Atlas of Procedures in Neonatology, 4th Edition

Tube Replacement

36

Thoracostomy Tubes

Khodayar Rais-Bahrami

Mhairi G. MacDonald

Martin R. Eichelberger

Thoracostomy Tubes

Pulmonary air leak is an anticipated risk of mechanical ventilation. Drainage of air and/or fluid accumulation in the chest is an important and necessary skill and is often performed on an emergency basis. Thoracostomy tubes are used in neonatal intensive care units for evacuation of air or fluid from the pleural space. The procedure is often performed because of an emergency. In addition to recognizing pathologic states that necessitate chest tube insertion, intensive care specialists are frequently involved in placement, maintenance, troubleshooting, and discontinuation of chest tubes. As with any surgical procedure, complications may arise. Appropriate training and competence in the procedure may reduce the incidence of complications. This chapter reviews current indications for chest tube placement, insertion techniques, and equipment. Guidelines for chest tube maintenance and discontinuation are also discussed.

  1. Indications
  2. Evacuation of pneumothorax
  3. Tension
  4. Lung collapse with ventilation/perfusion abnormality
  5. Bronchopleural fistula
  6. Evacuation of large pleural fluid collections
  7. Significant pleural effusion
  8. Postoperative hemothorax
  9. Empyema
  10. Chylothorax
  11. Extravasated fluid from a central venous line
  12. Extrapleural drainage after surgical repair of esophageal atresia and/or tracheoesophageal fistula
  13. Contraindications
  14. Small air or fluid collection without significant hemodynamic symptoms
  15. Spontaneous pneumothorax that, in the absence of lung disease, is likely to resolve without intervention
  16. Equipment

Sterile

  1. General all-purpose tray with no. 15 surgical blade and curved hemostats
  2. Gloves
  3. Surgical drapes
  4. Transillumination device
  5. Thoracostomy tube: Techniques of insertion differ with each type. See original references for description of technique variations (1,2and 3).
  6. Polyvinyl chloride (PVC) chest tube with or without trocar, in sizes 8, 10, and 12 French (Fr)
  7. Pigtail catheter for pleural drainage (Fig. 36.1)
  8. PVC with pigtail at 90-degree angle to shaft (1)
  9. 8 to 10 Fr
  10. Total length 10 cm
  11. Insertion with or without trocar
  12. Polyurethane modified vascular catheter with pigtail in same plane as shaft (2)
  13. 8.5 Fr
  14. Total length 15 cm
  15. Insertion guide wire and dilator for insertion by Seldinger technique
  16. Cook catheter (C-PPD-500/600-MP8561; Cook, Bloomington, IN, USA) (3)
  17. 5 and 6 Fr
  18. Cutting needle tip joined to a biopsy needle shaft with a collar that prevents the catheter from sliding up the needle during insertion
  19. Evacuation device
  20. Infant thoracostomy tube set: Several commercially available units are appropriate for infants (Fig. 36.2).
  21. Evacuation rate (4)
  22. With single tube, capacity depends on level of water in chamber (cm H2O).

P.264

 

FIG. 36.1. Pigtail catheter for pleural drainage (Fuhrman pleural drainage set). (Illustration provided by Cook Critical Care, Bloomington, IN, USA).

  1. With multiple tubes, capacity also depends on applied vacuum.
  2. Negative pressure of 20 cm H2O evacuates more than 4 L of air/min in experimental setting (4).
  3. Appropriate starting point for most infants with lung disease on ventilators is 10 to 15 cm H2O
  4. Potentially inadequate in a case of bronchopleural fistula
  5. Excessive suction pressure may draw tissue into the side holes of the chest tube and could also be potentially harmful in changing intrapulmonary air flow in presence of smaller pleural leak (always start with 10 cm H2O).

Measured rates across bronchopleural fistulas in infants have indicated ranges from 30 to 600 mL/min (5). If suction pressure is too high, gas flow to alveoli may be diverted across a fistula. The pressure and flow applied to the endotracheal tube also directly influence flow across a fistula (5). Because there are many interactive factors influencing how much air might have to be evacuated, there can be no single best suction level for all patients; the most effective, least harmful level has to be determined for each situation (6).

  1. Nonabsorbable suture on small cutting needle, 4.0
  2. Cotton-tipped applicators
  3. Semipermeable transparent dressing
  4. Antibiotic ointment
  5. Petroleum gauze

Nonsterile

  1. Tincture of benzoin
  2. ½-in adhesive tape
  3. Towel roll
  4. Factors Influencing Efficiency of Air Evacuation
  5. Contiguity of air to chest tube portals; they must be patent
  6. In supine infant, air accumulates in the medial, anterior, or inferior hemithorax, making low anterior location for tip of tube ideal for evacuation (7).

P.265

 

 

FIG. 36.2. One model of an underwater drainage system, demonstrating the three necessary chambers. Systems now are compact and easy to set up and read. This system is set at 22 cm H2O, which would be necessary only for a rapid rate of air accumulation.

  1. Negative pressure on chest tube may draw tissue into side portals and occlude them.
  2. Rate of air accumulation proportional to
  3. Airway flow and pressure

Dennis et al. (8) demonstrated in experimental rabbit models that a positive end-expiratory pressure level >6 cm H2O resulted in greater air leak than peak inspiratory pressure, up to 30 cm H2O.

