Before Procedure

Indications

• Most commonly to treat one of the following conditions:

• Pneumothorax

• Pleural fluid collection

Hemothorax

Simple effusion

Empyema

• Can be both a diagnostic and a therapeutic maneuver

Contraindications

• In an emergent situation (i.e., tension pneumothorax), there are no contraindications.

• In a nonurgent situation, caution should be exercised in the presence of:

• Known or suspected adhesions

Prior chest surgery or trauma

History of pleural space infection

Intrinsic parenchymal disease

• Complex, loculated air or fluid collection(s)

Typically noted on imaging studies

• In situations where insertion is not emergent and is anticipated to be difficult, consideration to placement by a skilled operator (surgeon) or under image guidance (computed tomography [CT], ultrasound) is recommended.

Equipment

• Chest tube of appropriate size and configuration (Figure W12-1)

Figure W12-1 Standard chest tube (top) with trocar (middle) and angled chest tube (bottom) without trocar.

• In general, larger tubes are required to drain blood, pus, or viscous fluid, and smaller tubes may suffice for a simple effusion or pneumothorax.

Sizes range from 20F to 40F for adults and 6F to 26F for pediatric patients.

• Straight tubes most commonly placed in the emergency department or intensive care unit.

Right-angled tubes are available but typically are placed by surgeons in the operating room.

• Commercially available collection system (Figure W12-2)

Figure W12-2 Modern chest drainage system. A, Accessory tubing to wall suction. B, Accessory tubing to chest tube/patient. C, Suction control. D, Float indicating suction is operative. E, Water seal chamber. F, Collection chamber. G, Air leak meter.

• Will include the following components:

Plastic connector of at least 0.25-inch diameter to connect the chest tube to the accessory tubing (a Y connector may be used in the case of multiple chest tubes, but caution is advised because these are prone to occlusion and subsequent drainage failure).

Accessory tubing (generally 0.5 inches in diameter and 6 feet long)

Drainage system (composed of a trap, water seal, and manometer compartments)

• Wall vacuum source with connection tubing

• Prepackaged chest tray

• At a minimum, should contain a scalpel and a clamp (large Kelly clamp or hemostat)

• Skin antiseptic

• Sterile drapes

• Sterile gown and gloves, mask, and cap

• Local anesthetic

• Intravenous narcotic and/or sedative

• Suture material (commonly 0 silk)

• Gauze

• Tape

Anatomy

Entry into the pleural space should generally be gained via a location based on ease of access, safety, and avoidance of complications. The American College of Surgeons Committee on Trauma recommends drain insertion between the anterior and posterior axillary lines at a level with or just above the fifth intercostal space (nipple level). In this location, the chest wall is thinnest, and the operator can avoid the pectoralis major muscle and breast parenchyma (anteriorly), the latissimus dorsi muscle (posteriorly), the axillary vessels/brachial plexus (superiorly), and the diaphragm/intraabdominal contents (inferiorly). Within the intercostal space, coursing along the inferior surface of each rib is the neurovascular bundle. Insertion of the tube over the superior aspect of the rib is recommended so that injury to these structures can be avoided (Figure W12-3). From superficial to deep, one will first encounter skin, followed by a variable amount of subcutaneous tissue, the superior surface of the rib, the intercostal space with its musculature, and finally the parietal pleura. The pulmonary parenchyma and mediastinal structures are deep to the parietal pleura, so it is important to avoid overzealous insertion of the chest tube. In some instances (e.g., a loculated collection), specialized placement may be required, and the assistance of a surgeon or insertion under image guidance is encouraged.

Figure W12-3 Use of Kelly clamp to enter pleural space.

Procedure