial chest auscultation, chest radiographs, volume of blood loss, and amount of air leakage to assess the functioning of chest tubes. If a chest tube becomes blocked, it usually may be replaced through the same incision. Chest tubes are generally removed when there has been air or fluid drainage of <100 mL/24 hours for more than 24 hours. 
  • PITFALL: Trying to open a blocked chest tube by irrigating or passing a smaller catheter through it seldom works well and increases the risk of infection.

  • Pearl: Consider keeping the chest tube in place if the patient is on a ventilator in case a new pneumothorax suddenly develops.

Step 11
Step 11

Percutaneous Method with the Seldinger Approach

Step 1
Patient positioning and preparation remain the same as the conventional method. An introducer needle is inserted over a rib in a similar manner to needle thoracentesis. 
Step 2
The obturator is removed, and a guidewire is placed through the needle into the pleural space. 
Step 3
Serial dilators are passed over the guidewire to create an adequately dilated tract. 
Step 4
The chest tube with its dilators inside is then passed, and the dilators and guidewire are removed, leaving the chest tube in place. The tube is anchored, dressed, and x-rayed as described previously. 

Removal

Step 1
For chest tube removal, place the patient in the same position in which the tube was originally inserted. Prep the area, untie the suture with the bow knot, loosen the purse-string stitch, and cut the other suture near the skin. Clamp the chest tube, and disconnect the suction system. Ask the patient to take a deep breath and perform a Valsalva maneuver. Place a gauze over the insertion site, and remove the tube with a swift motion. Tie the purse-string suture. Apply petroleum gauze or antibiotic ointment on gauze, and tape securely. Obtain a chest radiograph immediately and at 12 to 24 hours to rule out a recurrent pneumothorax. 
  • Pearl: If the patient is on a ventilator, pause the ventilator during chest tube removal.

Complications

  • Injury to the heart, great vessels, or lung

  • Diaphragmatic perforation

  • Subdiaphragmatic placement of the tube

  • Open or tension pneumothorax

  • Subcutaneous emphysema

  • Unexplained or persistent air leakage

  • Hemorrhage (especially from intercostal artery injury)

  • Recurrent pneumothorax

  • Empyema

  • Lung parenchyma perforation

  • Subcutaneous placement

  • Cardiogenic shock (from chest tube compression of the right ventricle)

  • Infection

There continues to be controversy concerning the need for prophylactic antibiotics in patients requiring a chest tube. Most trials show no benefit, although some have shown a reduction in infection in patients with penetrating chest trauma. 

Pediatric Considerations

Chest tubes usually come in two standard lengths. Either length is appropriate for use in adults, but the shorter length should be used in pediatric patients. 

Postprocedure Instructions

Patients are rarely discharged immediately after chest tube removal. Have the patient report any shortness of breath or other symptoms of disease recurrence immediately. The bandage should be left in place for at least 24 hours, and petroleum gauze should be kept on the wound for 2 to 3 days. The sutures should be removed in about 1 week. 

Coding Information and Supply Sources

Bibliography

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2008 MAG Mutual Healthcare Solutions, Inc.’sPhysicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.2007.
 
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