III. Precautions

  1. Tension Pneumothorax requires immediate Needle Decompression of Thorax
    1. Chest Tube placement is only after the Needle Decompression of Thorax has been completed
  2. Indications for operative management in Traumatic hemothorax
    1. Chest Tube output >1500-2000 cc total or
    2. Chest Tube output 150-200 cc/hour for several hours
  3. Do not choose an insertion site too low
    1. Ideal insertion site is at the 4th or 5th intercostal space (mid or anterior axillary line)
      1. Err on the side of higher instead of lower
    2. Diaphragm reaches the 7th intercostal space on expiration
    3. Peritoneal Chest Tube placement occurs in 1% of cases
    4. Emergency department doctors were below the 5th intercostal space in 64% of cases
      1. Below the 7th intercostal space 21% of cases (below the 8th in 9% of cases)
      2. Placement was more accurate in women than men
    5. British Thoracic Society recommends staying within the "triangle of safety", with apex at axilla
      1. Anterior to latissimus dorsi muscle
      2. Lateral to pectoralis major muscle
      3. Superior to horizontal nipple line (men) or xiphoid process (women)
    6. References
      1. Arora and Menchine in Herbert (2015) EM:Rap 15(2): 13
      2. Carter (2014) Emerg Med Australas 26(5): 450-4 +PMID:25212066 [PubMed]

IV. Equipment

  1. Tube size
    1. French tube size is diameter of tube in millimeters multiplied by 3 (e.g. 36 French = 12 mm diameter)
    2. Spontaneous uncomplicated Pneumothorax: 16 to 22 French (small bore)
    3. Unstable patient, Bronchopleural Fistula or Mechanical Ventilation: 24 to 28 French
    4. Complicated Pneumothorax or Hemothorax (Trauma): 28 to 32 French (large bore)
      1. Older recommendations were for 36-40 French Chest Tube in Hemothorax
      2. Recent evidence supports smaller Chest Tubes even for Hemothorax (28 French is most common)
        1. Similar complication rates (e.g. empyemea, retained Hemothorax) regardless of tube size
        2. Inaba (2012) J Trauma Acute Care Surg 72(2): 422-7 [PubMed]
  2. Chest Tube Suction Apparatus or pleur-evac
  3. Cell salvage device (autotransfusion blood bag, cell-saver) for Hemothorax blood recovery
    1. cvPtxCellSaver.png
    2. Filtered blood (and treated with citrate phosphate dextrose)
    3. Blood may be re-transfused in Massive Hemothorax for up to 6 hours after collection
    4. Replaces blood cells, platelets and Fresh Frozen Plasma (FFP)
      1. Hemoglobin is less concentrated than packed RBC (9 g/dl compared with 13 g/dl in pRBC)
    5. Spares utilization of allogenic blood and Platelet Transfusion
    6. Similar safety to allogenic transfusion
      1. Rhee (2015) J Trauma Acute Care Surg 78(4): 729-34 +PMID:25807402 [PubMed]

V. Preparation

  1. Personal Protection Equipment
  2. Betadine prep and drape
  3. Lidocaine 1% local anesthetic to skin and rib
  4. Chest Tube
    1. Clamp 1: Holds insertion end of Chest Tube
    2. Clamp 2: Clamps off the other end of tube, so chest contents does not spill from tube
  5. Optimize procedure conditions (esp. in obese patients, in whom landmarks are difficult)
    1. Adequate lighting
    2. Leave a wide prepped area free of draping to allow visualization of landmarks (chest, axilla)
    3. Use a longer incision in obese patients
    4. Procedural Sedation
    5. Patient positioning
      1. Hold Breast tissue away from surgical field via assistant or tape
      2. Consider arm abducted to 90 degrees and secured to Mayo stand
      3. Consider towel roll under the Shoulder to reposition axillary fat
    6. References
      1. Spangler and Inaba in Herbert (2016) EM:Rap 16(9): 7

