Makindo Medical Notes

In most cases it is appropriate to wait for the chest X-ray to identify a pneumothorax or haemothorax before placing a chest tube except for a suspected tension pneumothorax.

Precautions

• Only competent staff (or training staff supervised by competent staff) should perform this procedure

Contraindications

• Coagulopathy: should be managed and any bleeding tendency minimised but is not an absolute contraindication.
• Chest drains may be life-saving and must always be balanced with risks.

Graphic

A thoracic surgeon once taught me that just below the lowest axillary hair marks the spot. This works for post pubertal and non-arm pit shaving patients!

Absolute Indications

• Tension Pneumothorax
• Haemothorax
• Traumatic Arrest (bilateral)

Relative Indications

• Pneumothorax with underlying lung disease or that fails to improve with other interventions - see PTX
• Rib fractures & Positive pressure ventilation
• Profound hypoxia / hypotension & penetrating chest injury
• Profound hypoxia/hypotension and unilateral signs to a hemithorax A haemothorax may also be identified on FAST ultrasound examination. However, there are instances where the patient is in extremis and it is appropriate to place a chest tube without waiting for imaging studies. Patients in traumatic arrest with no cardiac output should have immediate decompression of both chest hemithoraces to exclude tension pneumothorax. Similarly, patients in shock or profoundly hypoxic with unilateral chest signs or evidence of penetrating trauma to a hemithorax should have a chest drain placed emergently.

Equipment

• Sterile gown and gloves
• Antiseptic solution, i.e. povidone-iodine or chlorhexidine
• Sterile drapes
• Local anaesthetic, e.g. 1% or 2% lidocaine
• Syringes and needles
• Scalpel and blade
• Suture e.g. 1/0 or 2/0 silk
• Forceps (round tipped) or Kelly clamp for blunt dissection
• Chest drain Closed drainage system with connecting tubing (sterile water if underwater seal used)
• Guide-wire and dilators for Seldinger drains
• Formal cutdown theatre instrument

Steps

• Ensure informed consent. Written consent may not be possible in extremis but should be obtained where possible. Wash hands and gown up. Clean and drape the area appropriately. The area of insertion is prepped with 10% povidone-iodine solution (or chlorhexidine) and draped with sterile towels. Use 1% lidocaine to anesthetise 2-3 cm area of skin and subcutaneous tissue down to pleural. The parietal pleural is painful when breached. A total infiltration of up to 10-20 ml 1% lidocaine is allowable. You should advance deep enough to aspirate air or fluid depending on the contents of pleural space.
• Aspiration of air or pleural fluid confirms the presence in the pleural space. If aspiration is not successful, then Ultrasound is the preferred form of imaging. This can be done by the bedside, allowing safe placement of the drain at the same time. If a complex pleural disease is suspected, computed tomography (CT) scanning with contrast is recommended.

Chest drain size selection

• The size of the chest tube that is required varies according to the indication for its placement. For pneumothoraces, it is increasingly common to use smaller drains (8-14 Fr which appear as effective as large bore ones. Some would advocate larger sizes (20-24F) in ventilated patients to facilitate drainage but this is unproven. In some cases, chest drain hole size or number suggest larger bores (24-32F) may be appropriate for haemothorax or penetrating chest wall injury. If pleurodesis is being contemplated, it is advisable to use a drain of at least 12 F, with adequate holes, to allow drainage of excess talc slurry (if that is the agent of choice).
• There is often concern regarding tube blockage which may be helped by saline or Heparin flushes. There is, on the other hand, the theoretical risk of introducing infection. This may be reduced by regular aspiration.

Insertion

• There is a traditional safety triangle. However, a thoracic surgeon once taught me that the last axillary hairs anteriorly usually marked the spot otherwise the fourth or fifth intercostal space, on the mid-axillary line. See diagram of safe triangle. Drains are very rarely placed nowadays on the 2nd Intercostal space.
• Chest drain traditional method: A 2 cm incision is made along the upper border of the rib below the intercostal space to be used. Always just go above a rib and avoid the undersurface where the neurovascular bundles lie. The incision should easily accommodate the operator's finger. Using a curved clamp the track is developed by blunt dissection only. The clamp is inserted into muscle tissue and spread to split the fibres. The track is developed with the operator's finger.
• Once the track comes onto the rib, the clamp is angled just over the rib and dissection continued until the pleural is entered. A finger is inserted into the pleural cavity and the area explored for pleural adhesions. A large-bore (32 or 36F) chest tube is mounted on the clamp and passed along the track into the pleural cavity. A trocar must be removed and NEVER used to insert the drain. The tube is connected to an underwater seal and sutured/secured in place. Ensure the drain and all holes are within the pleural space.
• Seldinger technique: This method is less traumatic and safer and involves needle and wire insertion, needle withdrawal leaving the wire in situ and then sliding a chest drain in over the wire and then removing the wire. Ensure the drain and all holes are within the pleural space.
• A U-stitch is placed for subsequent drain removal (see below) along with the tape. The chest is re-examined to confirm the effect. A chest X-ray is taken to confirm placement & position.

Drainage

• All that is needed is a simple one-way system that allows air and fluid to escape and prevents reflux of both. This is usually via an underwater drainage system however a flutter valve can serve the same purpose

Monitoring

• A chest X-ray needs to be performed post the procedure to check position. In the case of a large pleural effusion, it is wise to control drainage in order to prevent re-expansion of pulmonary oedema. This rare but potentially serious complication may occur depending on the extent and duration of the underlying collapsed lung. It has been suggested that the tube should be clamped for 1 hour after draining 1 litre. There is no need to clamp drains for pneumothoraxes unless raising the drain - age container above the level of percutaneous drain insertion.
• Suction has been suggested in cases of non-resolving pneumothorax and following chemical pleurodesis. This should be done via an underwater seal using a high volume/low-pressure system until full drainage is complete. Pressures between 10 and 20kPa are appropriate. A non-swinging chest tube is either misplaced, blocked, connected to suction or has achieved its role

Removal

• Remove when the original indication for placement is no longer present or the tube becomes non-functional. The exact timing is dependent on the clinical progress. The opinion is divided as to whether a chest tube placed for pneumothorax in a patient continuing to require mechanical ventilation may be removed if no air leak is present. Although somewhat controversial in patients with pneumothorax, many clinicians favour clamping the chest tube for 4-6 hours before removal in order to identify a persistent air leak.
• In preparation for removal, the suture anchoring the chest tube to the skin is cut, and a gauze dressing is available. Following inspiration, the patient performs a Valsalva manoeuvre and the tube is removed with simultaneous covering of the insertion site with the gauze dressing. The mattress suture inserted previously is tied to close the wound

Acute complications (technique)

• Haemothorax, usually from laceration of the intercostal vessel (may require thoracotomy)
• Lung laceration (pleural adhesions not broken down)
• Diaphragm / Abdominal cavity penetration (placed too low)
• Stomach / colon injury (diaphragmatic hernia not recognised)
• Tube placed subcutaneously (not in the thoracic cavity)
• Tube placed too far (pain)
• Tube falls out (not secured)

Late complications

• Blocked tube (clot, lung)
• Retained haemothorax
• Empyema
• Pneumothorax after removal (poor technique)