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How to Do Tube Thoracostomy

By Noah Lechtzin, MD, MHS, Johns Hopkins University School of Medicine

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Patient Education

Tube thoracostomy is insertion of a tube into the pleural space to drain air or fluid from the chest.

Indications

  • Pneumothorax that is recurrent, persistent, traumatic, large, under tension, or bilateral

  • Pneumothorax in a patient on positive-pressure ventilation

  • Symptomatic or recurrent large pleural effusion

  • Empyema

  • Chylothorax

Contraindications

There are no absolute contraindications to tube thoracostomy.

Relative contraindications include

  • Coagulopathy or bleeding disorder (may require blood products or coagulation factors)

Complications

  • Malpositioning of the tube in the lung parenchyma, in the lobar fissure, under the diaphragm, or subcutaneously

  • Blockage of the tube due to blood clots, debris, or kinking

  • Dislodgement of the tube, requiring replacement

  • Re-expansion pulmonary edema

  • Subcutaneous emphysema

  • Infection of residual pleural fluid or recurrent effusion

  • Pulmonary or diaphragmatic laceration

  • Intercostal neuralgia due to injury of the neurovascular bundle below a rib

  • Bleeding

  • Rarely perforation of other structures in the chest or abdomen

Equipment

  • Sterile gown, mask, gloves, and drapes

  • Petroleum-based and regular gauze dressings and tape

  • Cleansing solution such as 2% chlorhexidine solution

  • 25- and 21-gauge needles

  • 10-mL and 20-mL syringes

  • Local anesthetic such as 1% lidocaine

  • 2 Hemostat or Kelly clamps

  • Nonabsorbable, strong silk or nylon suture (eg, 0 or 1-0)

  • Scalpel (size 11 blade)

  • Chest tube: Size ranges from 16 to 36 French (Fr) and depends on intended use (20 to 24 Fr for pneumothorax; 20 to 24 Fr for malignant pleural effusion; 28 to 36 Fr for complicated parapneumonic effusions, empyema, and bronchopleural fistula; 32 to 36 Fr for hemothorax)

  • Suction

  • Water seal drainage apparatus and connecting tubing

Additional considerations

  • Elective chest tube insertion is best done by a physician trained in the procedure. Other physicians can relieve a tension pneumothorax with needle thoracostomy.

  • Chest tube placement is an inpatient procedure. If done in the emergency department, the patient is then admitted to the hospital.

Positioning

  • In a spontaneously breathing patient, the head of the bed is elevated 30 to 60° to limit the elevation of the diaphragm that occurs during expiration and thus decrease the risk of inadvertent intra-abdominal tube placement.

  • The arm of the affected side can also be placed in a position over the patient’s head or otherwise abducted.

  • The hand can be placed behind the head.

Relevant anatomy

  • Neurovascular bundles are located at the lower edge of each rib. Therefore, the tube must be placed over the upper edge of the rib to avoid damage to the neurovascular bundle.

Step-by-step description of procedure and key teaching points

  • If there is time, explain the procedure and obtain consent whenever possible from the patient or next of kin.

  • Connect a water seal suction apparatus sealed with sterile water to a source of suction. Usually, a commercially available apparatus that connects to wall suction and the thoracostomy tube with plastic connectors is used.

  • The insertion site can vary based on whether air or fluid is being drained. For pneumothorax, the tube is usually inserted in the 4th intercostal space, and for other indications in the 5th intercostal space, in the mid-axillary or anterior axillary line.

  • Mark the insertion site.

  • Prepare the area at and around the insertion site using an antiseptic solution such as chlorhexidine.

  • Drape the area.

  • Inject a local anesthetic such as 1% lidocaine into the skin, subcutaneous tissue, rib periosteum (of the rib below the insertion site), and the parietal pleura. Inject a large amount of local anesthetic around the highly pain-sensitive periosteum and parietal pleura. Aspirate with the syringe before injecting lidocaine to avoid injection into a blood vessel. Proper location is confirmed by return of air or fluid in the anesthetic syringe when entering the pleural space.

  • Estimate how deep the tube needs to be inserted so that all of the tube’s holes are inside the pleural space, accounting for all subcutaneous and fat tissue, particularly in obese patients. Note or record the mark on the tube that should be then visible at the skin.

