Introduction
Chest tube insertion is a common
therapeutic procedure used to provide evacuation of abnormal collections
of air or fluid from the pleural space. Chest tube insertion is often
required in a setting of trauma and can be a medical emergency. Chest
trauma is a common cause of emergency department visits and may result
in pneumothorax, hemothorax, or secondary infection. Patients with chest
trauma should be assessed for signs of respiratory insufficiency, such
as restlessness, agitation, altered or absent breath sounds, or
respiratory distress. In severe cases, patients may exhibit cyanosis,
deviated trachea, and paradoxical chest wall segment motion or shock.
Coagulation studies and a chest radiograph should be available. In
addition, tube thoracostomy may be indicated for pleural effusions
associated with malignancy or infection. In these situations, drainage
is imperative to allow for lung re-expansion.
Sedation may be used if the patient is
not in severe respiratory distress because of the procedural discomfort.
Placement requires universal precautions for body fluids, and use good
sterile technique, including a face mask and sterile gown whenever
possible. Selection of the proper chest tube size is important. An 18-
to 24-Fr chest tube typically is used for a pure pneumothorax. For a
hemothorax, empyema, or other fluid accumulation, a 28- to 40-Fr
catheter is more commonly employed.
View OriginalView Original
The classic technique for chest tube
insertion has remained the same for many years. Some practitioners opt
to perform a percutaneous tube thoracostomy with the Seldinger approach.
The patient positioning and preparation is the same as the conventional
method. An introducer needle is used to place a guidewire into the
pleural space. Then serial dilators are passed over the guidewire to
create an adequately dilated tract. The chest tube is then passed. A
disadvantage to this technique is that the chest cavity cannot be
digitally explored for adhesions; however, with careful consideration of
the location of the guidewire, this can be performed after the last
dilation. Some advantages to this technique are that an improved
hemostatic barrier exists, which may be especially advantageous to
pneumothoraces and patients prone to bleeding complications. This
technique can take longer than traditional techniques and may not be
optimal in emergency situations. There are references in literature
indicating that when used for empyema, the percutaneous drains are more
likely to become obstructed and stop draining. Thus far, this is only
observational data, and no large-scale studies are available.
Re-expansion pulmonary edema is a
potentially life-threatening complication of chest tube placement. It
usually occurs after rapid re-expansion in patients with a pneumothorax
but may follow evacuation of large pleural effusions. It is related to
the rapidity of lung re-expansion and to the severity and duration of
lung collapse. Patients typically present soon after lung re-expansion
and may range from simple radiographic changes to complete
cardiopulmonary collapse. Treatment is supportive, mainly consisting of
supplemental oxygen and, if necessary, mechanical ventilation. It is
usually self-limited and may be prevented by limiting initial drainage
to 1 to 1.5 L in the first 24 hours.
The chest tube may be removed if the lung
remains fully expanded on a chest radiograph performed on a water seal
or after the tube is clamped for 4 to 6 hours. Traditionally, experts
recommended that a chest tube be removed when the patient reached full
inspiration, often with a concomitant Valsalva maneuver. The theory is
that this is the point when intrathoracic pressure and lung volume are
maximal. The involuntary reflex while the tube is removed is a quick
inspiratory effort because of the pleural pain. In theory, this could
allow air to reaccumulate just as the tube is being removed,
necessitating reinsertion of another tube. However, research indicates
that discontinuation of chest tubes at the end of inspiration or at the
end of expiration has a similar rate of pneumothorax after removal and
that both methods are equally safe. With all other things being equal,
the end-inspiration timing remains the preferred technique.
Equipment
Kits, thoracostomy trays, and
suction-drainage system are available from Arrow Medical Products Ltd.,
2400 Bernville Road, Reading, PA 19605. Phone: 1-800-233-3187. Web site: http://www.arrowintl.com/products/critical_care/.
