By

MARITES A. ROSAPAPAN, RN
Clinical Instructor License No. 0274161

Chest tubes and bottles are some of the simplest devices used in the practice of medicine. Yet they are often misunderstood, sometimes misused and are a mystery to medical students, nurses and some practicing doctors.

Tube thoracostomy is the insertion of a tube into the pleural cavity to drain air, blood, bile, pus, or other fluids Provides continuous, large volume drainage until dealing with the underlying pathology Numerous indications in which patients are at great risk for major morbidity or mortality

 Pneumothorax
If > 20 % of the hemithorax In any ventilated patient Tension pneumothorax after initial needle relief Persistent or recurrent pneumothorax after simple aspiration Secondary spontaneous pneumothorax in patients over 50 years

Rapidly accumulating pleural effusion

 Empyema and complicated parapneumonic effusion Hemo or haemopneumothorax

Postoperative (in cardiac & mediastinal

surgery)

Chylothorax Chest trauma When pleurodesis is needed

Absolute:
The need for emergent thoracotomy
Fused pleural space

Relative : include the following:

Coagulopathy Pulmonary bullae

Pulmonary, pleural, or thoracic adhesions

Loculated pleural effusion or empyema Skin infection over the chest tube insertion site

Chest tubes in post thoracic surgery: 1. For lung resections: 2 tubes must be inserted one for air and one for fluid 2. For pneumonectomy: only one basal tube for fluid 3. For intra-thoracic extra pulmonary operations: only one basal tube if pleura is opened

 Chest tube drainage device with under water seal Sterile gloves Preparatory solution Sterile drapes Surgical marker Lidocaine 1% with epinephrine Syringes, 10-20 mL (2) Needle, 25 gauge (ga), 5/8 in Needle, 23 ga, 1.5 in; or 27 ga, 1.5 in; for instilling local anesthesia

Blade (No. 10 or 11) on a handle Large and medium Kelly clamps Scissors Silk or nylon suture, 0 or 1-0 Needle driver (holder) Vaseline gauze Sponge gauze squares, 4 x 4(10) Sterile adhesive tape, 4 wide Chest tube of appropriate size :
= Woman : 28F = Infant : 12-16F

= Man : 28-32F = Child : 12-28F = Neonate : 10-12F

Chest tubes (Catheters)

Different sizes
From infants to adults Small for air, larger for fluid

Different configurations
Curved or straight

Types of plastic
PVC Silicone

Coated/Non-Coated
Heparin Decrease friction

 Best is semi recumbent at a 30- 45 The arm on the affected side should be abducted and externally rotated A soft restraint or silk tape can be used to secure the arm in this location
Safe Triangle

Best positioning: 30 elevation, 45 rotation

 Identify the 5th space and the mid axillary line (MAL) Clean the area (remove excess hair)

Give O2 IV line Observe

Mark the site of insertion (4th or 5th space between MAL and AAL)
Wear sterile gloves, gown, hair cover, and goggles or face shield Apply sterile drapes to the area.

 Administer a systemic analgesic (unless contraindicated). Use the 25-ga needle to inject 5 mL of the local anesthetic solution into the skin overlying the initial skin incision Infiltrate the skin area of incision by 5 ml of the anesthetic then direct down to periosteum and infiltrate with 10 ml Advance the needle and aspirate to confirm entry to pleura

If no air or fluid aspirated?

 Use the No. 11 or 10 blade

Ideal is 2-4 cm long Overlying the rib that is below the desired ICS entry. The incision should be in the same direction as the rib itself.

 Use a hemostat or a medium Kelly clamp

Bluntly dissect a tract in the subcutaneous tissue by intermittently advancing the closed instrument and opening it Dissect down to intercostal muscles

 Further blunt dissection down to the intercostal muscle

 Further blunt dissection down to the pleura

 Palpate the tract with a finger as shown, and make sure that the tract ends at the upper border of the rib under the skin incision Adding more local anesthetic to the intercostal muscles and pleura at this time is recommended.

