Chest Tube Insertion

Doctor123.org

Chest Tube Insertion

Introduction

Equipment

Indications

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.

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

catheter is more commonly employed.

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

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.

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

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.

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:

intraluminal trocar are not recommended, because they are associated

with a higher incidence of intrathoracic complications.

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

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.

Step 1 View Original Step 1 View Original

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.

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

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.

Make a 2- to 3-cm

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

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

so that the tip of the tube protrudes beyond the jaws of the

2.5 to 5 cm (1 to 2 inches) inside the chest wall. Attach the

tube to the previously assembled suction-drainage system. The

cm beyond the rib margin. Position of the chest tube with all

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

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,

in a horizontal mattress or purse-string stitch around the tube

together, and tie a surgeon 's knot to close the skin

and finish the suture with a bow knot. The bow can be later

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.

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

amount of residual air or fluid as soon as possible after the

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

is anchored, dressed, and x-rayed as described previously.

tube was originally inserted. Prep the area, untie the suture

other suture near the skin. Clamp the chest tube, and disconnect

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

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

standard lengths. Either length is appropriate for use in adults, but

Patients are rarely discharged

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.

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

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

1Baldt MM, Bankier AA, Germann PS,

Radiology. 1995;195:539 " 543. [View Abstract] 2Bell RL, Ovadia P, Abdullah F,

Trauma. 2001;50:674 " 677. [View Abstract] 3Chan L, Reilly KM, Henderson C,

et al. Complication rates of tube

thoracostomy. Am J Emerg

1997;15:368 " 370. [View Abstract] 4Collop NA, Kim S, Sahn SA.

pulmonologists at a teaching hospital.

Chest. 1997;112:709 " 713. [View Abstract] 5Dalbec DL, Krome RL.

Emerg Med Clin North

Am. 1986;4:441. 6Daly RC, Mucha P, Pairolero PC,

Med. 1985;14:865. 7Gilbert TB, McGrath BJ, Soberman M.

Med. 1993;8:73 " 86. [View Abstract] 8Graber RE, Garvin JM.

Care. 1988;9:159. 9Grover FL, Richardson JD, Fewel JG,

of penetrating chest wounds: a prospective double-blind

study. J Thorac Cardiovasc

74:528. 10Hesselink DA, Van Der

Klooster JM, Bac EH,

et al. Cardiac tamponade secondary to chest tube

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,

2001;6:87 " 89. [View Abstract] 13Mahfood S, Hix WR, Aaron BL,

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

2004;57:742. [View Abstract] 15Millikan JS, Moore EE, Steiner E,

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.

Radiol. 2001;31:444 " 446. [View Abstract] 17Parulekar W, Di

Primio G, Matzinger F,

2001;120:19 " 25. [View Abstract] 18Rashid MA, Wikstrom T, Ortenwall P.

Surg. 1998;46:375 " 376. [View Abstract] 19Schmidt U, Stalp M, Gerich T,

injuries by physicians in the field: effectiveness and

1998;44:98 " 101. [View Abstract] 20Symbas PN.

Am. 1989;69:41. 212008 MAG Mutual Healthcare

Fee and Coding Guide. Duluth,

• 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

• 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.

• 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.

• Pearl: Prep a wide area so that an undraped area is not inadvertently exposed if the drape slides a little.

• 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.

• 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.

• 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.

• 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.

• 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.

• Pearl: If the patient is on a ventilator, pause the ventilator during chest tube removal.

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

Pediatric Considerations

Postprocedure Instructions

Coding Information and Supply Sources

Bibliography