Chest Tubes

Published on 10/03/2015 by admin

Filed under Critical Care Medicine

Last modified 22/04/2025

Print this page

This article have been viewed 1282 times

Chapter 16 Chest Tubes

Gwendolyn M. van der Wilden, MSc , David R. King, MD, FACS

1 What is a chest tube?

A chest tube is properly called a tube thoracostomy and is generally used to evacuate the pleural space of air, blood, serous effusion, bile, chyle, pus, or other fluid. This allows reexpansion of the lung and reapposition of the visceral and parietal pleura.

2 Define occult pneumothorax

An occult pneumothorax occurs when air is trapped within the pleural space but is only identified on a computed tomography scan after a normal chest radiograph. It can be spontaneous or caused by blunt and/or penetrating trauma. Approximately 2% to 10% of trauma patients will be seen with an occult pneumothorax. There are generally no associated clinical findings.

An occult pneumothorax requires reimaging to evaluate progression but usually does not require treatment. The need for positive-pressure ventilation (PPV) (i.e., a trip to the operating room for nonchest or nonlung injury) is not an indication for pleural space decompression of an occult pneumothorax.

3 What is a hemothorax and how to treat it?

When blood accumulates in the pleural cavity because of blunt or penetrating injuries, it is called a hemothorax. Before a hemothorax can be detected on a standard chest radiograph, 200 to 300 mL of blood must be present within the pleural space. It takes up to 1 L before systemic signs of shock and hypoperfusion will manifest.

Normally, large chest tubes (32 F-40 F) will be used to evacuate a large-volume hemothorax, and in 85% the bleeding will spontaneously cease and the lung will reexpand. Large amounts of undrained clotted blood (loculated hemothorax) will be evacuated via operative drainage (video-assisted thoracoscopic surgery). Thoracotomy is required only rarely (Box 16-1).

Box 16-1 Indications for Thoracotomy after Trauma

1. Initial chest tube output of 1500 mL of blood (massive hemothorax)

2. Persistent drainage of 200 to 300 mL/hr

4 What are the indications to place a chest tube?

See Table 16-1.

^{Table 16-1} Indications to Place a Chest Tube

In Acute Setting	Nonacute
PTX Spontaneous (when PTX is large or progressive and if the patient is clinically unstable) Iatrogenic (when PTX is large or progressive or the patient is clinically unstable) Tension PTX Caused by penetrating chest trauma Hemothorax Esophageal rupture with leak into pleural space

Drainage of pleural effusions

Parapneumonic effusion or empyema

Postoperative care (e.g., after coronary bypass, thoracotomy, or lobectomy)

PTX, Pneumothorax.

6 How do you choose between a pigtail and a chest tube?

See Table 16-2.

^{Table 16-2} Choosing Between a Pigtail and a Chest Tube

Indication	Size (F)
Pneumothorax Large but stable Large and unstable With mechanical ventilation Traumatic (blood in addition to air) Hemothorax Malignant pleural effusion Parapneumonic effusion or empyema

Pigtail (14 or smaller)

Pigtail (14 or smaller)

10-14 or 16-24 (when fluid is viscous)

7 What does the triangle of safety mean?

A chest tube is placed in the anterior axillary or midaxillary line in the fifth to sixth intercostal space. This is between the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, the apex just below the axilla, and a line above the horizontal level of the nipple: the triangle of safety. It is a safe place because of its location above the diaphragm and a very thin chest wall musculature, allowing rapid and minimally painful insertion.

8 Describe the consecutive steps of a tube thoracostomy

Prepare and drape the skin around the area of insertion.

Administer local anesthesia (1% lidocaine) if the patient is conscious.

Make a 2-cm incision over the rib, below the site chosen for insertion.

Create a subcutaneous tunnel, using blunt dissection, and spread the muscle using a Kelly clamp.

Gently enter the pleural space. Explore the space digitally to make sure you are in the pleural cavity and that no adhesions exist between the visceral and parietal pleura.

Insert the tube (clamped at the insertion end with the Kelly clamp), and place apically and anteriorly for a pneumothorax or superiorly and posteriorly for a hemothorax or pleural effusion.

