Abstract
Chest tubes are plastic tubes inserted into the pleural cavity for drainage of fluid or air. This chapter will explain the indications, contraindications, techniques, and complications of the procedure. Both standard and Seldinger techniques for insertion are described.
13 Chest Tube Insertion
13.1 Introduction
A chest tube is a sterile silicone or polyvinyl chloride (PVC) tube inserted into the pleural cavity through the chest wall for drainage of fluid (pleural effusion, empyema, hemothorax) or air (pneumothorax). It is usually done as a bedside procedure but sometimes is performed in the operating room (OR) after thoracic surgery.
13.2 Relevant Anatomy/Physiology
The space between the lung and chest wall is called the pleural space. It is lined by a single layer of mesothelium called pleura. Parietal pleura supplied by intercostal vessels covers the chest wall and visceral pleura supplied by pulmonary vessels lines the lung. An extensive lymphatic network that drains into the thoracic duct lines both pleural surfaces.
Parietal capillaries, visceral capillaries, and interstitium generate the pleural fluid. Visceral capillaries have lower pressure than the parietal capillaries. The summation of hydrostatic and oncotic pressure gradients between the pleural and plasma facilitates the production of pleural fluid. Pleural fluid is drained by lymphatics and capillaries at an estimated rate of 20 mL/hour/hemithorax 1 in a 70 kg man.
13.3 Indications
13.3.1 Emergency Indications
Pneumothorax: Pneumothorax is defined as entry of air in the pleural space. It can be traumatic, iatrogenic, or spontaneous. Treatment involves removing air from the space, helping the lung to re-expand and to prevent re-accumulation of air. Chest tubes are indicated in pneumothorax patients if they are clinically unstable, are on mechanical ventilation, or exhibit signs of tension pneumothorax, or if the pneumothorax is large or occurs as a result of trauma.
Hemothorax: Management for hemothorax includes resuscitation and drainage to ensure lung inflation and monitoring for blood loss. Complete drainage of blood is important to prevent empyema and fibrothorax. 2
Esophageal rupture with gastric leak into pleural space. Chest tube is placed mostly postoperatively in these patients.
13.3.2 Nonemergent Indications
Pleural effusions: Accumulation of fluid in the pleural space could be either transudative or exudative based on the composition of the fluid and etiology. Para-pneumonic and large recurrent transudative pleural effusions require chest tubes for drainage.
Empyema: Drainage of empyema is required for source control.
Chylothorax.
Treatment with sclerosing agents or pleurodesis.
Postoperative care.
13.4 Contraindications
No absolute contraindications to the procedure.
Coagulopathy: If the patient is on anticoagulants or has a bleeding disorder there is a risk of bleeding with the procedure. 3 Assess the risks versus benefits before proceeding. If a chest tube needs to be placed emergently, simultaneous correction of the bleeding disorder should be carried out.
Hepatohydrothorax: Cirrhotic patients with transudative effusions should not be managed with chest tubes. 3
Pulmonary blebs.
Complete adhesion of the lung to chest wall.
13.5 Equipment
Chest tube kits usually come with all the required materials (▶ Fig. 13.1). Below is a list of materials needed:
Sterile gown and gloves
Chlorhexidine
Sterile drape
1% lidocaine
10-mL syringe and a 20-mL syringe
One small-gauge needle (size 25) and one large-gauge needle for deeper anesthetic infiltration (size 18–21)
Several dissecting instruments, such as curved Kelly clamps or hemostats
Needle driver
Scissors
0 silk sutures
Chest tube of appropriate size (see ▶ Table 13.1).
Indication | Size | Technique |
Tension pneumothorax | 14–28 | Needle decompression then Seldinger |
Pleural effusion (Transudate or malignancy) | 14–16 | Seldinger |
Empyema | 16–28 | Seldinger-Standard |
Hemothorax | 18–40 | Seldinger-Standard |
Parapneumonic | 14–24 | Seldinger |
Bronchopleural fistula | 20–28 | Seldinger-Standard |
Pleural drainage system, such as the Pleur-evac (Teleflex Medical), should also be ready for connection after the chest tube is inserted.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