 A closed and locked Kelly clamp is used to enter into the pleural cavity by controlled pressure and twist.

Make sure to guide the clamp over the upper margin of the rib.
Once inside the pleural cavity, open the clamp to enlarge the entry and withdraw it open

 Use a sterile, gloved finger to appreciate the size of the tract and to feel for lung tissue and possible adhesions

 Rotate the finger 360 to appreciate the presence of dense adhesions that cannot be broken and require placement of the chest tube at another site

 The proximal end of the chest tube is held with a Kelly clamp that guides the chest tube through the tract. The distal end of the chest tube should always be clamped until it is connected to the drainage device.

Tube insertion guided by a curved Kelly clamp

 Desired intra pleural length equals the distance between incision and lung apex Direct the tube upwards and posteriorly in pneumothorax and above the diaphragm in effusion Before securing the tube with stitches, look for a respiration-related swing in the fluid level of the water seal

 Two separate through-and-through, simple, interrupted stitches on each side of the chest tube are recommended Each stitch should be tightly tied to the skin, then wrapped tightly around the chest tube several times to cause slight indentation, and then tied again

 Sealing suture: A central vertical mattress stitch with ends left long and knotted together can be placed to allow for sealing of the tract once the chest tube is removed. Place petrolatum (eg, Vaseline) gauze over the skin incision as shown

Prepare a Y-shaped fenestrated Apply support gauze dressing drain gauze from regular gauze around the chest tube and (4 x 4 in). secure it to the chest wall with 4-in adhesive tape

THORACOSTOMY TUBE

Single-Bottle Water Seal System Two-Bottle Water Seal System Three-Bottle Water Seal System Pleur-evac Operating System - single unit with all three bottles identified as chambers. Commercially prepared

THORACOSTOMY TUBE CARE

1.

2.

3.

4.

The amount of suction is regulated by the wall gauge in two-bottle. The amount of suction is regulated by the depth of the tip of venting glass submerged in the water not by the suction machine (continuous negative pressure) in three-bottle. Water seal bottle fluctuates during: inhalation = up exhalation = down (tidaling is a normal sign) bubbling means persistent leak of air from the lungs or leak in the system When applying clamp always near to the patient (1st clamp ) and 6 inches away for the 2nd clamp (rubberized tip only) only for a few seconds and as necessary

THORACOSTOMY TUBE CARE

1.

2. 3.

Emergency equipment must be available always in the bedside extra bottles petrolatum gauze adhesive tape clamp with rubberized tip Milk the tube in the direction of the bottle. Fluctuation/tidaling will stop when: lung has re expanded dependent loop develops and suction is not working

THORACOSTOMY TUBE CARE

1. 2.

3.

4.

Always put the drainage system below chest. Never clamp the chest tube during transport or prolonged period of time. Location of the tip of chest tube will be confirmed by an X-ray and full expansion of the affected lung. Chest tube is removed when the lungs have re-expanded in 24 hours to several days.

THORACOSTOMY TUBE CARE

1.

During tube removal avoid a sudden large inspiration this may produce pneumothorax.
When tube is accidentally disconnected. What to do? Place the distal-end tube in a container with sterile water When tube is accidentally pulled-out from the chest Ask client to do valsalvas maneuver then apply an occlusive dressing

2.

3.

 Dont get out the SAFE TRIANGLE

Wait sufficiently for anesthesia to give effect

Avoid too small and too large incisions Keep track above the upper border of the rib In case of tension empyema or effusion remove 50-200 mls by a syringe to avoid spraying out pleural contents on opening the pleura Check for optimal position of the tube inside the chest by X-ray

Right side chest tube in a wrong position

Left side chest tube in a good position

 Complications are reduced when done by experienced operators Good experience is gained after doing at least 10 SUPERVISED procedures (ATS) Experience maintained by doing 5 procedures / year (ATS) Complications may be dangerous and fatal so good tube care and follow up is essential

