Chest Tube Insertion

13 Chest Tube Insertion

Amna Sheikh and Amandeep S. Dolla

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.

Keywords: chest tube, pneumothorax, hemothorax, empyema, pleural effusion

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:

Fig. 13.1 Chest tube kit. Courtesy: Cook Medical.

•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).

Table 13.1 Size of chest tubes

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.

13.6 Technique

13.6.1 Preparation

•Positioning: Place the patient in a supine or semi-recumbent position. Place the ipsilateral arm behind the patient’s head.

•Site: Chest tubes placed emergently (without image guidance) should enter the thorax through the “triangle of safety” (▶ Fig. 13.2). This safe zone is defined by the anterior border of latissimus dorsi, the lateral border of pectoralis major, and a horizontal line at the level of the nipple (in males) or the infra-mammillary crease (in females)—both of which correspond approximately to the fourth intercostal space. The apex of the triangle lies just below the axilla. In nonemergent scenarios in which ultrasound guidance is utilized, it may be desirable to enter through a lower intercostal space (e.g., as low as possible for pleural effusion).