Chest tube

Chest tube
Intervention
The free end of the Chest Drainage Device is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest.
ICD-9-CM	34.04
MeSH	D013907

Size of Chest Tube:
Adult or Teen Male = 28–32 Fr
Pp Adult or Teen Female = 28 Fr
Child = 18 Fr
Newborn = 12–14 Fr
^[1]

A chest tube (chest drain or tube thoracostomy in British medicine or intercostal drain) is a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air (pneumothorax) or fluid (pleural effusion, blood, chyle), or pus (empyema) from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter.

Indications

• Pneumothorax: accumulation of air in the pleural space
• Pleural effusion: accumulation of fluid in the pleural space
  • Chylothorax: a collection of lymphatic fluid in the pleural space
  • Empyema: a pyogenic infection of the pleural space
  • Hemothorax: accumulation of blood in the pleural space
  • Hydrothorax: accumulation of serous fluid in the pleural space

Contraindications

Contraindications to chest tube placement include refractory coagulopathy, lack of cooperation by the patient, and diaphragmatic hernia. Additional contraindications include scarring in the pleural space (adhesions)

Technique

The insertion technique is described in detail in an article of the NEJM.^[2] The free end of the tube is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest. Alternatively, the tube can be attached to a flutter valve. This allows patients with pneumothorax to remain more mobile.

British Thoracic Society recommends the tube is inserted in an area described as the "safe zone", a region bordered by: the lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi and a horizontal line superior to the nipple^{[citation needed]}. More specifically, the tube is inserted into the 5th intercostal space slightly anterior to the mid axillary line.^[3]

Chest tubes are usually inserted under local anesthesia. The skin over the area of insertion is first cleansed with antiseptic solution, such as iodine, before sterile drapes are placed around the area. The local anesthetic is injected into the skin and down to the muscle, and after the area is numb a small incision is made in the skin and a passage made through the skin and muscle into the chest. The tube is placed through this passage. If necessary, patients may be given additional analgesics for the procedure. Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied to the area. Once the drain is in place, a chest radiograph will be taken to check the location of the drain. The tube stays in for as long as there is air or fluid to be removed, or risk of air gathering.

Chest tubes can also be placed using a trocar, which is a pointed metallic bar used to guide the tube through the chest wall. This method is less popular due to an increased risk of iatrogenic lung injury. Placement using the Seldinger technique, in which a blunt guidewire is passed through a needle (over which the chest tube is then inserted) has been described.

Chest Drainage Canister

A chest drainage canister device is typically used to drain chest tube contents (air, blood, effusions). There are generally three chambers. The first chamber is a collecting chamber. The second is the "water seal" chamber which acts as a one way valve. Air bubbling through the water seal chamber is usual when the patient coughs or exhales but may indicate, if continual, a pleural or system leak that should be evaluated critically. It can also indicate a leak of air from the lung. The third chamber is the suction control chamber. The height of the water in this chamber determines the negative pressure of the system. Bubbling should be kept a gentle bubble to limit evaporating the fluid. Increased wall suction does not increase the negative pressure of the system. Newer systems are designed not to need the water seal chamber, so there is not a column of water that can spill and mix with blood, mandating the replacement of the canister. Even newer systems are smaller and more ambulatory so the patient can be sent home for drainage if indicated.

Complications

Major complications are hemorrhage, infection, and reexpansion pulmonary edema. Chest tube clogging can also be a major complication if it occurs in the setting of bleeding or the production of significant air or fluid. When chest tube clogging occurs in this setting, a patient can suffer from pericardial tamponade, tension pneumothorax, or in the setting of infection, an empyema. All of these can lead to prolonged hospitilization and even death. To minimize potential for clogging, surgeons often employ larger diameter tubes. These large diameter tubes however, contribute significantly to chest tube related pain. Even larger diameter chest tubes can clog.^[4] In most cases, the chest tube related pain goes away after the chest tube is removed, however, chronic pain related to chest tube induced scarring of the intercostal space is not uncommon.

In recent years surgeons have advocated using softer, silicone Blake drains rather than more traditional PVC conventional chest tubes to address the pain issues. Clogging and chest tube occlusion issues have been a problem, including reports of life threatening unrecognized bleeding that occurs in the chest due to an occluded or clogged drain.^[5] Thus when a chest tube is inserted for whatever reason, maintaining patency is critical to avoid complications.

Injury to the liver, spleen or diaphragm is possible if the tube is placed inferior to the pleural cavity. Injuries to the thoracic aorta and heart have also been described.

Minor complications include a subcutaneous hematoma or seroma, anxiety, shortness of breath (dyspnea), and cough (after removing large volume of fluid).

Subcutaneous emphysema indicates backpressure created by a clogged drain or insufficient negative pressure.

References

1. ^ http://apps.med.buffalo.edu/procedures/chesttube.asp?p=7
2. ^ Dev SP, Nascimiento B, Simone C, Chien V (October 2007). "Videos in clinical medicine. Chest-tube insertion". N. Engl. J. Med. 357 (15): e15. doi:10.1056/NEJMvcm071974. PMID 17928590. http://www.nejm.org/doi/abs/10.1056/NEJMvcm071974?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed. 
3. ^ http://www.up.ac.za/academic/medicine/anatomy/current/ecp/ecpst05e.html
4. ^ Shalli S, Saeed D, Fukamachi K, et al. (2009). "Chest tube selection in cardiac and thoracic surgery: a survey of chest tube-related complications and their management". J Card Surg 24 (5): 503–9. doi:10.1111/j.1540-8191.2009.00905.x. PMID 19740284. http://onlinelibrary.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0886-0440&date=2009&volume=24&issue=5&spage=503. 
5. ^ Clark G, Licker M, Bertin D, Spiliopoulos A (March 2007). "Small size new silastic drains: life-threatening hypovolemic shock after thoracic surgery associated with a non-functioning chest tube". Eur J Cardiothorac Surg 31 (3): 566–8. doi:10.1016/j.ejcts.2006.12.010. PMID 17215136. http://linkinghub.elsevier.com/retrieve/pii/S1010-7940(06)01125-0. 

External links