Many kits and supplies from various
companies (including Baxter and American Hospital Supply) can be
obtained from Cardinal Health, Inc., 7000 Cardinal Place, Dublin, OH
43017 (phone: 1-800-234-8701); Allegiance Healthcare Corp., McGraw Park,
IL 60085 (phone: 847-689-8410; Web site: www.cardinal.com/allegiance), and Owens and Minor, 4800
Cox Road, Glen Allen, VA 23060-6292 (phone: 804-747-9794; fax:
804-270-7281).
Chest tubes that are equipped with an
intraluminal trocar are not recommended, because they are associated
with a higher incidence of intrathoracic complications.
Indications
- Pneumothorax (especially
if it is large or progressive or if the patient is
symptomatic) - Tension pneumothorax
- Penetrating chest
trauma - Hemothorax
- Chylothorax
- Empyema
- Drainage of recurrent
pleural effusion - Prevention of hydrothorax
after cardiothoracic surgery - Bronchopleural fistula
Contraindications (Relative)
- Anticoagulation or a
bleeding dyscrasia - Systemic
anticoagulation - Small, stable pneumothorax
(may spontaneously resolve) - Empyema caused by
acid-fast organisms - Loculated fluid
accumulation
The Procedure
Classic Technique
Step 1
Identify the
insertion site, which is usually at the fourth or fifth
intercostal space in the anterior axillary or midaxillary line
(just lateral to the nipple in males) immediately behind the
lateral edge of the pectoralis major muscle. Direct the tube as
high and anteriorly as possible for a pneumothorax. For a
hemothorax, the tube is usually inserted at the level of the
nipple and directed posteriorly and laterally. Elevate the head
of the bed 30 to 60 degrees, and place (and restrain) the arm on
the affected side over the patient 's head.
- PITFALL: Do not direct the tube toward
the mediastinum because contralateral pneumothorax may
result. - PITFALL: The diaphragm, liver, or
spleen can be lacerated if the patient is not properly
positioned or the tube is inserted too low.
Step 1 View Original Step 1 View Original
Step 2
Assemble the
suction-drain system according to manufacturer 's
recommendations. Connect the suction system to a wall suction
outlet. Adjust the suction as needed until a small, steady
stream of bubbles is produced in the water column.
- Pearl: If a suction-drain system is
not immediately available, place a Penrose drain at the
end of the chest tube to act as a one-way valve until an
appropriate system is available.
Step 2 View Original Step 2 View Original
Step 3
Prep the skin with
povidone-iodine or chlorhexidine solution and allow
it to dry (see Appendix E). Drape the site with a fenestrated
sheet. Using the 10-mL syringe and 25-gauge needle, raise a skin
wheal at the incision area (in the interspace one rib below the
interspace chosen for pleural insertion) with a 1%
solution of lidocaine with epinephrine.
- Pearl: Prep a wide area so that an
undraped area is not inadvertently exposed if the drape
slides a little.
Step 3 View Original Step 3 View Original
Step 4
Liberally infiltrate
the subcutaneous tissue and intercostal muscles, including the
tissue above the middle aspect of the inferior rib to the
interspace where pleural entry will occur and down to the
parietal pleura. Using the anesthetic needle and syringe,
aspirate the pleural cavity, and check for the presence of fluid
or air. If none is obtained, change the insertion site.
- PITFALL: Use <7 mL/kg of lidocaine with epinephrine to avoid toxicity.
- PITFALL: Be careful to keep away from
the inferior border of rib to avoid the intercostal
vessels.
Step 4 View Original Step 4 View Original
Step 5
Make a 2- to 3-cm
transverse incision through the skin and the subcutaneous
tissues overlying the interspace. Extend the incision by blunt
dissection with a Kelly clamp through the fascia toward the
superior aspect of the rib above. After the superior border of
the rib is reached, close and turn the Kelly clamp, and push it
through the parietal pleura with steady, firm, and even
pressure. Open the clamp widely, close it, and then withdraw
it.
