Chest
ReviewChest Tubes: Indications, Technique, Management and Complications
Section snippets
Historic Perspective
Hippocrates was the first to consider drainage of the pleural space when he described incision, cautery, and metal tubes to drain empyemas.1 This concept reemerged in the midnineteenth century. Hunter,2 in the 1860s, developed a hypodermic needle capable of being inserted into the pleural space for drainage purposes. Playfair3 placed a drainage tube with an underwater seal in 1872, and Hewitt4 described closed tube drainage of an empyema in 1876. Due to technical problems, the procedure was not
Characteristics of Chest Tubes
Modern chest tubes are distinctly different from their earlier counterparts. They are made of clear plastic of varying internal diameter, with distance markers, multiple drainage holes, and a radiopaque stripe, which outlines the proximal drainage hole. This addition permits better determination of appropriate tube position on a postplacement chest roentgenogram. They are pliable but not supple enough to kink or obstruct drainage. Tube diameter can vary from 20 to 40 French (5 to 11 mm internal
Indications for Chest Tubes
Indications for insertion of a chest tube are listed below, but those of most import to the pulmonologist include spontaneous pneumothorax, iatrogenic pneumothorax, and drainage of malignant effusions with pleurodesis.
Indications for tube thoracostomy include the following:
- (1)
Spontaneous pneumothorax (large, symptomatic or presence of underlying lung disease)
- (2)
Tension pneumothorax (or suspected)
- (3)
Iatrogenic pneumothorax (progressive)
- (4)
Penetrating chest injuries
- (5)
Hemopneumothorax in acute trauma
- (6)
Patient in
Selected Pulmonary Indications for Chest Tube Insertion
When pneumothorax is encountered, size, symptoms, and presence of underlying lung disease guide therapeutic intervention. Those patients with minimal, transient symptoms, and a pneumothorax less than 20 to 25 percent without evidence of an increase in the pneumothorax over several hours can be observed. Those with moderate to severe pain, respiratory distress, or evidence of continued air leak should have tube thoracostomy performed. Obviously, any acute pneumothorax under tension should be
Technique of Chest Tube Placement
Traditional teaching suggests that the site of insertion depends upon the substance being removed from the pleural space.15 The relatively wide, avascular second intercostal space in the midclavicular line generally is the recommended insertion site for treatment of a pneumothorax, as air rises to the apical region of the pleural space.16 If cosmetic results are of prime concern, the third to fifth intercostal space in the midaxillary line, just below the pectoralis major muscle in the axilla,
Drainage Systems
Once secured, tubing and connectors should be selected to attach the chest tube to a drainage device. In a survey of 328 thoracic surgeons, Munnell and Thomas18 found that clear, plastic, serrated connectors of at least Va inch internal diameter were preferred and that glass or opaque connectors were avoided. Glass connectors are subject to breakage and opaque connectors hide possible obstruction. The larger the connector, the less likely that blood, fluid, or tissue will obstruct this smallest
Chest Tube Trouble Shooting
When the functional status of a tube is questioned, several simple maneuvers can be employed to assess its integrity. Observation of synchronous water seal and respiratory motion suggest the tube is still functioning in the pleural space and all connections are tight. If the tube is not functioning and occlusion of the drainage holes is suspected, the tube can be disconnected and flushed with saline solution, in an effort to dislodge obstructing debris. In the past, instillation of
Chest Tube Removal
When the indication for tube thoracostomy is no longer present or the tube is nonfunctional, it should be removed. Authors differ on the methods to remove chest tubes.15, 26, 27 Opinion is divided as to the necessity of clamping prior to tube removal, with 75 percent of thoracic surgeons surveyed favoring clamping for 12 to 24 hours prior to removal.18 Clamping allows for identification of persistent air leak or re-accumulation of fluid. We suggest that in preparation for removal, the bandage
Complications
Few studies of thoracostomy tube complications exist; most reports are anecdotal. Milliken et al28 retrospectively analyzed complications in patients receiving tube thoracostomy in the setting of acute trauma over an 11-year-period. Technical complications were analyzed in a subgroup of 447 patients whose tubes were placed by blunt dissection after trocar insertion was no longer performed. Four of 447 (1 percent) patients suffered a technical complication including diaphragm lacerations (two),
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