Chest Tube

1. Indications
   1. Tension Pneumothorax
   2. Simple Pneumothorax
   3. Open Pneumothorax
   4. Massive Hemothorax
2. Equipment
   1. Spontaneous uncomplicated Pneumothorax: 14 to 22 French (small bore)
   2. Complicated Pneumothorax or Hemothorax: 34-38 French (large bore)
   3. Chest Tube Suction Apparatus or pleur-evac
3. Technique
   1. Insertion Site
      1. Level of 5th intercostal space, over 6th rib
         1. Nipple level in men, inframammary fold in women
      2. Insert anterior to mid-axillary line
   2. Preparation
      1. Betadine prep and drape
      2. Lidocaine 1% local anesthetic to skin and rib
   3. Insertion Procedure
      1. Incise Horizontally 2-3 cm over the 6th rib
      2. Bluntly dissect through subcutaneous tissue over rib
      3. Carefully puncture parietal pleura with clamp tip
      4. Insert finger into incision and make 360 degree sweep
         1. Check for organs, adhesions and enlarge path
      5. Insert chest tip with clamp
      6. Look for tube condensation indicating good placement
   4. 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
   5. Suction
      1. Keep Chest Tube clamped until suction applied
      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 (Pleurovac contains no bubbles with respiration)
      5. Do not apply a heimlich valve in cases of trauma (use only for simple Spontaneous Pneumothorax in a patient going home)
      6. References
         1. Majoewsky (2012) EM:RAPC3 2(1): 1-2
4. Precautions: Indications for operative management
   1. Chest Tube output >1500-2000 cc total or
   2. Chest Tube output 150-200 cc/hour for several hours