In honor of Trauma Tuesday, we’re going to talk about something that isn’t COVID related today! Instead, we’ll talk about chest tubes and what to do when something goes wrong.
Indications
Pneumothorax
Hemothorax
Pleural Effusion
Malignant Effusion
Empyema/abscess
Procedure
Find your position
This should be in the “triangle of safety” which is bordered by the pectoralis major, lateral dorsalis, and 5th intercostal space
If you stay in this triangle of safety, you should avoid damaging other organs like the diaphragm, liver, or spleen, as well as the axillary vascular located above that triangle
Always go above the rib edge, not below
This is to avoid the neurovascular bundle that runs along the inferior edge of the rib
Prepare your space
This should be a sterile procedure whenever possible (sterility is less important if your doing a thoracotomy on a traumatic arrest patient)
Prep the area with chlorhexidine and lay out your sterile drape in a way that will allow access to the triangle of safety so that you aren’t breaking sterility while performing the procedure
Place the chest tube!
Use lots of local anesthetic and go all the way down to the rib, including the periosteum; this is a painful procedure and you don’t want them moving on you
Measure the chest tube from the incision site to the clavicle on the same side to estimate how deep you should place the chest tube
Clamp 1 end of the chest tube
Make an incision along the superior border of the 5th rib that is large enough for your finger and the tube
Use a Kelly clamp to dissect the soft tissue, opening it periodically as you go to make sure the space in the soft tissue is large enough for the procedure
Once you get to the rib, use your finger to guide the clamp over the superior aspect of the rib and into the pleural space. Once in, spread the clamp to open up the hole you made in the pleura
Place your finger in the hole and sweep 360o to check for adhesions; be careful if there are any broken ribs, they are sharp and can cut you!
Clamp the other end of the chest tube with the Kelly clamp and use this to guide the tube into the pleural cavity along your finger which should still be in the hole you made
Advance the tube until all fenestrations are in the pleural cavity (you should have an idea of how deep to go by your measurement earlier on!) and direct the tube superoanteriorly for pneumothorax or posteriorly for a fluid collection
Hook up the chest tube to the pleurovac and secure everything in place
So now we know when to place a chest tube and how to do it, but what do we do when something goes wrong?
Malposition
A common problem associated with chest tube placement
Can be the result of the direction the tube was placed in or the result of the tube being in the wrong place entirely (ie in the subcutaneous tissue, within the lung itself, or buried in a fissure of the lung)
Xray can help you determine where the chest tube is located and whether it is malpositioned
If it is malpositioned:
You can’t pull back and readjust the chest tube, as it is no longer sterile
If the chest tube is still draining something, then it is reasonable to discuss with the admitting team whether the tube should be replaced entirely or if it should be left in place for the time-being
If it is not draining, it should be removed entirely and a new chest tube should be inserted using sterile techniques
Obstruction
A tube can be occluded by blood clots or particularly thick, viscous fluid
You can assess for an obstruction by looking at the water-seal in the pleuro-vac when it is set to gravity
Under normal circumstances, the water-seal in the chamber should vary with respiration or coughing
If you aren’t seeing variation with respiration or coughing, the tube may be occluded or the lung may be completely re-expanded
Occlusions typically resolve spontaneously without further intervention
You should not strip or “milk” the chest tube, as there is no evidence demonstrating that this will resolve an obstruction and can cause harm by creating increases in negative pressure within the thoracic cavity
If the obstruction is not resolving spontaneously, you may need to replace the chest tube
Air leak
An air leak can be normal when you first insert the chest tube or while attempting to resolve a pneumothorax
A new or persistent air leak is concerning and suggests there may be a problem with the circuit preventing the chest tube from functioning correctly
An air leak can occur due to bronchopulmoary injury or fistula, entry of air from the insertion site, or having some of the holes at the end of the chest tube outside of the body
To identify an air leak, check the water-seal for constant bubbling
If you suspect air may be entering from the insertion site, you should attempt to further close or bandage the site to stop the leak and create a closed system
If the holes on the chest tube are not fully within the body, the chest tube will need to removed and replaced; again you cannot insert the chest tube further once the procedure is complete, as it will no longer be sterile
Subcutaneous emphysema
This can occur if the tube is completely or partially in the subcutaneous tissue rather than the pleural cavity
This can be identified by feeling for crepitus and checking an xray
If subcutaneous emphysema is present but the tube is correctly positioned within the pleural cavity, the emphysema will resolve spontaneously and no further action is necessary
If the tube is incorrectly positioned, it should be removed and replaced
Lung injury
The lung parenchyma can be injured during chest tube placement, typically resulting in a pulmonary laceration
These injuries can result in bronchopleural fistula formation
Such injuries may be identified by the presence of persistent bleeding or on xray
Check for tube placement on xray to ensure it is not in the lung itself, as well as for an effusion that may appear as a result of a pulmonary laceration
If you suspect lung injury and the patient is stable, CT chest can also help determine the exact location of the chest tube
If you are concerned there may be lung injury, consult cardiothoracic surgery immediately
Re-expansion pulmonary edema
This is the formation of pulmonary edema as a result of rapid re-expansion of the lung after the resolution of a large pneumothorax, hemothorax, or pleural effusion
Likely a result of an inflammatory response following the rapid change
To best try and avoid this, avoid removing more than 1L of fluid at one time
After removing 1L of fluid, the tube should be left in place but clamped to avoid further drainage