  1. Size of fistula or tear
  2. Infant position

If the affected side is the dependent hemithorax and therefore is splinted, there is a lower rate of air leak than if the affected side is not dependent or is elevated (9).

  1. Rate of evacuation
  2. Directly proportional to
  3. Internal radius of chest tube (r4)
  4. Pressure gradient across tube (DP)
  5. Suction pressure applied

The negative pressure applied may affect intrapleural pressure only in the immediate vicinity of the tip of the tube (4).

  1. Positive intrathoracic pressure during exhalation, spontaneous or mechanical
  2. Inversely proportional to length of tube and viscosity

Poiseuille's law regarding flow across a tube is F = DPπr4/8hl, where F = flow; DP = pressure gradient; r = radius; h = viscosity; and l = length.

  1. Precautions
  2. Anticipate which infant is at risk of developing pulmonary air leakage and keep equipment for diagnosis and emergency evacuation at hand (6,10,11).
  3. Recognize that transillumination may be misleading (12,13).
  4. True positive
  5. Follows shape of thoracic cavity (not corona of light source)
  6. Varies with respiration and position
  7. Has larger area compared with corona of light at another normal site
  8. False positive
  9. Subcutaneous edema
  10. Subcutaneous air
  11. Severe pulmonary interstitial emphysema
  12. False negative
  13. Thick chest wall
  14. Darkly pigmented skin
  15. Area over air accumulation obscured by dressing/monitor probe
  16. Weak light because of fiber-optic deterioration or voltage turned too low
  17. Room too light
  18. Abnormal color vision in observer
  19. Distinguish pleural air collections from skin folds, thymus, Mach effect, artifacts, or other nonpleural intrathoracic air collections on radiograph (Figs. 36.3,36.4,36.5 and 36.6) (7,14).
  20. Select the appropriate insertion site (Figs. 36.7 and 36.8).

Allen et al. (15) recommend inserting the thoracostomy tube in the anterosuperior portion of the chest wall, in the first to third intercostal space at the midclavicular line, to ensure anterior placement of the

P.266

 

P.267


chest tube tip. However, although an anterior insertion may be appropriate for the right-angled pigtail tube used by Allen et al., a properly placed lateral tube will have its tip anterior but, more important, will not leave a (more visible) scar on the anterior chest and completely avoids the nipple (see Fig. 36.19).

 

FIG. 36.3. Sequential radiographs. A: Anteroposterior radiograph demonstrating a cystic lucency at the left base behind the heart (arrows) that resembles the artifact caused by taking a film through the hole in the top of an incubator. Note also the coarse, irregular lucencies of interstitial emphysema (PIE) in the left lung. B: Lateral film showing the lucency to be real (arrows) and, in this case, a pneumomediastinum located most probably in the left inferior pulmonary ligament. C: PIE and air in the pulmonary ligament are often harbingers of impending pneumothorax, in this case, a tension pneumothorax. Note low position of endotracheal tube.

 

FIG. 36.4. Radiographic artifact of cystic lucency behind the heart (arrows) caused by taking film through top of incubator. The lateral film was negative, therefore excluding a cystic pulmonary lesion or air in the pulmonary ligament.

  1. Reduces complications
  2. Facilitates insertion of thoracostomy tube into appropriate position
  3. Anteromedial tip for air collections
  4. Posterior tip for fluid accumulation (Fig. 36.9A, B).
  5. While inserting the chest tube, allow some air to remain within pleural space as protective buffer between lung and chest wall (6).
  6. Use emergency pneumothorax evacuation only if patient is critically compromised. If emergency evacuation is used, remove air only until vital signs are stable.
  7. Position infant so point of entry is the most elevated area of the chest.
  8. Allows air to rise to provide protective buffer.
  9. Direct tip of the chest tube anteriorly toward the apex of the thorax.
  10. Consider the possibility that a rapid, complete evacuation may cause an abrupt increase in mean arterial blood pressure and cerebral blood velocity to undesirable, supranormal levels (16).
  11. Avoid positioning infant in lateral decubitus position for any longer than necessary with “normal” lung dependence, thereby further compromising ventilation.
  12. To prevent laceration of lung parenchyma, avoid inserting needles beyond parietal pleura for diagnostic or emergency taps. Use a straight clamp perpendicular to the needle shaft to limit depth of penetration (Fig. 36.10).
  13. Do not use purse-string suturing of the incision site, because resulting scars tend to pucker (6,17) (see Fig. 36.19).
  14. Recognize that air leaks are likely to persist after initial evacuation in the presence of continuing lung disease or positive-pressure ventilation. Air leaks resolve in 50% of patients within the first 4 days after chest tube placement, and 83% resolve after 7 days (18).
  15. Continue to watch for patency of the chest tube (Fig. 36.11).
  16. Verify the correct position of the tube.
  17. Modify positive-pressure ventilator patterns to minimize risk of further air leaks (10).
  18. Decrease inspiratory time.
  19. Decrease mean airway pressure.
  20. Position infant with the side of the pleural gas leak dependent (9).
  21. Technique (See also Procedures DVD)

Insertion of Anterior Tube for Pneumothorax

  1. Determine location of air collection.
  2. Physical examination

Auscultation of the small neonatal chest may be misleading because the breath sounds normally are bronchotubular and may be relatively well transmitted across an air-filled hemithorax. In addition, shift of the point of maximal impulse toward the other side is unusual in the presence of noncompliant lungs. Physical findings of acute abdominal distention, irritability, and cyanosis or a change in transthoracic impedance suggest an air leak but not its location (19,20). Supplementary diagnostic procedures are usually necessary.