- PITFALL: Be careful to prevent the tip
of the clamp from penetrating the lung, especially if no
chest radiograph was obtained or if the x-ray film does
not clearly show that the lung is retracted from the
chest wall. - PITFALL: Avoid being contaminated by
the air or fluid that may rush out when the pleura is
opened.
Step 5 View Original Step 5 View Original
Step 6
Insert an index
finger to verify that the pleural space, not the potential space
between the pleura and chest wall, has been entered. Check for
unanticipated findings, such as pleural adhesions, masses, or
the diaphragm.
Step 6 View Original Step 6 View Original
Step 7
Grasp the chest tube
so that the tip of the tube protrudes beyond the jaws of the
clamp, and advance it through the hole into the pleural space
using your finger as a guide. Direct the tip of the tube
posteriorly for fluid drainage or anteriorly and superiorly for
pneumothorax evacuation. Advance it until the last side hole is
2.5 to 5 cm (1 to 2 inches) inside the chest wall. Attach the
tube to the previously assembled suction-drainage system. The
chest tube should be inserted with the proximal hole at least 2
cm beyond the rib margin. Position of the chest tube with all
drainage holes in the pleural space should be assessed by
palpation. Confirm the correct location of the chest tube by the
visualization of condensation within the tube with respiration
or by drained pleural fluid seen within the tube. Ask the
patient to cough, and observe whether bubbles form at the
water-seal level. If the tube has not been properly inserted in
the pleural space, no fluid will drain, and the level in the
water column will not vary with respiration.
- Pearl: If a significant hemothorax is
present, consider collecting the blood in a heparinized
autotransfusion device so that it can be returned to the
patient.
Step 7 View Original Step 7 View Original
Step 8
Suture the tube in
place with 1-0 or 2-0 silk or other nonabsorbent sutures. The
two sutures are tied so as to pull the soft tissues snugly
around the tube and provide an airtight seal. Tie the first
suture across the incision, and then wind both suture ends
around the tube, starting at the bottom and working toward the
top. Tie the ends of the suture very tightly around the tube,
and cut the ends.
Step 8 View Original Step 8 View Original
Step 9
Place a second suture
in a horizontal mattress or purse-string stitch around the tube
at the skin incision site. Pull the ends of this suture
together, and tie a surgeon 's knot to close the skin
around the tube. Wind the loose ends tightly around the tube,
and finish the suture with a bow knot. The bow can be later
undone and used to close the skin when the tube is removed.
Alternatively some choose to only use the purse-string stitch to
secure the chest tube. This usually involves wrapping the suture
around the tube several more times than in the other method to
ensure the tube does not slip from location.
Step 9 View Original Step 9 View Original
Step 10
Place petroleum gauze
around the tube where it meets the skin. Make a straight cut
into the center of two additional 4 4-inch sterile
gauze pads, and place them around the tube from opposite
directions. Tape the gauze and tube in place, and tape together
the tubing connections. Obtain posteroanterior and lateral chest
radiographs to check the position of the chest tube and the
amount of residual air or fluid as soon as possible after the
tube is inserted.
- Pearl: Silastic chest tubes contain a
radiopaque strip with a gap that serves to mark the most
proximal drainage hole. - PITFALL: A bedside, portable x-ray
device is preferable to sending the patient to another
location, because the suction usually must be removed
and the tube may become displaced. - PITFALL: If the patient is sent to
another location for radiographs, do not clamp the chest
tube, because any continuing air leakage can collapse
the lung or produce a tension pneumothorax. Keep a
water-seal bottle 1 to 2 feet lower than the
patient 's chest during transport. If a
significant air leak develops, perform chest films.
Step 10 View Original Step 10 View Original
Step 11
Use serial chest
auscultation, chest radiographs, volume of blood loss, and
amount of air leakage to assess the functioning of chest tubes.
If a chest tube becomes blocked, it usually may be replaced
through the same incision. Chest tubes are generally removed
when there has been air or fluid drainage of <100 mL/24
hours for more than 24 hours.
