Chest tubes
We have a commercial kit for chest tube insertion along with a wide variety of chest tube sizes depending on the indication for the chest tube. Our inpatient unit will take care of our chest tube patients if admission at YKHC is indicated. Generally multi-system trauma patients are medevac’d to ANMC for management of their multiple injuries.
Chest tube placement is indicated for the evacuation of hemothorax. It can also relieve simple pneumothorax if pigtail catheter or thoracic vent is unavailable. There is not consensus in the literature regarding optimal chest tube size. Typically, for evacuation of simple pneumothorax in adults, an 8-14 Fr is sufficient, with a 28-36 Fr used for evaluation of hemothorax. Multiple chest tubes may be necessary for evacuation of large hemothorax.
Complications
Typically from accidental placement in the abdominal cavity rather than thoracic cavity, which can result in hepatic or splenic lacerations, or placement in a false tract created in thoracic wall. Trauma and puncture of the lung may occur, though if tube is placed in the thoracic cavity this will relieve any resultant pneumothorax.
Technique
- Place patient in supine position.
- Provider dons sterile attire and patient is sterilely prepped and draped.
- Mark the insertion site at the 5th intercostal space at mid-axillary line, about the level of the nipple in most patients.
- Inject a generous amount of lidocaine to the level of the rib then slide superiorly as vessels run inferior to ribs and inject remainder of lidocaine at the pleura.
- Once area is anesthetized, use a scalpel to make a ~2 cm incision and bluntly push through to the thoracic cavity with a long hemostat/curved Kelly clamp. There will be a definitive give when the pleura is pushed through and the thoracic cavity entered.
- Open the hemostats widely, place your finger in the cavity created and remove hemostats. Some providers remove hemostats before placing finger in the cavity, however I find this makes it easy to lose the created cavity as muscle slides back over pleura.
- Verify that thorax has been breached and move finger around inner pleura.
- Grasp the chest tube with the hemostats and insert into the chest cavity, using your finger as a guide.
- Direct the tube posteriorly for hemothorax/hemopneumothorax and superiorly for evacuation of simple pneumothorax.
- Hook to pleurovac.
- Suture chest tube in place and surround with air-tight petroleum-gauze dressing.
- Obtain a portable CXR to confirm tube placement.
Resources/References
- UCSD Standardized Procedure Chest Tube Placement (Adult)
- Dev et al. Chest-Tube Insertion. N Engl J Med 2007; 357:e15. DOI: 10.1056/NEJMvcm071974 (video)
