Chest tube: Difference between revisions
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== Indications | {{Adult top}} [[chest tube (peds)]] | ||
==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 | |||
== Equipment Needed | *Sterile drapes | ||
*Silk sutures | |||
*Syringes and needles for anesthesia | |||
*[[Lidocaine]] | |||
*Betadine | |||
*Sterile gown/gloves | |||
*Face shield | |||
*Pleur-evac | |||
==Procedure== | |||
#Consider antibiotic (e.g. [[cefazolin]]) | |||
#If possible; Elevate HOB to 30-60 degrees to lower diaphragm-decreasing risk of injury to diaphragm/intra-abdominal organs | #If possible; Elevate HOB to 30-60 degrees to lower diaphragm-decreasing risk of injury to diaphragm/intra-abdominal organs | ||
#Expose insertion site by moving upper extremity above head on affected side | #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 | ||
#Clean | #**Place 1-3 intercostal spaces higher in pregnant patients (esp those in 3rd trimester) due to elevated diaphragm. | ||
#Confirm rib space and anesthetize | #Clean with betadine and drape | ||
# | #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 | |||
#Incise along upper border of the lower rib of the intercostal space | #Incise along upper border of the lower rib of the intercostal space | ||
#Use curved clamp to bluntly dissect through the muscle until you reach the rib | #Use curved clamp to bluntly dissect through the muscle until you reach the rib | ||
Line 50: | Line 52: | ||
#Premeasure chest tube from skin incision to ipsi clavicle to avoid advancing chest tube too far | #Premeasure chest tube from skin incision to ipsi clavicle to avoid advancing chest tube too far | ||
#Clamp the prox end of the chest tube and pass it along the tract into the pleural cavity | #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 | ||
#Once in the space, remove the clamp | #Once in the space, remove the clamp | ||
#Feed the chest tube until all the holes are inside the thoracic cavity | #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 | ||
#Rotate the tube 360 degrees | #Rotate the tube 360 degrees | ||
# | #*Reduces likelihood of tube kinking | ||
# | #*If tube rotates easily, can help indicate correct location inside pleural cavity | ||
#Attach distal end of tube to the pleur-evac and place on suction (20-30cmH2O suction) | #Attach distal end of tube to the pleur-evac and place on suction (20-30cmH2O suction) | ||
#Secure tube with silk suture and cover with gauze and cloth tape | #Secure tube with silk suture and cover with gauze and cloth tape | ||
#Obtain CXR position of tube | #Obtain CXR position of tube | ||
{{Chest tube size table}} | |||
===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]] | *[[Pneumothorax]] | ||
*[[Hemothorax]] | *[[Hemothorax]] | ||
*[[Chest Tube (Peds)]] | *[[Chest Tube (Peds)]] | ||
==External Links== | ==External Links== | ||
*[http://lifeinthefastlane.com/own-the-chest-tube/ Chest Tube LITFL] | *[http://lifeinthefastlane.com/own-the-chest-tube/ Chest Tube LITFL] | ||
*[http://www.trauma.org/archive/thoracic/CHESTdrain.html Trauma.org Chest Tubes] | |||
== | ==References== | ||
<references/> | |||
[[Category:Procedures]] [[Category:Trauma]] [[Category: | [[Category:Procedures]] | ||
[[Category:Trauma]] | |||
[[Category:Pulmonary]] |
Revision as of 22:54, 28 November 2019
This page is for adult patients. For pediatric patients, see: chest tube (peds)
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
- Consider antibiotic (e.g. cefazolin)
- If possible; Elevate HOB to 30-60 degrees to lower diaphragm-decreasing risk of injury to diaphragm/intra-abdominal organs
- 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.
- Insertion site = mid- to ant axillary line at 4th/5th intercostal space
- Clean with betadine and drape
- 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
- Incise along upper border of the lower rib of the intercostal space
- Use curved clamp to bluntly dissect through the muscle until you reach the rib
- Angle the clamp to go above and over the rib and push until enter the pleural space
- Open the clamp and pull it out with the clamp still open to create a larger tract
- Premeasure chest tube from skin incision to ipsi clavicle to avoid advancing chest tube too far
- 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
- Once in the space, remove the clamp
- 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
- Aim superoanterior for pneumothorax; aim posteriorly for hemothorax
- Rotate the tube 360 degrees
- Reduces likelihood of tube kinking
- If tube rotates easily, can help indicate correct location inside pleural cavity
- Attach distal end of tube to the pleur-evac and place on suction (20-30cmH2O suction)
- Secure tube with silk suture and cover with gauze and cloth tape
- Obtain CXR position of tube
Adult Chest Tube Sizes
Chest Tube Size | Type of Patient | Underlying Causes |
Small (8-14 Fr) |
|
|
Medium (20-28 Fr) |
|
|
Large (36-40 Fr) |
|
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