Atlas of Primary Care Procedures, 1st Edition

General Procedures

4

Chest Tube Insertion

Chest tube placement is a common 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 urgency. 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 more severe cases, patients may also exhibit symptoms of cyanosis, deviated trachea, and paradoxical chest wall segment motion or shock. Coagulation studies and a chest radiograph should be available.

Sedation may be used if the patient is not in severe respiratory distress, because the procedure is painful. Follow 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 is important. An 18- to 24-Fr chest tube typically is used for a pure pneumothorax. For a hemothorax, empyema, or other fluid accumulation, a 32- to 40-Fr catheter is more commonly employed.

Injury to the heart, great vessels, or lung may occur during chest tube insertion. Other possible complications include subdiaphragmatic placement of the tube, open or tension pneumothorax, subcutaneous emphysema, unexplained or persistent air leakage, or localized hemorrhage. Some physicians believe that primary care physicians should have surgical backup available, especially in trauma situations, in case one of the major complications occurs. As with all procedures that penetrate the skin, infection is a possibility. There continues to be controversy concerning the need for prophylactic antibiotics in patients requiring a chest tube. Some data suggest that, for a traumatic hemothorax or pneumothorax, there is a reduction in the incidence of empyema when at least one dose of antibiotics is administered.

Traditionally, experts recommended that a chest tube be pulled out 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 being pulled is a quick inspiratory effort because of the pleural pain. In theory, this could suck in air just as the tube is being removed, necessitating reinsertion of another tube. However, research indicates that discontinuation of chest tubes at the end of inspiration or

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at the 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.

INDICATIONS

  • Pneumothorax
  • Hemothorax
  • Chylothorax
  • Empyema
  • Drainage of recurrent pleural effusion
  • Prevention of hydrothorax after cardiothoracic surgery

CONTRAINDICATIONS

  • Bleeding dyscrasia
  • Systemic anticoagulation
  • Small, stable pneumothorax (may spontaneously resolve)
  • Empyema caused by acid-fast organisms
  • Loculated fluid accumulation

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PROCEDURE

Identify the insertion site, which is usually at the fifth intercostal space in the anterior axillary 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 hemothorax, the tube is usually inserted at the level of the 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.

 

(1) Identify the insertion site, which is usually at the fifth intercostal space in the anterior axillary line (just lateral to the nipple in males) and immediately behind the lateral edge of the pectoralis major muscle.

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.

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Assemble the 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. 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.

 

(2) Connect the suction system to a wall suction outlet, and adjust the suction as needed until a small, steady stream of bubbles is produced in the water column.

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Prep the area around the insertion site with povidone-iodine solution, and drape 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 interspace chosen for pleural insertion) with a 1% solution of lidocaine with epinephrine. Liberally infiltrate 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.

 

(3) Using a 10-mL syringe and 25-gauge needle, raise a skin wheal at the incision area with 1% lidocaine with epinephrine, and liberally infiltrate the subcutaneous tissue and intercostal muscles.

PITFALL: Use less than 0.7 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.

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Make a 2- to 3-cm transverse incision through the skin and the subcutaneous tissues overlying the interspace (Figure 4A). Extend the incision by blunt dissection with a Kelly clamp through the fascia toward the superior aspect of the rib above (Figure 4B). 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 (Figure 4C). Open the clamp widely, close it, and then withdraw it.

 

(4) Make a 2- to 3-cm transverse incision through the skin and the subcutaneous tissues overlying the interspace, and extend the incision by blunt dissection with a Kelly clamp through the fascia toward the superior aspect of the rib above.

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.

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Insert an index 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 the diaphragm.

 

(5) Insert an index finger to verify that the pleural space has been entered, and check for adhesions, masses, or the diaphragm.

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Grasp the chest tube so that the tip of the tube protrudes beyond the jaws of the clamp, and advance it through the hole into the pleural space using your finger as a guide. Direct the tip of the tube posteriorly for fluid drainage or anteriorly and superiorly for pneumothorax evacuation. Advance it until the last side hole is 2.5 to 5 cm (1 to 2 inch) inside the chest wall. Attach the tube to the previously assembled suction-drainage system. Ask the patient to cough, and observe whether bubbles form at the water-seal level. If the tube has not been properly inserted in the pleural space, no fluid will drain, and the level in the water column will not vary with respiration.

 

(6) Advance the chest tube through the hole into the pleural space using your finger as a guide until the last side hole is 2.5 to 5 cm inside the chest wall.

PITFALL: If a significant hemothorax is present, consider collecting the blood in a heparinized autotransfusion device so that it can be returned to the patient.

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Suture the tube in place with 1-0 or 2-0 silk or other nonabsorbable 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, and cut the ends.