  1. Transillumination (12)
  2. Radiograph (7,21)
  3. Support the infant with artificial ventilation as required. The majority of infants with a pneumothorax requiring a chest tube also need ventilatory support.

P.268

 

  1. Monitor vital signs. Move any electrodes from the operative site to alternative monitoring areas.
  2. Position infant with affected side elevated 60 to 75 degrees off the bed and support the back with a towel roll. Secure arm across the head, with shoulder internally rotated and extended (Fig. 36.12A).

This position is very important because it allows air to rise to the point of tube entry into the thoracic cavity, outlines the latissimus dorsi muscle, and encourages the correct anterior direction of the tube.

  1. Prepare the skin with an iodophor antiseptic over the entire lateral portion of chest to the midclavicular line. Blot excess antiseptic and allow skin to dry.
 

FIG. 36.5. A: Anteroposterior radiograph demonstrates ventral air over the hemidiaphragms and around the heart (arrowheads). The sometimes difficult question of pneumothorax versus pneumomediastinum is answered by the decubitus films. B: The left lateral decubitus radiograph (right side up) shows that the right-sided gas is a pneumothorax (arrowheads). C: The right decubitus film indicates that the adventitial air fails to come up over the lung and is located in the mediastinum (arrowheads). This important distinction is made obvious by the decubitus radiographs.

  1. Drape surgical area from third to eighth ribs and from latissimus dorsi muscle to midclavicular line (Fig. 36.12B). Using a transparent aperture drape allows continued visualization of landmarks.
  2. Locate essential landmarks (Fig. 36.12C).
  3. Nipple and fifth intercostal spaces
  4. Midaxillary line
  5. Skin incision site is at point midway between midaxillary and anterior axillary lines in the fourth or fifth intercostal space. A horizontal line from the nipple is a good landmark for identifying the fourth intercostal space. Keep well away from breast tissue (22).
  6. Remove trocar from tube.

P.269

 

 

FIG. 36.6. A: On this anteroposterior supine film, there is a line that parallels the chest wall (arrowheads), which suggests the presence of a pneumothorax. B: This left decubitus film (right side up) confirms this line to be a skin fold, negative for air. When there is a question of potential adventitial air or of the anatomic location of real adventitial air, a decubitus film with the side in question up is the most important radiographic study.

We do not recommend using a trocar during tube insertion because of the greater likelihood for lung perforation. Dissection to the pleura should be performed as described here, with puncture of the pleura by the tip of the closed forceps, not by a trocar. Should a trocar be used after dissecting to the pleura, there should be a straight clamp perpendicular to the shaft at 1 to 1.5 cm from its tip to avoid penetrating too deeply (Fig. 36.10).

  1. Estimate length for insertion intrathoracic portion of tube (skin incision site to mid-clavicle). This should be approximately 2 to 3 cm in a small preterm infant and 3 to 4 cm in a term infant. (These are approximate guidelines only.)
  2. Infiltrate skin at incision site with 0.125 to 0.25 mL of 1% lidocaine.
  3. Using a no. 15 blade, make incision through skin the same length as chest tube diameter or no more than 0.5 to 1.0 cm (Fig. 36.12C).
  4. Puncture pleura immediately above the fifth rib by applying pressure with index finger (Fig. 36.12D).
  5. Place the forefinger as shown in Fig 36.12D and not further forward on the forceps, to prevent the tip from plunging too deeply into the pleural space.
  6. A definite “give” will be felt as the forceps tip penetrates the pleura; there may also be an audible rush of air.
 

FIG. 36.7. Anterior versus posterior position of the tube for drainage of air or fluid. Because air collects anteromedially in the supine neonate, the posterior tip is less appropriate.

  1. P.270
  2. After puncturing pleura, open hemostat just wide enough to admit chest tube.
  3. Leaving hemostat in place, thread tube between opened tips to the predetermined depth (Fig. 36.12E).
  4. Alternatively, insert closed tips of mosquito hemostat into side port of tube to its end. The disadvantage of this method is that the forceps will have to be withdrawn from the opening in the chest; it is common that the intercostal muscles then render the opening undetectable (22,23).
 

FIG. 36.8. Sequential radiographs in patient with right pneumothorax. An air collection in supine neonates (A) is most effectively treated with an anteromedial chest tube (B, C). The medial extension is falsely exaggerated by the slight right posterior oblique position of the chest. Pulling this tube back might put the side holes outside the pleural space. There is a pneumomediastinum, most evident on the lateral view, not drained by the pleural tube. Note the nuchal air on all three films.

