Trauma: Tube Thoracostomy (Chest Tube)

Tube Thoracostomy (Chest Tube)

Tube Selection

  • PTX: 8-14 French
  • Tension PTX: 24-28 French; After Needle Decompression
  • HTX: 24-28 French
    • *Older Teaching to Use the Largest Possible (36-40 French) Falling Out of Favor, In General Clotted Blood Will Not Drain No Matter How Big
    • Use Smaller Sizes in Peds

Chest Tube Sizes Compared to Average Intercostal Space (Mid-Axillary 5th Space) 1

Standard Technique

  • Prepare:
    • Supine, Arm Extended & Skin Prep
    • Inject Local Anesthetic All the Way Down to the Pleura
  • Incision:
    • Target 4th/5th Intercostal Space at Anterior Axillary or Mid-Axillary Line
      • For PTX May Consider 2nd Intercostal Space at the Midclavicular Line
    • Make 2-3 cm Incision Over the Inferior Rib
    • Using Curved Clamp Bluntly Dissect & Tunnel Immediately Above the Rib
      • Never Go Below the Rib (Risk Damage to Neurovascular Bundle)
    • Penetrate Pleura & Spread the Penetration Site
  • Insertion:
    • Insert Finger to Confirm Position & Bluntly Dissect Any Surrounding Adhesions
    • Insert the Chest Tube Using a Clamp & Direct into Position
      • PTX: Anterior/Superior
      • HTX: Posterior
  • Suture Anchor the Tube to the Skin
  • CXR to Confirm Placement & Lung Expansion

Other Techniques

  • Seldinger Technique
  • US-Guided
  • IR-Guided

Thoracic Irrigation

  • May Consider Irrigation with 1 L Warmed Saline Immediately Upon Placement
  • For Hemothorax Only (Not Pneumothorax)
  • Some Data Suggests Decreased Rates of Retained Hemothorax & Secondary Interventions

Chest Tube Placement 2

Triangle of Safety 3

Drainage System

  • Classic “Three Bottle” System
    • Bottle #1 (Collecting Bottle): Collects Fluid from the Patient
    • Bottle #2 (Water Seal): Allows Air to Escape but Prevents External Air Entry Back into the Chest
      • “Bubbling” Indicates an Air Leak
    • Bottle #3 (Suction Control): Adjustable Manometer Set to Specific Depths to Set a Controlled Suction Pressure
      • Most Often Set to 20 cm H2O
  • “Four Bottle” System
    • Adds an Additional Venting Bottle Connected to the Collecting Bottle
    • Fourth Bottle is Vented to the Air & Not Connected to Suction
    • Acts as an Additional Water Seal to Prevent Pneumothorax in the Event of Unexpected Suction Failure
  • Modern Collecting Systems (Atrium, Pleur-Evac)
    • Entire System is Combined in a Single Piece of Equipment
    • Collecting Chamber Acts as Bottle #1
    • Water Seal Acts as Bottle #2
    • Suction Control Can be “Wet Suction” or “Dry Suction”
      • Wet Suction: Acts as a Traditional Bottle #3 Using Fluid
      • Dry Suction: Controls Suction Using a Pressure Control Valve

Classic “Three Bottle” System 4

Modern Collecting System 5

Removal

  • Use an Occlusive Dressing to Prevent Inspiration of Air Back into the Pleural Cavity
    • Ex: Xeroform or Vaseline-Soaked Gauze
  • Remove Chest Tube on Expiration, After A Complete Full Inspiration
    • Increases Intrathoracic Pressure to Decrease the Risk of Recurrent Pneumothorax Upon Pull
    • *Exact Timing is Debated and Some Prefer Pulling with an Inspiratory Hold
  • Repeat Chest Radiograph After Chest Tube Removal (Post-Pull CXR)
    • Often Done at 4 Hours or 24 Hours
    • *No Evidence that Post-Pull CXR is Necessary – Some Prefer Repeat Imaging Based Solely on Symptoms

References

  1. Gammie JS, Banks MC, Fuhrman CR, Pham SM, Griffith BP, Keenan RJ, Luketich JD. The pigtail catheter for pleural drainage: a less invasive alternative to tube thoracostomy. JSLS. 1999 Jan-Mar;3(1):57-61. (License: CC BY-NC-ND-3.0)
  2. Mohammed HM. Chest tube care in critically ill patient: A comprehensive review. Egyptian Journal of Chest Diseases and Tuberculosis. 2015. 64(4):849-855. (License: CC BY-NC-ND-4.0)
  3. Hill J. Taming the SRU. (License: CC BY-NC-SA-3.0)
  4. Shi H, Mei L, Che G. [The current concepts of closed chest drainage in lobectomy of lung cancer]. Zhongguo Fei Ai Za Zhi. 2010 Nov;13(11):999-1003. (License: CC BY-4.0)
  5. British Columbia Institute of Technology (BCIT). Wikimedia Commons. (License: CC BY-SA-4.0)