- PITFALL: Trying to open a blocked
chest tube by irrigating or passing a smaller catheter
through it seldom works well and increases the risk of
infection. - Pearl: Consider keeping the chest tube
in place if the patient is on a ventilator in case a new
pneumothorax suddenly develops.
Step 11 View Original Step 11 View Original
Percutaneous Method with the Seldinger Approach
Step 1
Patient positioning
and preparation remain the same as the conventional method. An
introducer needle is inserted over a rib in a similar manner to
needle thoracentesis.
Step 1 View Original Step 1 View Original
Step 2
The obturator is
removed, and a guidewire is placed through the needle into the
pleural space.
Step 2 View Original Step 2 View Original
Step 3
Serial dilators are
passed over the guidewire to create an adequately dilated
tract.
Step 3 View Original Step 3 View Original
Step 4
The chest tube with
its dilators inside is then passed, and the dilators and
guidewire are removed, leaving the chest tube in place. The tube
is anchored, dressed, and x-rayed as described previously.
Step 4 View Original Step 4 View Original
Removal
Step 1
For chest tube
removal, place the patient in the same position in which the
tube was originally inserted. Prep the area, untie the suture
with the bow knot, loosen the purse-string stitch, and cut the
other suture near the skin. Clamp the chest tube, and disconnect
the suction system. Ask the patient to take a deep breath and
perform a Valsalva maneuver. Place a gauze over the insertion
site, and remove the tube with a swift motion. Tie the
purse-string suture. Apply petroleum gauze or antibiotic
ointment on gauze, and tape securely. Obtain a chest radiograph
immediately and at 12 to 24 hours to rule out a recurrent
pneumothorax.
- Pearl: If the patient is on a
ventilator, pause the ventilator during chest tube
removal.
Step 1 View Original Step 1 View Original
Complications
- Injury to the heart, great
vessels, or lung - Diaphragmatic
perforation - Subdiaphragmatic placement
of the tube - Open or tension
pneumothorax - Subcutaneous emphysema
- Unexplained or persistent
air leakage - Hemorrhage (especially
from intercostal artery injury) - Recurrent pneumothorax
- Empyema
- Lung parenchyma
perforation - Subcutaneous placement
- Cardiogenic shock (from
chest tube compression of the right ventricle) - Infection
There continues to be controversy
concerning the need for prophylactic antibiotics in patients requiring a
chest tube. Most trials show no benefit, although some have shown a
reduction in infection in patients with penetrating chest trauma.
Pediatric Considerations
Chest tubes usually come in two
standard lengths. Either length is appropriate for use in adults, but
the shorter length should be used in pediatric patients.
Postprocedure Instructions
Patients are rarely discharged
immediately after chest tube removal. Have the patient report any
shortness of breath or other symptoms of disease recurrence immediately.
The bandage should be left in place for at least 24 hours, and petroleum
gauze should be kept on the wound for 2 to 3 days. The sutures should be
removed in about 1 week.
Coding Information and Supply Sources
View Large CPT CODE DESCRIPTION 2008 AVERAGE50 TH PERCENTILE FEE GLOBAL PERIOD 32551 Tube thoracostomy with or without water seal (e.g., abscess,
hemothorax, empyema) $740 0 32422 Thoracentesis, with insertion of tube, includes water seal
(e.g., for pneumothorax) when performed (separate
procedure) $508 0 76942-26 Ultrasound guidance for needle placement $496 XXX 77002-26 Fluoroscopic guidance for needle placement $396 XXX 77012-26 CT guidance for needle placement $277 XXX XXX = Global concept does not
apply.CPT is a registered trademark of the American
Medical Association.2008 average 50th Percentile Fees are provided courtesy of2008
MMH-SI 's copyrighted Physicians ' Fees and
Coding Guide.
Bibliography
1Baldt MM, Bankier AA, Germann PS,
et al. Complications after emergency tube
thoracostomy: assessment with CT.