  1. Direct chest tube cephalad, toward apex of thorax (midclavicle), and advance tip to midclavicular line, ensuring that all side holes are within pleural space.
  2. Observe for humidity or bubbling in chest tube to verify intrapleural location.
  3. Connect tube to vacuum drainage system and observe fluctuations of meniscus and pattern of bubbling (Fig. 36.11). Avoid putting tension on tube.
  4. Secure chest tube to skin with suture (Fig. 36.13A).

P.271

 

 

FIG. 36.9. A: Photograph of a pigtail catheter placed posteriorly for pleural fluid drainage. B: Serosanguineous pleural fluid collection into the chest tube set.

  1. Use one suture to close end of skin incision and make airtight seal with chest tube. Tie ends of suture around tube in alternating directions, without constricting tube.

Because using a traditional purse-string suture to secure the tube leaves an unsightly scar, we do not recommend it. Unless skin incision has been made unnecessarily long, a single suture is usually sufficient.

 

FIG. 36.10. Chest wall in cross section. If there is need to use a needle or trocar to enter the pleural space, its depth of penetration should be limited by a perpendicular clamp.

  1. Apply tincture of benzoin to chest tube near chest wall and to skin several centimeters below incision. When tacky, encircle tube with a 2-in length of tape, leaving tab posterior (Fig. 36.13B).
  2. Place suture through skin and tab of tape to stabilize chest tube in straight position (Fig. 36.13B).
  3. Alternatively, secure tube with tape bridge (Fig. 36.14) or clear adhesive dressing (the latter may not be optimal; chest tubes tend to function optimally when allowed to exit from the skin at as close to a 90-degee angle as possible).
  4. Apply antibiotic ointment or petroleum gauze around skin incision. Cover with small semiporous transparent dressing.

It is important not to cover the wound with a heavy dressing, which restricts chest wall movement,

P.272


obscures tube position, and makes transillumination more difficult. If the position of tube is in doubt, secure with temporary tape bridge before covering with dressing until correct position is confirmed.

  1. Verify proper positioning of tube.
 

FIG. 36.11. Evaluation of a chest tube: Flow chart to determine how well a chest tube is evacuating pleural air leak and when tube should be removed.

  1. Anteroposterior and lateral radiographs (6,24,25 and 26)

Both views are recommended to detect anterior course of tube. See Tables 36.1 and 36.2 for radiographic clues on malpositions. Malpositioned tube tip results in an increased risk of complications and/or poor air evacuation. Chest radiograph should confirm that the side holes are within the chest cavity.

TABLE 36.1 Clues to Recognize Thoracostomy Perforation of the Lung

1. Bleeding from endotracheal tube

2. Continuous bubbling in underwater seal

3. Hemothorax

4. Blood return from chest tube

5. Increased density around tip of tube on radiograph

6. Persistent pneumothorax despite satisfactory position on frontal view

7. Tube lying neither anterior nor posterior to lung on lateral view

8. Tube positioned in fissure

  1. Pattern of bubbling (Fig. 36.11)
  2. Strip tube if meniscus stops fluctuating or as air evacuation decreases. Take extreme care not to dislodge tube by holding tube firmly with one hand close to chest wall.

Insertion of Posterior Tube for Fluid Accumulation

The technique is similar to that for an anteriorly positioned tube, with the following differences.

  1. Position infant supine, elevating the affected side by 15 to 30 degrees from the table. Secure the arm over the head (Fig. 36.15).
  2. Prepare skin over lateral portion of hemithorax from anterior to posterior axillary line.

TABLE 36.2 Clues to Thoracostomy Tube Positioned in Fissure

1. Major interlobar fissure

1. Frontal view: Upper medial hemithorax

2. Lateral view: Oblique course posterior and upward

2. Minor fissure (on right)

1. Horizontal course toward medial side of lung

P.273

 

  1. Make skin incision of 0.5 to 0.75 cm in length, just behind the anterior axillary line in the fourth to sixth intercostal space and following direction of rib.
  2. Fourth or fifth space for high posterior tube tip
  3. Sixth space for low posterior tube tip
  4. Taking care to position forceps tip immediately above a rib to avoid the intercostal vessels that run under the inferior surface, penetrate the pleura as described for anterior chest tube.
  5. Insert tube only deeply enough to place side holes within pleural space.
  6. Collect drainage material for culture, chemical analysis, and volume.
  7. Connect to underwater seal drainage system that includes a specimen trap.
  8. Strip tube regularly.
  9. Monitor and correct any imbalance caused by loss of fluid, electrolytes, protein, fats, or lymphocytes.

Removal of Thoracostomy Tube

  1. Ascertain that tube is no longer functioning or needed.
  2. Evaluate as suggested in Fig. 36.11.
  3. Leave chest tube connected to water seal without suction for 2 to 12 hours. Do not clamp tube.
  4. Transilluminate to detect reaccumulation.
  5. Obtain radiograph.
  6. Document absence of significant drainage.
  7. Assemble equipment.
  8. Antiseptic solution
  9. Sterile gloves
  10. Scissors
  11. Forceps
  12. Petroleum gauze cut and compressed to 2-cm diameter
  13. Gauze pads, 2 x 2 in
  14. 1-in tape
  15. Cleanse skin in area of chest tube with antiseptic.
  16. Release tape and suture holding tube in place. Leave wound suture intact if skin is not inflamed.
  17. Palpate pleural entry site and hold finger over it to prevent air from entering chest as tube is withdrawn until gauze is applied. After removing tube, approximate wound edges and place petroleum gauze over incision. Keep pressure on pleural wound until dressing is in place.
  18. Cover petroleum gauze with dry, sterile gauze. Limit taping to as small an area as possible so that transillumination will be possible.
  19. Remove sutures when healing is complete.
  20. Complications
  21. Misdiagnosis with inappropriate placement
  22. Burn from transillumination devices (27)