VI. Technique

  1. Image
    1. LungChestTubeLandmarks.jpg
  2. Insertion Site
    1. See precautions above
    2. Insert anterior to mid-axillary line
    3. Level of 5th intercostal space, over 6th rib
      1. Men: Nipple line
      2. Women: Xiphoid process level or inframammary fold
    4. Triangle of safety
      1. Apex: Axilla
      2. Posterior boundary: Latissimus dorsi muscle (anterior edge)
      3. Anterior boundary: Pectoralis major muscle (lateral edge)
      4. Inferior boundary: Nipple line in men or xiphoid process in women (as above)
  3. Insertion length or tube
    1. Estimate distance from the 6th intercostal space to the Shoulder
    2. Note the marker position on the Chest Tube that covers that distance (deepest insertion point)
    3. Last hole on Chest Tube must be in chest or it will need to be replaced
    4. Tube distance marks are measured from the last hole position to the tip
  4. Insertion Procedure
    1. Incise horizontally 3 cm parallel and over the top of the 6th rib
    2. Bluntly dissect through subcutaneous tissue over rib with clamp
    3. Carefully puncture parietal pleura with clamp tip
      1. Firmly grasp Chest Tube several centimeters from insertion site
      2. Hand acts as a stopper
        1. Prevents clamp from being forced too deep on puncture of the pleural space
    4. Insert finger into incision and make 360 degree sweep
      1. Check for organs, adhesions and enlarge path
    5. Insert Chest Tube tip with clamp
      1. Firmly grasp tube and hold in place while withdrawing clamp
      2. Insert at least 12 cm to ensure all Chest Tube holes are in chest
        1. May need to insert 16 cm or more in very large patients
        2. Smaller patients may only allow 10 cm of insertion
    6. Clinical signs of proper tube placement
      1. Look for tube condensation indicating good placement (unclamp proximal tube end)
      2. Rotate tube - should turn freely if not kinked
  5. Procedure Completion
    1. Suture tube in place
    2. Attach Chest Tube to suction
      1. Underwater seal apparatus and suction (-20 cm H2O)
      2. Pleur-evac
    3. Chest XRay
      1. Verify position and function of tube
  6. Suction
    1. Keep Chest Tube clamped until suction applied
      1. Can place to passive water seal initially
    2. Suction can be delayed initially in most cases to allow for securing the tube
      1. Exceptions include a large Bronchopleural Fistula which requires immediate suction
    3. Hemothorax will often drain without wall suction (blood is forced out with respirations)
    4. Pneumothorax requires suction until no air leak remains
      1. Pleurovac contains no bubbles with respiration
    5. Do not apply a Heimlich Valve in cases of Trauma
      1. Use only for simple Spontaneous Pneumothorax in a patient going home
    6. References
      1. Majoewsky (2012) EM:RAPC3 2(1): 1-2

VII. Complications

  1. Typical complications (similar to any invasive procedure)
    1. Infection
      1. Empyema
      2. Chest wall Cellulitis
      3. Necrotizing Fasciitis
    2. Bleeding
    3. Scarring
  2. Chest Tube specific complications
    1. Chest Tube malposition (most common)
    2. Blocked Chest Tube drain
    3. Chest Tube dislodgement
    4. Reexpansion pulmonary edema
    5. Subcutaneous Emphysema
    6. Chylothorax
  3. Organ injury
    1. See precautions above
    2. Lung injury
    3. Nerve injury
    4. Great Vessel injury
    5. Liver injury (right)
    6. Spleen or Stomach injury (left)

VIII. Resources

  1. Chest Tube Insertion (NEJM) - Part 1
    1. http://www.youtube.com/watch?v=hQlt57AyQmg
  2. Chest Tube Insertion (NEJM) - Part 2
    1. http://www.youtube.com/watch?v=ZRoJzkY7SMA
  3. Regions Trauma Professional's Blog (Michael McGonigal, MD) - Chest Tube insertion
    1. http://www.youtube.com/watch?v=qyJkh-ghl70

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

Ontology: Chest Tubes (C0008034)