 

(7) Suture the tube in place with 1-0 or 2-0 silk or other nonabsorbable sutures.

Place a second suture in a horizontal mattress or purse-string stitch around the tube at the skin incision site. Pull the ends of this suture together, and tie a surgeon's knot to close the skin around the tube. Wind the loose ends tightly around the tube, and finish the suture with a bow knot. The bow can be later undone and used to close the skin when the tube is removed.

 

(8) Place a second suture in a horizontal mattress or purse-string stitch around the tube at the skin incision site.

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Place petroleum gauze 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 radiographs to check the position of the chest tube and the amount of residual air or fluid as soon as possible after the tube is inserted.

 

(9) Place petroleum gauze around the tube where it meets the skin, and tape the gauze and tube in place along with the tubing connections.

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.

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Use serial chest 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 through the same incision. Chest tubes are generally removed when there has been air or fluid drainage of less than 100 mL/24 hours for more than 24 hours.

 

(10) The chest tube is generally removed when there has been air or fluid drainage or less than 100 mL/24 hour for more than 24 hours.

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.

PITFALL: Consider keeping the chest tube in place if the patient is on a ventilator in case a new pneumothorax suddenly develops.

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For chest tube removal, place the patient in the same position in which the tube was originally inserted. Prep the area with povidone-iodine solution. Untie the suture with the bow knot, loosen the purse-string stitch, and cut the other suture near the skin. Clamp the chest tube, and disconnect the suction system. Ask the patient to take a deep breath and perform a Valsalva maneuver. Place a gauze over the insertion site, and remove the tube with a swift motion. Tie the purse-string suture.

 

(11) For chest tube removal, place gauze over the insertion site, and remove the tube with a swift motion.

Apply petroleum gauze or antibiotic ointment on gauze, and tape securely. Obtain a chest radiograph immediately and at 12 to 24 hours to rule out a recurrent pneumothorax.

 

(12) Apply petroleum gauze or antibiotic ointment on gauze, and tape securely.

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

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CODING INFORMATION

CPT® Code

Description

2002 Average 50th Percentile Fee

32020

Tube thoracostomy with or without water seal (e.g., abscess, hemothorax, empyema)

$553.00

CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING

Chest tubes kits, thoracostomy trays, and suction-drainage system are available from Arrow Medical Products Ltd.; 2400 Bernville Road, Reading, PA 19605 (phone: 800-233-3187; 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, Ohio 43017 (phone: 800-234-8701); Allegiance Healthcare Corp., McGraw Park, IL 60085 (phone: 847-689-8410;http://www.cardinal.com/allegiance), and Owens and Minor, 4800 Cox Road, Glen Allen, VA 23060-6292 (phone: 804-747-9794; fax: 804-270-7281). Chest tubes that are equipped with an intraluminal trocar are not recommended, because they are associated with a higher incidence of intrathoracic complications.

BIBLIOGRAPHY

Baldt MM, Bankier AA, Germann PS, et al. Complications after emergency tube thoracostomy: assessment with CT. Radiology1995;195:539–543.

Bell RL, Ovadia P, Abdullah F, et al. Chest tube removal: end-inspiration or end-expiration? J Trauma 2001;50:674–677.

Chan L, Reilly KM, Henderson C, et al. Complication rates of tube thoracostomy. Am J Emerg Med 1997;15:368–370.

Collop NA, Kim S, Sahn SA. Analysis of tube thoracostomy performed by pulmonologists at a teaching hospital. Chest 1997;112:709–713.

Gilbert TB, McGrath BJ, Soberman M. Chest tubes: indications, placement, management, and complications. J Intensive Care Med1993;8:73–86.

Graber RE, Garvin JM. Chest tube insertion. Patient Care 1988;9:159.

Hesselink DA, Van Der Klooster JM, Bac EH, et al. Cardiac tamponade secondary to chest tube placement. Eur J Emerg Med 2001;8:237–239.

Jones PM, Hewer RD, Wolfenden HD, et al. Subcutaneous emphysema associated with chest tube drainage. Respirology 2001;6:87–89.

Nahum E, Ben-Ari J, Schonfeld T, et al. Acute diaphragmatic paralysis caused by chest-tube trauma to phrenic nerve. Pediatr Radiol2001;31:444–446.

Parulekar W, Di Primio G, Matzinger F, et al. Use of small-bore vs large-bore chest tubes for treatment of malignant pleural effusions.Chest 2001;120:19–25.

Rashid MA, Wikstrom T, Ortenwall P. Mediastinal perforation and contralateral hemothorax by a chest tube. Thorac Cardiovasc Surg1998;46:375–376.

Schmidt U, Stalp M, Gerich T, et al. Chest tube decompression of blunt chest injuries by physicians in the field: effectiveness and complications. J Trauma 1998;44:98–101.