P.274

 

 

FIG. 36.12. Insertion of a soft chest tube. A: Position the infant with back support so the point of tube entry will be highest. Fix arm over the head without externally rotating it. Note the midaxillary (MA) line and the line from the nipple through the fourth intercostal space (ICS). B: Drape so head of the infant is visible. C: Same landmarks without the drape, showing the incision in the fourth ICS in the MA line with entry into the chest at the intersection of the nipple line and the MA line. D: Turning the hemostat to puncture into the pleura in the fourth ICS. E: With the index finger marking the fourth ICS puncture site, the tube may now be passed between the hemostat blades, along the tunnel into the pleural space.

  1. Trauma
  2. Lung laceration or perforation (28,29) (Fig. 36.16)
  3. Perforation and hemorrhage from a major vessel (axillary, pulmonary, intercostal, internal mammary) (15,30) (Fig. 36.17)
  4. Puncture of viscus within path of tube (Fig. 36.18)
  5. Residual scarring (17) (Fig. 36.19)
  6. Permanent damage to breast tissue (17)
  7. Chylothorax (31)
  8. Nerve damage
  9. Horner syndrome caused by pressure from tip of right-sided, posterior chest tube near second thoracic ganglion at first thoracic intervertebral space (32)
  10. Diaphragmatic paralysis or eventration from phrenic nerve injury (33,34 and 35)
  11. Misplacement of tube
  12. Tube outside pleural cavity in subcutaneous placement (Fig. 36.20)

P.275

 

  1. Side hole outside pleural space (Fig. 36.21)
  2. Tip across anterior mediastinum (Fig. 36.22)
  3. Equipment malfunction
  4. Blockage of tube by proteinaceous or hemorrhagic material
  5. Leak in evacuation system, usually at connection sites
  6. Inappropriate suction pressures (36,37) (Fig. 36.11)
  7. Excessive pressure
  8. Aggravation of leak across bronchopleural fistula
  9. Interference with gas exchange
  10. Suction of lung parenchyma against holes of tube
  11. Inadequate pressure with reaccumulation
  12. Infection
  13. Cellulitis
  14. Inoculation of pleura with skin organisms including Candida(38)
  15. Subcutaneous emphysema secondary to leak of tension pneumothorax through pleural opening

P.276

 

 

FIG. 36.13. Securing a chest tube. A: Make the incision site airtight with the tube. Do not use a purse-string suture around the incision, because it will form a puckered scar. The initial incision should be made small enough to require only a single suture. B:After painting the tube and skin with benzoin, encircle the suture around the tube or attach a bandage and suture it to the skin.

 

FIG. 36.14. Tape bridge. A: Two tape towers. B, C: Bridge under the tube and towers overlapping on top. D: Additional cross tape to keep the chest tube flat without kinking.

P.277

 

 

FIG. 36.15. Insertion of a posterior chest tube. With the infant supine, the incision is in or just below the anterior axillary line with the tube entry into the pleura more posteriorly Take care to enter pleural space over the top of a rib.

 

FIG. 36.16. Postmortem examination of infants who died with uncontrolled air leaks. A: Perforation of the right superior lobe by a chest tube inserted without a trocar, demonstrating that virtually any tube can penetrate into the lung. B: Perforation of the left upper lobe by a chest tube (arrow).

P.278

 

 

FIG. 36.17. Posterior view of thoracic organs. Traumatic hemorrhage of the left upper lobe was due to perforation by a thoracostomy tube.

 

FIG. 36.18. Postmortem examination of an infant with bilateral pneumothorax, pneumomediastinum, and pneumoperitoneum secondary to pulmonary air leaks. Attempted needle aspirations, as seen by multiple skin puncture sites of the pneumomediastinum and pneumothorax (A), resulted in needle punctures of the liver (arrows, B) with peritoneal hemorrhage.

P.279

 

 

FIG. 36.19. Scar from thoracostomy insertion, emphasizing the importance of avoiding the breast area. Massage of a healed wound with cocoa butter helps break down adhesions that lead to dimpling at the scar.

 

FIG. 36.20. The thoracostomy tube is completely outside the pleural space on this slightly oblique chest film. Note that the long feeding tube is not in an appropriate position for transpyloric feeding. Indwelling tubes may dislodge when other emergency procedures are performed.

 

FIG. 36.21. The side holes of both thoracostomy tubes are outside the pleural space on this radiograph.

 

FIG. 36.22. The tip of the thoracostomy tube has been advanced too far medially and is kinked against the mediastinum. Withdrawing the tube 1 or 2 cm would improve drainage at the medial pneumothorax. Note the endotracheal tube tip in the right mainstem bronchus.

P.280

 

 

FIG. 36.23. Emergency evacuation with a vascular cannula. Puncture the skin and enter the pleura at a 45-degree angle immediately above a rib.

