Brian Locke

Chest tubes

###indications:

  • Pneumothorax if (ventilated, tension, persistent/recurrent, secondary large + 50y/o)
  • Penetrating chest trauma
  • Severe blunt trauma causing hemopneumothorax
  • Malignant pleural effusion +/- pleurodesis
  • Chylothorax
  • Empyema and complicated effusion (pH < 7.0, glu < 40, gram stain or purulence, loculations)
  • Post surgery (thoracic, cardiac, esophageal)

Phsyiology: evacuate air/blood/fluids, monitors possible thoracic bleeding, prevent tension pneumohthorax, enhance lung reexpansion.

Positioning:

  • arm placed behind head, supine on bed with slight rotation away. 30 degree head of bed elevation is ideal.
  • safe triangle = lat dorsi, pec major, nipple
  • beware if prior thoracic surgery (?pleurodesis, ?raised diaphragm)
  • ideal: 5th intercostal space at the midaxillary line, which is often lateral to the nipple (though go up a space if abdominal space occupying process)

Surgical Chest Tube

Equipment:

  • Chest tube tray (must include kelly clamps x2, forceps x1)
  • sterile dressings, gloves, and drape. Chloroprep
  • large bore > 20 french. small bore < 20 french (1 fr = outer diameter 0.333 mm)
  • Pleurivac system
  • Scalpel w #10 blade
  • suture (1-0, 2-0 silk commonly used)
  • gauze dressing and a dressing tape
  • 20 guage (for drawing med) and 25 gauge (for injection) + local anesthetic 1% lidocaine (2% also ok)

###Procedure

  • set up collection canister (e.g. inject water in to create the seal and set up to suction to test it)
  • draw up and inject lidocaine, give any premedication
  • put a Kelly clamp in to the end of the chest tube (but don't have the clamps extending beyond the end of the tubing.
  • clean area with chlorhex.
  • set up sterile drapes
  • at 6th rib, anesthetize the skin and along the track to 5th or 4th intercostal space.
  • 2-3 cm incision over 6th rib surface
  • use a kelly clamp to dissect the sufrace of the rib until you create a track to the top of the rib superior to where you'll go in to the intercostal space. Then dissect the intracostal muscle above the rib, find the pleura, then puncture it with the clamp closed.
  • use your index finger to feel inside the chest cavity (confirm location), don't remove figure.
  • advance the kelly plus tube along your finger and in to the cavity.
  • insert ~16 cm (goal is to have up to the superior portion of lung and all fenestrations inside).
  • remove finger, clamps, and suture the skin incision closed with interrupted sutures. Apply 4x4 a folded one inferior and then a nonfolded one over the top and occlusive tape.
  • listen for breath sounds, US vs CXR to confirm no pneumo.

###Complications: 5-10% rate. Early (24-48h):

  • pulmonary laceration (esp if prior surgery/adhesions)

  • diaphragmatic injury (esp if obese, ascites, late preg)

  • Cardiac/vessel injury, mediastinal injury, esophageal injury

  • incorrect placement (location), dislodgement, kink

Seldinger Technique

Chest tube Management

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1st container: trap aka collection chamber, which separates out fluid from air leaving the chest wall. This is needed for quantification, cleanliness, and to keep the seal pressure (x) from increasing.

2nd container: seal = fluid x cm above the tube (meaning that it acts as a 1 way valve that has to overcome the pressure from x centimeters. for air to flow out).

3rd container: manometer, which sets the gauge pressure in the suction system (recall, vacuum line in hospital is 0.3 atm). Thus the height of the adjustment tube controls pressure in the manometer. Pressure in the trap/patient drain is manometer - h (from seal height). By adjusting the manometer height, the change in pressure between the device and the chest is adjusted.

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Modern systems (e.g. Atrium Ocean) have this laid out like so:

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###Suction PTX - not necessarily required to reinflate (forced expiration?) as long as intrapleural pressure occasioally is above the water lock depth (then 1 way valve will lead to less intrapleural air)