Chest Tube Placement, Care, and Removal

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W12 Chest Tube Placement, Care, and Removal

Gregory A. Watson, Brian G. Harbrecht

image Before Procedure

Indications

• Most commonly to treat one of the following conditions:

• Pneumothorax
• Pleural fluid collection

image Hemothorax
image Simple effusion
image 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

image Prior chest surgery or trauma
image History of pleural space infection
image Intrinsic parenchymal disease

• Complex, loculated air or fluid collection(s)

image 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)

image

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.

image 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.

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

• Commercially available collection system (Figure W12-2)

image

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:

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

image 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.

image

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

image Procedure

• If nonemergent, perform a “time out” to verify the indication(s), review the relevant imaging and coagulation studies, and confirm the correct patient and laterality.
• Obtain necessary equipment (see earlier), and fill the water seal compartment of the collection system with water.
• Position as follows:

• Supine or slight elevation of the head of the bed
• Ipsilateral arm behind the head or abducted
• Bed at comfortable height for the operator
• Ensure adequate lighting.

• Practice aseptic technique, and apply Universal Precautions.
• Prep the area broadly with skin antiseptic.
• Drape widely such that anatomic landmarks (e.g., the nipple) are visible.
• Plan the skin incision to overlie the rib just inferior to the chosen intercostal space (i.e., if entering the fifth interspace, place the incision along the superior aspect of the sixth rib).
• Consider premedication with a narcotic or anxiolytic.
• Inject local anesthetic (apply aspiration at all times):

• First anesthetize the skin.
• Then angle the needle slightly cephalad to anesthetize the periosteum of the rib and the deeper tissues.
• Several passes may be required to cover an area 1 to 2 cm in diameter.
• If air or fluid is aspirated, retract the needle while aspirating it until it ceases, then inject additional local to anesthetize the parietal pleura.

• Make an incision large enough to accommodate the operator’s index finger and chest tube at the same time.
• Bluntly dissect (with index finger and/or Kelly clamp) along an oblique path angled superiorly to the chosen intercostal space, with care taken to remain on the superior border of the rib (see Figure W12-3).
• If the patient is on a ventilator, hold respirations temporarily.
• Gently enter the pleural space with the tip of the clamp.

• AVOID EXCESSIVE CLAMP INSERTION TO MINIMIZE INJURY TO DEEPER STRUCTURES.
• Typically will feel a “pop” and get return of air and/or fluid

• Open the clamp slightly to sufficiently enlarge the opening into the pleural space.
• Insert index finger to confirm entry into the pleural space.

• Should be able to palpate parietal pleura and, at times, the lung
• Note the presence of any adhesions (seen in up to 15% of cases).

• Discard the chest tube trocar, and grasp the end of the tube with the Kelly clamp.
• Insert index finger alongside the chest tube, and guide the tube into the pleural space away from the lung parenchyma.

• Direct anteroapically for a pneumothorax and posterobasally for fluid.
• Ensure that the last drainage hole is well within the pleural space.

• Connect the tube immediately to the collecting system.
• If suction is desired, adjust the wall vacuum source to provide slow, consistent bubbling.

• Typically, the collection system is set initially to −20 cm water suction.

• Secure the tube to the skin at the exit site with sutures (avoid a “purse-string” stitch).
• Cover the wound with dry gauze and tape.
• Obtain a chest x-ray to document proper placement, evaluate expansion of the lung, and assess for residual pleural fluid or air.

image After Procedure

Postprocedure Care

• Daily assessment:

• System must remain upright and should be kept below chest level.
• The accessory tubing should be in a straight or coiled position and not kinked.
• Be certain the water level in the system is maintained.
• If suction is being used, verify the proper setting and confirm that it is functional (the float should be visible in the window).
• Note the amount of drainage, presence of bubbling, and respiratory variation.

• Troubleshooting:

• Observation of synchronous water seal and motion with respiration suggests the tube is still functioning in the pleural space and that all connections are tight.
• If the tube is not functioning and occlusion of the drainage holes is suspected:

image Disconnect and flush with normal saline, or
image Consider fibrinolytics (particularly if a parapneumonic effusion is present)

• If an air leak within the system is suspected:

image Sequentially clamp the accessory tubing with distal suction applied. The leak will cease when a clamp is placed proximal to the site, and the problem can then be addressed.
image If the accessory tubing or the connections are not the problem, check the insertion site. If the skin incision is too large, the leak may be audible and can readily be addressed with an additional stitch. Also, be certain the last drainage hole has not migrated out of the pleural space.
image If neither of the above identifies the problem, a major airway injury or bronchopleural fistula may be to blame.

• Removal:

• Should be performed once the indication for tube thoracostomy has resolved
• Will vary somewhat according to the patient population and the indication for insertion
• For simple pneumothorax, hemothorax, or pleural effusion, we recommend:

image Placement of the tube on −20 cm water suction initially to facilitate lung reexpansion and/or evacuation of fluid
image Continue suction until the lung is reexpanded and there is no air leak, then convert to water seal.
image Obtain a radiograph on water seal to confirm lung expansion.
image Remove when drainage is negligible (<150-200 mL per day).

• For empyema, the infectious process must be resolved, there should be no residual empyema cavity on imaging studies, and drainage must be scant prior to removal.

image It is common for empyema tubes to remain in place for weeks.