After placement, secure the tube to the skin of the chest wall, and connect to an underwater seal with controlled negative pressure suction.

9 How is a pigtail placed?

A pigtail is placed by using the Seldinger technique.

Prepare and drape the skin around the area of insertion.

Administer local anesthesia (1% lidocaine) if the patient is conscious.

Make a very small incision parallel to the intercostal space, just above the rib, and insert an introducer needle into the pleural space and aspirate for air or fluid.

Insert a guidewire through the introducer needle into the pleural space, again apical for a pneumothorax or inferiorly for a fluid collection.

Dilate the tract for the chest tube by passing a dilator(s) over the guidewire. Pass the chest drain with dilator over the guidewire into the pleural space, and finally remove guidewire and dilator, leaving the chest drain in place.

Make sure to suture the chest tube into place, and connect it to the drainage system.

The entire process may be facilitated by ultrasonographic guidance at the bedside.

10 When can you remove a chest tube?

Before you remove the chest tube, there needs to be compliance with the following criteria:

1. The lung must be fully expanded again (a final chest radiograph can be helpful here).

2. During Valsalva maneuver or coughing, there must be no air leak in the water seal chamber.

3. The daily amount of fluid drainage should be less than 100 to 200 mL.

4. The fluid should be serous.

5. The patient’s clinical status has improved.

11 How long does a trial of water seal need to be before chest tube removal?

For chest tubes placed for a traumatic pneumothorax, a prospective randomized trial demonstrated that a short 6-hour trial of water seal is adequate to allow occult air leaks to become clinically or radiographically apparent. Therefore chest tubes placed for a traumatic pneumothorax may safely be removed after 6 hours on water seal.

12 Do you need to give the patient antibiotics before placing a chest tube?

Much controversy exists as to whether prophylactic antibiotics should be administered before placing a chest tube. Some trials show a reduction in infections (especially in patients with penetrating chest trauma), but most trials showed no benefit. Generally, a single dose of gram-positive coverage should be given before chest tube placement if the tube is being placed for trauma. Otherwise, no antibiotics are indicated.

13 What is a tension pneumothorax or hemothorax?

Box 16-3 Tension Pneumothorax or Hemothorax

What Happens:		All Leading to the Following:
Complete lung collapse Tracheal deviation Mediastinal shift

Decreased venous return to the heart

Respiratory distress

Clinical Signs:

Distended neck veins

14 Needle decompression or tube thoracostomy?

Needle decompression is the standard of care, first-line treatment for a tension pneumothorax by rapidly decompressing the pleural space. A large-bore needle is inserted in the second intercostal space in the midclavicular line. Subsequently, a regular chest tube will be placed.

In every other pneumothorax or hemothorax, a chest tube is generally recommended.

For spontaneous pneumothoraces, two recent studies, however, showed that needle aspiration alone in the emergency department is at least as safe and effective as a regular chest tube. It also shortened the hospital length of stay.

15 Why avoid rapid pulmonary reexpansion?

Rapid reexpansion can lead to reexpansion pulmonary edema, which has a mortality rate as high as 20%. It occurs during rapid evacuation of a chronic pleural effusion or rapid reexpansion of the lung in case of a chronic pneumothorax.

Treatment of this reexpansion pulmonary edema is supportive, because the disease is usually self-limited. Supplemental oxygen and sometimes mechanical ventilation are necessary.

Asking the patient to breathe deeply and cough to expand the lung before applying suction can prevent rapid reexpansion from occurring.

16 How do you place a chest tube in a patient who is either morbidly obese or has anorexia nervosa?

Morbidly obese: Because of enormous amounts of subcutaneous tissue, safe placement of a chest tube sometimes is not feasible. A recent case report describes the use of a minimally invasive trocar with laparoscope to visualize the intercostal musculature, parietal pleura, and lung parenchyma. The laparoscope was then withdrawn, and the tube was placed through the trocar and into the chest. Finally, the trocar was withdrawn, keeping the tube in place.