Radiology. 1995;195:539 " 543. [View Abstract] 2Bell RL, Ovadia P, Abdullah F,
et al. Chest tube removal: end-inspiration or
end-expiration?J
Trauma. 2001;50:674 " 677. [View Abstract] 3Chan L, Reilly KM, Henderson C,
et al. Complication rates of tube
thoracostomy. Am J Emerg
Med.
1997;15:368 " 370. [View Abstract] 4Collop NA, Kim S, Sahn SA.
Analysis of tube thoracostomy performed by
pulmonologists at a teaching hospital.
Chest. 1997;112:709 " 713. [View Abstract] 5Dalbec DL, Krome RL.
Thoracostomy.
Emerg Med Clin North
Am. 1986;4:441. 6Daly RC, Mucha P, Pairolero PC,
et al. The risk of percutaneous chest tube
thoracostomy for blunt thoracic trauma.
Ann Emerg
Med. 1985;14:865. 7Gilbert TB, McGrath BJ, Soberman M.
Chest tubes: indications, placement,
management, and complications.
J Intensive Care
Med. 1993;8:73 " 86. [View Abstract] 8Graber RE, Garvin JM.
Chest tube insertion.
Patient
Care. 1988;9:159. 9Grover FL, Richardson JD, Fewel JG,
et al. Prophylactic antibiotics in the treatment
of penetrating chest wounds: a prospective double-blind
study. J Thorac Cardiovasc
Surg. 1977;
74:528. 10Hesselink DA, Van Der
Klooster JM, Bac EH,
et al. Cardiac tamponade secondary to chest tube
placement. Eur J Emerg
Med. 2001;8:237 " 239. [View Abstract] 11Horsley A, Jones L, White J,
et al. Efficacy and complications of small-bore,
wire-guided chest drains.
Chest. 2006;130:1857 " 1863. [View Abstract] 12Jones PM, Hewer RD, Wolfenden HD,
et al. Subcutaneous emphysema associated with
chest tube drainage.
Respirology.
2001;6:87 " 89. [View Abstract] 13Mahfood S, Hix WR, Aaron BL,
et al. Reexpansion pulmonary
edema. Ann Thorac
Surg. 1988;45:340. [View Abstract] 14Maxwell RA, Campbell DJ, Fabian TC,
et al. Use of presumptive antibiotics following
tube thoracostomy for traumatic hemopneumothorax in the
prevention of empyema and pneumonia " a multi-center
trial. J
Trauma.
2004;57:742. [View Abstract] 15Millikan JS, Moore EE, Steiner E,
et al. Complications of tube thoracostomy for
acute trauma. Am J
Surg.
1980;140:738. [View Abstract] 16Nahum E, Ben-Ari J, Schonfeld T,
et al. Acute diaphragmatic paralysis caused by
chest-tube trauma to phrenic nerve.
Pediatr
Radiol. 2001;31:444 " 446. [View Abstract] 17Parulekar W, Di
Primio G, Matzinger F,
et al. Use of small-bore vs large-bore chest
tubes for treatment of malignant pleural
effusions.
Chest.
2001;120:19 " 25. [View Abstract] 18Rashid MA, Wikstrom T, Ortenwall P.
Mediastinal perforation and contralateral
hemothorax by a chest tube.
Thorac Cardiovasc
Surg. 1998;46:375 " 376. [View Abstract] 19Schmidt U, Stalp M, Gerich T,
et al. Chest tube decompression of blunt chest
injuries by physicians in the field: effectiveness and
complications. J
Trauma.
1998;44:98 " 101. [View Abstract] 20Symbas PN.
Chest drainage tubes.
Surg Clin North
Am. 1989;69:41. 212008 MAG Mutual Healthcare
Solutions,
Inc. 'sPhysicians '
Fee and Coding Guide. Duluth,
Georgia. MAG Mutual
Healthcare Solutions,
Inc.2007.