  • Make a 1.5- to 2-cm skin incision, and then bluntly dissect the intercostal soft tissue down to the pleura by advancing a clasped hemostat or Kelly clamp and opening it. Identify the rib below the insertion site and move over the rib to find the pleural space above the rib. Then perforate the pleura with the clamped instrument (usually indicated by a pop and/or sudden decrease in resistance) and open in the same way.

  • Use a finger to widen the tract and confirm entry into the pleural space and the absence of adhesions.

  • Clamp the chest tube on the outside end.

  • Insert the chest tube, with another clamp grasping the tip, through the tract and direct it inferoposteriorly for effusions, or apically for pneumothorax, until all of the tube’s holes are inside the chest wall.

  • Suture the chest tube to the skin of the chest wall using one of many suture methods. One way is to use a purse-string suture. In addition, place an interrupted suture next to the tube across the incision and tie the suture around the tube. Another method is to substitute a second interrupted suture across the incision on the other side of the tube for the purse string suture and tie that suture to the tube as well.

  • Place a sterile dressing with petroleum gauze to help seal the wound over the site.

  • Cut 2 sterile gauze pads halfway across and place them around the tube.

  • Remove the draping.

  • Tape the dressing in place using pressure dressings. Consider taping the outside part of the tube to the dressing or the patient separately.

  • Connect the tube to the water seal suction apparatus to prevent air from entering the chest through the tube and to allow drainage with or without suction.

Aftercare

  • An anteroposterior chest x-ray should be obtained at the bedside to check the tube’s position. If there are concerns about positioning or functioning of the chest tube, posteroanterior and lateral x-rays or a chest CT should be obtained ( 1).

  • The chest tube is removed when the condition for which it was placed resolves. With a pneumothorax, suction is stopped and the tube is placed on just water seal for several hours to ensure that the air leak has stopped and that the lung remains expanded. Chest x-ray is often repeated 12 to 24 h after the last evidence of an air leak before removing the tube. For pleural effusions or hemothorax, the tube is typically removed when the drainage is < 100 to 200 mL/day of serous fluid.

  • Removal of a chest tube in patients on mechanical ventilation, especially those with high oxygen requirements, positive pressure ventilation, chronic lung disease, or increased risk of recurrent pneumothorax, should be done only after consultation with the pulmonary specialist.

  • To remove the tube, the patient should be semi-erect. After removal of the sutures, at the moment of removal, the patient is asked to take a deep breath and then to forcibly exhale; the tube is removed during exhalation and the site is covered with petroleum gauze, a sequence that reduces the chance of pneumothorax during removal.

  • The purse-string suture, if inserted during tube insertion, is closed, and/or additional sutures may be needed to close the incision.

  • A chest x-ray should be repeated several hours after chest tube removal. If no pneumothorax is seen on the x-ray after chest tube removal, there is no need for further chest x-rays except as dictated by clinical changes in the patient's condition.

Warnings and common errors

  • The water seal suction apparatus must be kept 40 in (or 100 cm) below the patient to avoid retrograde flow of fluid or air back into the pleural space.

  • Some clinicians recommend draining no more than 1.5 L of pleural fluid in 24 h due to a concern about causing re-expansion pulmonary edema. However, there is little evidence that the risk of re-expansion pulmonary edema is directly proportional to the volume of fluid removed. Thus, it is reasonable to completely drain effusions at the time of chest tube insertion in properly monitored patients.

  • If the chest x-ray shows that the chest tube is not far enough into the chest and the aspiration holes in the tube are not in the chest cavity, the chest tube will need to be replaced. Simply advancing the chest tube can introduce non-sterile tubing into the chest.

  • Common insertion errors include inadequate quantities of local anesthetic and an initial incision that is too small ( 2, 3).

  • Lock the stretcher before inserting the tube, which may take significant force.

Tips and tricks

  • Conscious sedation prior to the procedure can be used in selected cases.

  • When marking the insertion point, use a skin marking pen or make an impression with a pen so that the skin cleansing prep will not remove the mark ( 4).

References

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* This is the Professional Version. *