Anorexia nervosa: Because of starvation, the total lung protein content, connective tissue, hydroxyproline, and elastin levels decrease. This makes the lung much more vulnerable to iatrogenic injury at the time of chest tube insertion. A review of the literature suggests that these patients may require higher levels of suction, promoting lung expansion, or switching from suction or water seal drainage to a Heimlich valve earlier in the patient’s course.

17 Do you place chest tubes in a population with high prevalence of human immunodeficiency virus (HIV) and tuberculosis?

A high rate of complications is related to chest tube placement in patients with HIV, such as pneumonia, empyema, sepsis, and necrotizing fasciitis. A recent review of the literature suggested that conservative management of small pneumothoraces may be appropriate.

18 What is the influence of PPV on chest tube removal?

A retrospective study showed that PPV does not influence the rate of recurrent pneumothorax or chest tube placements after removal. Consequently presence of mechanical PPV is not an indication to leave a chest tube in place.

Key Points Chest Tubes

1. All patients in unstable condition with hemothorax or pneumothorax should have a tube thoracostomy.

2. Large tubes are chosen for hemothorax, and smaller tube (or pigtails) are selected for pneumothorax or serous effusions.

3. Tube thoracostomy is not required for occult pneumothoraces.

4. Chest tubes placed for a traumatic pneumothorax may safely be removed after 6 hours on water seal.

5. Presence of mechanical PPV is not an indication to leave a chest tube in place.

1 Ali H.A., Lippmann M., Mundathaje U., et al. Spontaneous hemothorax: a comprehensive review. Chest. 2008;134:1056.

2 Baumann M.H., Strange C., Heffner J.E., et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001;119:590.

3 Biffl W.L., Narayanan V., Gaudiani J.L., et al. The management of pneumothorax in patients with anorexia nervosa: a case report and review of the literature. Patient Safety in Surgery. 2010;4(1):1.

4 Dev S.P., Nascimiento B.Jr. Simone C, et al: Videos in clinical medicine. Chest-tube insertion. N Engl J Med. 2007;357:e15.

5 Ho K.K., Ong M.E., Koh M.S., et al. A randomized controlled trial comparing minichest tube and needle aspiration in outpatient management of primary spontaneous pneumothorax. Am J Emerg Med. 2011;29:1152–1157.

6 Kim Y.K., Kim H., Lee C.C., et al. New classification and clinical characteristics of reexpansion pulmonary edema after treatment of spontaneous pneumothorax. Am J Emerg Med. 2009;27:961–967.

7 Martino K., Merrit S., Boyakye K., et al. Prospective randomized trial of thoracostomy removal algorithms. J Trauma. 1999;46:369–371. discussion 372-373

8 Maxwell R.A., Campbell D.J., Fabian T.C., et al. Use of presumptive antibiotics following tube thoracostomy for traumatic hemopneumothorax in the prevention of empyema and pneumonia—a multi-center trial. J Trauma. 2004;57:742.

9 Moore F.O., Goslar P.W., Coimbra R., et al. Blunt traumatic occult pneumothorax: is observation safe? Results of a prospective. AAST multicenter study. J Trauma. 2011;70:1019–1025.

10 Schaefer G.P., Pender J., Toschlog E.A., et al. Endoscopically-assisted tube thoracostomy placement in a super-morbidly obese patient with penetrating thoracoabdominal trauma. Am Surg. 2011;77:119–120.

11 Schulman C.I., Cohn S.M., 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;59:92–95.

12 Sethuraman K.N., Duong D., Mehta S., et al. Complications of tube thoracostomy placement in the emergency department. J Emerg Med. 2011;40:14–20.

13 Tawil I., Gonda J.M., King R.D., et al. Impact of positive pressure ventilation on thoracostomy tube removal. J Trauma. 2010;68:818–821.

14 Tebb Z.D., Talley B., Macht M., et al. An argument for the conservative management of small traumatic pneumathoraces in populations with high prevalence of HIV and tuberculosis: an evidence-based review of the literature. Int J Emerg Med. 2010;3:391–397.

15 Zehtabchi S., Rios C.L. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Ann Emerg Med. 2008;51:91–100.

Related

Critical Care Secrets 5e