  1. Aortic obstruction with posterior tube (39)
  2. Loss of contents of pleural fluid
  3. Water, electrolytes, and protein (effusion)
  4. Lymphocytes and chylomicrons (chylothorax)

Emergency Evacuation of Air Leaks

Life-threatening air accumulations require emergency evacuation. This provides temporary relief to the patient while preparing for thoracostomy tube placement. The following techniques using modified equipment are less traumatic than using straight needles or scalp vein sets. We suggest using an anterior approach for emergency evacuation because position will not interfere with the preparation of the lateral chest site for an indwelling chest tube.

Tubes used for emergency evacuation require suction pressures as high as 30 to 60 cm H2O to overcome the resistance of their small diameters (40). This requirement and their tendency to occlude make these cannulas unreliable for continuous drainage of a significant air leak.

  1. Indications

Temporary evacuation of life-threatening air accumulations while preparing for permanent tube placement

  1. Contraindications
  2. When patient's vital signs are stable enough to allow placement of permanent thoracostomy tube without prior emergency evacuation
  3. When air collection is likely to resolve spontaneously without patient compromise (nontension pneumothorax).

Use of Angiocatheter (41)

  1. Equipment
  2. Sterile gloves
  3. Antiseptic solution
  4. 18- to 20-gauge angiocatheter
  5. Intravenous extension tubing
  6. Three-way stopcock
  7. 10- and 20-mL syringes
  8. Technique
  9. Prepare skin of appropriate hemithorax with antiseptic.
  10. Connect male end of three-way stopcock to female end of intravenous extension tubing. Connect syringe to three-way stopcock.
  11. Insert angiocatheter at point that is
  12. at a 45-degree angle to skin, directed cephalad
  13. in second, fourth, or fifth intercostal space, just over top of rib, well above or below the areolar of the breast
  14. in midclavicular line (Fig. 36.23A)
  15. As angiocatheter enters pleural space, decrease angle to 15 degrees above chest wall and slide cannula in while removing stylet (Fig. 36.23A).
  16. Attach male end of intravenous extension tubing to angiocatheter, open stopcock, and evacuate air with syringe (Fig. 36.23B).

P.281

 

  1. Continue evacuation as patient's condition warrants while preparing for permanent tube placement.
  2. Cover insertion site with petroleum gauze and small dressing after procedure.

Diagnostic Tap of Pleural Fluid

Follow the procedure for the insertion of a posterior chest tube, with the following differences.

  1. Differences
  2. Use an angiocatheter, 20 gauge.
  3. Position patient without elevating side of fluid collection. It will be necessary to turn the affected side down only if quantity of fluid is small.
  4. Select insertion site in anterior or midaxillary lines below breast tissue for diffuse pleural collections. Direct catheter posteriorly after penetrating into pleural space.
  5. Keep system closed to prevent leakage of air into pleural space.

Anterior Mediastinal Drainage

Most mediastinal air collections cause only mild symptoms and are not under enough tension to require drainage. Their presence often precedes tension pneumothorax in the presence of lung disease and positive-pressure ventilation. Posterior mediastinal tube insertion, as described in the literature (42), is rarely required.

  1. Indications
  2. Significant air accumulation with physiologic compromise (43)
  3. Increased intracranial pressure (44)
  4. Poor cardiac output because of impeded venous return
  5. Critical interference with artificial ventilation
  6. Competition with lungs for thoracic volume
  7. Negative effect on pulmonary compliance
  8. Drainage of fluid
  9. Mediastinitis after esophageal perforation
  10. Postoperative
  11. Contraindications

None absolute

  1. Equipment
  2. Transillumination device with sterile transparent bag to cover tip
  3. Antiseptic for skin preparation
  4. Sterile gauze pads
  5. Sterile aperture drapes
  6. Surgical gloves
  7. 11 surgical blade
  8. Local anesthetic, as required
  9. Curved mosquito hemostat
  10. Drainage tube (see equipment for emergency evacuation of air leaks)
  11. 10-Fr soft thoracostomy tube
  12. Intravenous cannula system
  13. 14- to 16-gauge angiocatheter
  14. Intravenous extension tubing
  15. Three-way stopcock
  16. 10- to 20-mL syringe
  17. ½-in adhesive tape
  18. 4-0 nonabsorbable suture on small cutting needle with needle holder
  19. Connecting tubing and underwater suction device for indwelling tube
  20. Precautions and Complications

The problems encountered in evacuating material from the mediastinum are similar to those encountered in placement of chest tubes. In contrast to tension pneumothorax, mediastinal collections tend to accumulate more gradually. For this reason, careful preparation of the patient and use of sterile technique are possible and essential. Refer to E and G under Thoracostomy Tubes at the beginning of this chapter for precautions and complications.

  1. Technique

Drainage for longer than 12 hours normally dictates placing a 10- to 12-Fr tube by direct dissection because smaller tubes occlude readily. Select indwelling tubes only in the presence of significant lung disease or mediastinitis, where continued accumulations are anticipated. Remove the tubes as soon as possible because of the risks for infection.

