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Subject: Chest Tube Insertion
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if it is large or progressive or if the patient is
Drainage of recurrent
Prevention of hydrothorax
after cardiothoracic surgery
Anticoagulation or a
Small, stable pneumothorax
(may spontaneously resolve)
Empyema caused by
PITFALL: Do not direct the tube toward
the mediastinum because contralateral pneumothorax may
PITFALL: The diaphragm, liver, or
spleen can be lacerated if the patient is not properly
positioned or the tube is inserted too low.
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.
Pearl: Prep a wide area so that an
undraped area is not inadvertently exposed if the drape
slides a little.
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
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
PITFALL: Avoid being contaminated by
the air or fluid that may rush out when the pleura is
Pearl: If a significant hemothorax is
present, consider collecting the blood in a heparinized
autotransfusion device so that it can be returned to the
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.
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
Pearl: Consider keeping the chest tube
in place if the patient is on a ventilator in case a new
pneumothorax suddenly develops.
Pearl: If the patient is on a
ventilator, pause the ventilator during chest tube
Injury to the heart, great
vessels, or lung
of the tube
Open or tension
Unexplained or persistent
from intercostal artery injury)
Cardiogenic shock (from
chest tube compression of the right ventricle)