• In lung resection patients, management is more complex because the routine use of suction may potentiate air leaks. We recommend consultation with the patient’s surgeon regarding management of the tube(s).
• The timing of chest tube removal relative to the respiratory cycle (i.e., end inspiration or end expiration) does not appear to be important, even in ventilator-dependent patients.
• Although routine chest radiography after removal is not a universal practice, we recommend obtaining one within 4 hours of removal to confirm lung expansion.

• Routine clamping of chest tubes should generally be avoided.

Complications

• Reported to be as low as 2% and as high as 30%
• Improper insertion technique, operator inexperience, and forceful use of sharp trocars are avoidable errors that account for many of the complications.
• Common:

• Malpositioning:

image Generally around 3%, though a recent study of critically ill patients who underwent CT following tube thoracostomy reported an incidence of 30%.

• Infectious:

image Insertion site (wound) infection
image Pleural space infection (empyema) rates vary from 1% to 11%.

• Unresolved pneumothorax
• Persistent pleural fluid collection

• Infrequent:

• Injury to the lung:

image May manifest as hemothorax, persistent air leak, residual pneumothorax, or subcutaneous emphysema

• Injury to the intercostal vessels:

image May manifest as hemothorax and occasionally requires surgery to achieve hemostasis

• Chylothorax
• Long thoracic nerve injury (winging of the scapula)
• Intercostal neuralgia
• Horner’s syndrome
• Phrenic nerve palsy

• Serious rare complications:

• Reexpansion pulmonary edema

image Manifests as dyspnea (in the absence of lung collapse) following drainage of a large pneumothorax or hemothorax
image Ipsilateral edema seen on chest radiograph
image Treatment is supportive
image Some recommend slow removal of large effusions (<1 liter in the first 30 minutes) to minimize the risk.

• Esophageal rupture
• Perforation of the heart or great vessels
• Laceration of the subclavian vessels
• Injury to the diaphragm and/or upper abdominal structures (liver, spleen, stomach, colon)
• Puncture of silicone breast implants (intrathoracic silicosis)

image Outcomes and Evidence

• Few aspects of chest tube management have been subjected to rigorous study or are standardized.
• Patient outcomes following tube thoracostomy are related to their underlying condition(s).

• Deaths due to the procedure itself are infrequent.

• No clear consensus exists regarding the role of prophylactic antibiotics for tube thoracostomy, but they may be of some benefit.

• Recent meta-analysis of studies performed in trauma patients revealed a reduction in the risk of posttraumatic empyema and pneumonia.
• If one elects to administer antibiotics, coverage against Staphylococcus should be chosen.

Suggested Reading

Laws D, Neville E, Duffy J, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the insertion of a chest drain. Thorax. 2003 May;58(Suppl. 2):ii53-ii59.

Durai R, Hoque H, Davies TW. Managing a chest tube and drainage system. AORN J. 2010 Feb;91(2):275-280.

Miller KS, Sahn SA. Chest tubes: indications, techniques, management, and complications. Chest. 1987;91:258-264.

American College of Surgeons Committee on Trauma. Thoracic trauma. In Student manual of advanced trauma life support course for physicians, 5th ed, Chicago: American College of Surgeons; 1993:111-139.

Peek GJ, Firmin RK, Arsiwala S. Chest tube insertion in the ventilated patient. Injury. 1995;26:425-426.

Baumann MH. What size chest tube? What drainage system is ideal? And other chest tube management questions. Curr Opin Pulm Med. 2003 Jul;9(4):276-281.

Cerfolio RJ, Bryant AS. The management of chest tubes after pulmonary resection. Thorac Surg Clin. 2010 Aug;20(3):399-405.

Schulman CI, Cohn SM, Blackbourne L, et al. How long should you wait for a chest radiograph after placing a chest tube on water seal? A prospective study. J Trauma. 2005 Jul;59(1):92-95.

Martino K, Merritt S, Boyakye K, et al. Prospective randomized trial of thoracostomy removal algorithms. J Trauma. 1999 March;46(3):369-371.

Younes RN, Gross JL, Aguiar S, et al. When to remove a chest tube? A randomized study with subsequent prospective consecutive validation. J Am Coll Surg. 2002 November;195(5):658-662.

Bell RL, Ovadia P, Abdullah F, et al. Chest tube removal: end-inspiration or end-expiration? J Trauma. 2001 April;50(4):674-677.

Pizano LR, Houghton DE, Cohn SM, et al. When should a chest radiograph be obtained after chest tube removal in mechanically ventilated patients? a prospective study. J Trauma. 2002 December;53(6):1073-1077.

Palesty JA, McKelvey AA, Dudrick SJ. The efficacy of x-rays after chest tube removal. Am J Surg. 2000 January;179(1):13-16.

Etoch SW, Bar-Natan MF, Miller FB, et al. Tube thoracostomy. Factors related to complications. Arch Surg. 1995;130:521-526.

Chan L, Reilly KM, Henderson C, et al. Complication rates of tube thoracostomy. Am J Emerg Med. 1997 July;15(4):368-370.

Aylwin CJ, Brohi K, Davies GD, et al. Pre-hospital and in-hospital thoracostomy: indications and complications. Ann R Coll Surg Engl. 2008 Jan;90(1):54-57.

Remerand F, Luce V, Badachi Y, et al. Incidence of chest tube malposition in the critically ill: a prospective computed tomography study. Anesthesiology. 2007 Jun;106(6):1112-1119.

Sanabria A, Valdivieso E, Gomez G, et al. Prophylactic antibiotics in chest trauma: a meta-analysis of high-quality studies. World J Surg. 2006 Oct;30(10):1843-1847.

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