Soft Mediastinal Tube Insertion

  1. Follow sterile technique throughout.
  2. Monitor infant for vital signs and oxygenation.

P.282

 

 

FIG. 36.24. Sequential radiographs. A: Tension pneumomediastinum (arrows). A mediastinal collection this massive is unusual. B:Successful drainage tube (arrow). C: The apparent slipping of the mediastinal cannula (arrow) is an artifact of patient rotation on this lateral view. There is still mediastinal air superiorly, but there was no patient compromise at this time.

  1. Determine by transillumination or radiograph the region of maximal mediastinal air accumulation (Fig. 36.24).
  2. Cover tip of transillumination light with sterile, clear plastic bag for use after skin preparation.
  3. Cleanse skin with antiseptic.
  4. Drape patient with aperture drape without obscuring infant.
  5. Infiltrate insertion site with 0.25 mL of local anesthetic.
  6. With no. 11 blade, make small stab wound through skin at subxiphoid.
  7. Using curved mosquito hemostat, dissect in the midline at 30-degree angle to chest wall in cephalad direction until entering mediastinal space. The mediastinum under tension should bulge downward.
  8. Insert soft chest tube into dissected tunnel, and direct tube cephalad and toward area of maximal transillumination.
  9. Observe tube for air rush or condensation while completing insertion. If loculations are evident, break them up with blunt dissection.

P.283

 

  1. Connect to closed drainage system at vacuum of 5 cm H2O, and increase to 10 cm H2O if necessary.

Accumulation in mediastinum is usually relatively slow; therefore, lower suction pressures are effective.

  1. Use low pressure to keep tube side holes patent while clearing air collection.
  2. Monitor efficacy by radiograph and transillumination (Fig. 36.24).
  3. Secure tube with suture, and tape as for thoracostomy tubes.
  4. If drainage stops with significant accumulation still evident on transillumination or radiograph:
  5. Verify that accumulation is in mediastinum by lateral decubitus and lateral radiographs.
  6. Verify tube position on radiographs.
  7. Rotate tube.
  8. Aspirate, but do not irrigate, tube; reattach to continuous drainage.
  9. Change position of infant to move air toward tube.

Temporary Mediastinal Drainage with Intravenous Cannula

  1. Assemble equipment and prepare patient as for insertion by mediastinal dissection.
  2. Make a small stab wound in subxiphoid notch.

Mediastinal air under tension should be located in this area, pushing the liver and heart away from needle tip.

  1. Insert cannula with stylet at 45-degree angle to chest wall in cephalad direction.
  2. As soon as cannula passes through skin, lower cannula to 30 degrees from skin.
  3. Remove stylet, and attach connecting tubing, stopcock, and syringe.
  4. Advance cannula into mediastinal space cephalad and medially but toward area of maximal transillumination. Aspirate while advancing, and monitor cardiac tracing. Stop insertion if there is resistance, blood, or arrhythmia.
  5. Secure cannula in effective position, and attach intravenous extension tubing to underwater drainage system with suction pressure of 10 cm H2O. The smaller cannula will require higher suction pressures unless the air accumulates slowly. Because air loculates within the mediastinum and the side holes occlude easily, small catheters are rarely effective for anything other than acute relief of tension. Remove cannula as soon as possible.

References

  1. Jung AL, Nelson J, Jenkins MB, et al. Clinical evaluation of a new chest tube used in neonates. Clin Pediatr.1991;30:85.
  2. Lawless S, Orr R, Killian A, et al. New pigtail catheter for pleural drainage in pediatric patients. Crit Care Med.1989;17:173.
  3. Wood B, Dubik M.A new device for pleural drainage in newborn infants. Pediatrics. 1995;96:955.
  4. Rothberg AD, Marks KH, Maisels MJ.Understanding the Pleurevac. Pediatrics. 1981;67:482.
  5. Gonzalez F, Harris T, Black P, et al. Decreased gas flow through pneumothoraces in neonates receiving high-frequency jet versus conventional ventilation. J Pediatr.1987; 110:464.
  6. MacDonald MG.Thoracostomy in the neonate: a blunt discussion. NeoReviews. 2004;5:c301.
  7. Moscowitz PS, Griscom NT.The medial pneumothorax. Radiology. 1976;120:143.
  8. Dennis J, Eigen H, Ballantine T, et al. The relationship between peak inspiratory pressure and positive end expiratory pressure on the volume of air lost through a bronchopleural fistula. J Pediatr Surg.1980;15:971.
  9. Zidulka A, Braidy TF, Rissi MC, et al. Position may stop pneumothorax progression in dogs. Am Rev Respir Dis.1982; 126:51.
  10. Primhak RA.Factors associated with pulmonary air leak in premature infants receiving mechanical ventilation. J Pediatr.1983;102:764.
  11. Ryan CA, Barrington KJ, Phillips HJ, et al. Contralateral pneumothoraces in the newborn: incidence and predisposing factors.Pediatrics.1987;79:417.
  12. Kuhns LR, Bednarek FJ, Wyman ML.Diagnosis of pneumothorax or pneumomediastinum in the neonate by transillumination.Pediatrics. 1975;56:355.
  13. Wyman ML, Kuhns LR.Accuracy of transillumination in the recognition of pneumothorax and pneumomediastinum in the neonate.Clin Pediatr. 1977;16:323.
  14. Albelda SM, Gefter WB, Kelley MA, et al. Ventilator-induced subpleural air cysts: clinical, radiographic, and pathologic significance. Am Rev Respir Dis.1983;127:360.
  15. Allen RW, Jung AL, Lester PD.Effectiveness of chest tube evacuation of pneumothorax in neonates. J Pediatr. 1981;99: 629.
  16. Batton DG, Hellmann J, Nardis EE.Effect of pneumothorax-induced systemic blood pressure alterations on the cerebral circulation in newborn dogs. Pediatrics. 1984;74:350.
  17. Cartlidge PHT, Fox PE, Rutter N.The scars of newborn intensive care. Early Hum Dev. 1990;21:1.
  18. Bhatia J, Mathew OP.Resolution of pneumothorax in neonates. Crit Care Med. 1985;13:417.
  19. Merenstein GB, Dougherty K, Lewis A.Early detection of pneumothorax by oscilloscope monitor in the newborn infant. J Pediatr.1972;80:98.
  20. Noack G, Freyschuss V.The early detection of pneumothorax with transthoracic impedance in newborn infants. Acta Paediatr Scand. 1977;66:677.
  21. Swischuk LE.Two lesser known but useful signs of neonatal pneumothorax. AJR. 1976;127:623.
  22. Genc A, Ozcan C, Erdener A, et al. Management of pneumothorax in children. J Cardiovasc Surg.1998;39:849.
  23. Mehrabani D, Kopelman AE.Chest tube insertion: a simplified technique. Pediatrics. 1989;83:784.