Definition (MSH) Plastic tubes used for drainage of air or fluid from the pleural space. Their surgical insertion is called tube thoracostomy.
Concepts Medical Device (T074)
MSH D015505
SnomedCT 258643002
LNC LP7139-1, MTHU001287, LA9948-6
English Tube, Chest, Chest Tube, Drains, Thoracic, Chest tube, thoracic drain, thoracic tubes, thoracic tube, chest tubes, chest tube, chest drain, chest drains, Chest Drains, Tubes, Chest, Thoracic Tubes, Chest Tube(s), Chest drain, Chest drain (physical object), Chest Tubes
Swedish Toraxdrän
Czech hrudní trubice
Finnish Pleuradreenit
Russian DRENAZHNYE PLEVRAL'NYE TRUBKI, PLEVRAL'NYE DRENAZHNYE TRUBKI, GRUDNAIA POLOST', TRUBKI DRENAZHNYE, ГРУДНАЯ ПОЛОСТЬ, ТРУБКИ ДРЕНАЖНЫЕ, ДРЕНАЖНЫЕ ПЛЕВРАЛЬНЫЕ ТРУБКИ, ПЛЕВРАЛЬНЫЕ ДРЕНАЖНЫЕ ТРУБКИ
French Drains thoraciques
Polish Dreny klatki piersiowej
Norwegian Toraksdren, Thoraxdren, Pleuradren
Spanish drenaje torácico (objeto físico), drenaje torácico, Tubos Torácicos
German Pleuradrainage, Thoraxdrainage
Italian Sonde toraciche
Dutch Drain, thorax-, Thoraxdrain
Portuguese Tubos Torácicos

Ontology: Thoracostomy (C0039990)

Definition (MSH) Surgical procedure involving the creation of an opening (stoma) into the chest cavity for drainage; used in the treatment of PLEURAL EFFUSION; PNEUMOTHORAX; HEMOTHORAX; and EMPYEMA.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D013907
SnomedCT 367408005, 12639009
CPT 1005962
English Thoracostomies, thoracostomy, Thoracostomy, NOS, Thoracostomy
Swedish Torakostomi
Czech torakostomie, Torakostomie
Dutch thoracostomie, Thoracostomie
Japanese 胸部造瘻術, キョウブゾウロウジュツ
Finnish Torakostomia
Russian TORAKOSTOMIIA, ТОРАКОСТОМИЯ
Polish Wytworzenie przetoki w klatce piersiowej, Torakostomia
Hungarian Thoracostomia
Norwegian Torakostomi
Spanish toracostomía, Toracostomía
French Thoracostomie
German Thorakostomie
Italian Toracostomia
Portuguese Toracostomia

Ontology: Insertion of pleural tube drain (C0189476)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 57291005, 177819000, 264957007
CPT 32551
English ICC - Insert intercostal cath, ICD - Insert intercostal drain, Insertn of pleural tube drain, Insertion of pleural tube drain, chest tube insertion (treatment), chest tube insertion, chest insertion tubes, chest insertion tube, insertion chest tube, insertion of chest tube, thoracostomy tube, of chest tube insertion, tube thoracostomy, insertion of chest drain, Chest tube insertion, Retired procedure (procedure) [P1-28154], Insertion of tube drain into pleural cavity, Retired procedure [P1-28154], Insertion intercostal drain, ICC - Insertion of intercostal catheter, ICD - Insertion of intercostal drain, Insertion of chest drain, Insertion of intercostal drain, Insertion of chest tube, Insertion of pleural tube drain (procedure), Tube thoracostomy
Italian Inserzione di tubo toracico
Japanese 胸腔チューブ挿入, キョウクウチューブソウニュウ, キョウコウチューブソウニュウ
Czech Zavedení hrudního drénu
Hungarian Mellkasi drain behelyezés
Spanish procedimiento retirado - RETIRADO -, procedimiento retirado - RETIRADO - (concepto no activo), inserción de tubo de drenaje pleural (procedimiento), inserción de tubo de drenaje pleural, Inserción de tubo a través de la pared costal
Portuguese Inserção de tubo torácica
Dutch borstkas tubeplaatsing
French Insertion de tubulure dans le thorax
German Anbringen einer Thoraxdrainage