P.284

 

  1. Mauer JR, Friedman PJ, Wing VW.Thoracostomy tube in an interlobar fissure: radiologic recognition of a potential problem. AJR.1981;139:1155.
  2. Strife JL, Smith P, Dunbar JS, et al. Chest tube perforation of the lung in premature infants: radiographic recognition. AJR.1983;141:73.
  3. Bowen A, Zarabi M.Radiographic clues to chest tube perforation of neonatal lung. Am J Perinatol. 1985;2:43.
  4. McArtor RD, Saunders BS.Iatrogenic second-degree burn caused by a transilluminator. Pediatrics. 1979;63:422.
  5. Moessinger AC, Driscoll JM, Wigger HJ.High incidence of lung perforation by chest tube in neonatal pneumothorax. J Pediatr.1978;92:635.
  6. Banagle RC, Outerbridge EW, Aranda JV.Lung perforation: a complication of chest tube insertion in neonatal pneumothorax. J Pediatr. 1979;94:973.
  7. Jung A, Minton S, Roan Y.Pulmonary hemorrhage secondary to chest tube placement for pneumothorax in neonates. Clin Pediatr (Phila). 1980;19:624.
  8. Kumar SP, Belik J.Chylothorax—a complication of chest tube placement in a neonate. Crit Care Med. 1984;12:411.
  9. Rosegger H, Fritsch G.Horner's syndrome after treatment of tension pneumothorax with tube thoracostomy in a newborn infant. Eur J Pediatr. 1980;133:67.
  10. Odita JC, Khan AS, Dincsoy M, et al. Neonatal phrenic nerve paralysis resulting from intercostal drainage of pneumothorax. Pediatr Radiol.1992;22:379.
  11. Arya H, Williams J, Ponsford SN, et al. Neonatal diaphragmatic paralysis caused by chest drains. Arch Dis Child.1991;66:441.
  12. Nahum E, Ben-Ari J, Schonfeld T, Horev G.Acute diaphragmatic paralysis caused by chest-tube trauma to phrenic nerve. Pediatr Radiol. 2001;31:444.
  13. Yeh TF, Pildes RS, Salem MR.Treatment of persistent tension pneumothorax in a neonate by selective bronchial intubation.Anesthesiology. 1978;49:37.
  14. Grosfeld JL, Lemons JL, Ballantine TVN, et al. Emergency thoracostomy for acquired bronchopleural fistula in the premature infant with respiratory distress. J Pediatr Surg.1980; 15:416.
  15. Faix RG, Naglie RA, Barr M.Intrapleural inoculation of Candida in an infant with congenital cutaneous candidiasis. Am J Perinatol.1986;3:119.
  16. Gooding C, Kerlan R Jr, Brasch R.Partial aortic obstruction produced by a thoracostomy tube. J Pediatr. 1981;98:471.
  17. Ragosta KG, Fuhrman BP, Howland DF.Flow characteristics of thoracotomy tubes used in infants. Crit Care Med. 1990; 18:662.
  18. Arda IS, Gurakan B, Aliefendioglu D, Tuzun M.Treatment of pneumothorax in newborns: use of venous catheter versus chest tube. Pediatr Int. 2002;44:78.
  19. Purohit DM, Lorenzo RL, Smith CE, et al. Bronchial laceration in a newborn with persistent posterior pneumomediastinum. J Pediatr Surg.1985;20:82.
  20. Moore JT, Wayne ER, Hanson J.Malignant pneumomediastinum: successful tube mediastinostomy in the neonate. Am J Surg.1987;154:687.
  21. Tyler DC, Redding G, Hall D, et al. Increased intracranial pressure: an indication to decompress a tension pneumomediastinum. Crit Care Med.1984;12:467.