1. Improper placement
Horizontal (over the diaphragm)
(Acceptable for hemothorax)

Subcutaneous - Must be repositioned Placed too far into the chest (against
the apical pleura) - Should be retracted In inter lobar fissure: Correct

Placed into the abdominal space Should be removed

2. Bleeding
Local - Usually responds to direct
pressure

Hemothorax (lung vs IC artery injury) - Might require

thoracotomy if it does not resolve spontaneously

3. Organ penetration and injury:

Lung - Occurs as a result of pleural
adhesions or use of a thoracostomy tube trocar

Liver or spleen with hemoperitoneum - Requires emergent laparotomy

Stomach, colon, or diaphragm - Occurs
as a result of unrecognized diaphragmatic hernia

4. Dislodgement:
Due to accidental pull re-introduce a sterile tube

5. Pleural infection and empyema:

If sterilization is poor

6. Mal or non function:

replace

 The tube must be sealed after insertion

Sealing is by underwater system or Heimilch valve

Underwater seal is the most commonly used It is either single bottle, two bottles or three bottles system The seal is a straw that pass through the bottle cap and settle 2-3 cm below water

 When intrapleural pressure rises above 3 cm water contents of pleura are expelled but hydrostatic pressure of water prevent water from gaining into the pleura

Excess fluid accumulated in the bottle must be removed regularly otherwise back pressure occurs
The bottle must be kept below the bed level (100cm below insertion)

CONCEPT

Most basic concept

Just like a straw in a drink, air can be pushed through the straw, but air cant be drawn back up the straw
Tube open to atmosphere vents air

Straw concept

Tube from the patient

UNDER WATER SEAL

Trap

Seal

Manometer

Disposable 3 bottle one unit system (Pleuro-Evac)

Heimlich Flutter Valve

One way flutter valve Used for ambulant patients with pneumothorax Must be placed in a correct position otherwise will be fatal

When functioning makes a duck like quacks

Expiration

Inspiration

 Proper connection to the seal Connections must be sealed with adhesive tape No prophylactic antibiotics needed No dependent loops to be present 1or 2 loops near the patient facilitate movements and minimize pain While in bed fix the tube to the bed with a pin Dressing must be changed if soaked
Dependent loop Wrong connection

Two loops near the patient

The following can significantly restrict tube function and could be dangerous:
A full bottle with glass straw tip deep under the fluid surface.
Too narrow or too soft tubing may spontaneously kink or collapse or the patient may lie on it An obstructed or small size air vent permits pressure to build up in the chest bottle. Any fluid in a dependent loop of tubing will obstruct flow and create back pressure, especially to an air leak

Patient must be taught:

To keep the bottle down To have good inspirations to inflate the lungs To observe any change in the bottle and to call for help when: Develops respiratory distress Excess bubbling occurs Excess blood seen Oscillation stops The tube move from place
100 cm

CHEST TUBE FOLLOW UP CHART

Morning Evening 24 hour total

Date

Air

Fluid

Others

Air

Fluid

Others

WALL

Use of suction to chest bottles is somewhat controversial

When properly applied, chest tube suction is very useful There are different ways: thoracic pumps or wall suction
PUMP

Conditions where Suction is Useful:

1. Pneumothorax:
Persistent leak after 18-24 hrs A defect in seal system that cannot be corrected

2. Effusion:
When thick and not easily drained

3. Hemothorax:
Unless active bleeding is present

4. After open heart surgery

Clamping the tube is indicated in:

1. During insertion and if signs of REPE develops 2. During transportation 3. During seal changing 4. As a test for leaking connections 5. After introducing pleural sclerosant 6. After pneumonectomy: controlled 7. For milking and striping 8. Before removal

A chest tube can be safely removed when:

1. 2. 3. 4. Patient clinically well X-ray shows fully expanded lung In pneumothorax: no leak for 24 hrs In effusion: less than 50-80 ml ( some: 200300 ml) fluid gain/24 hrs

The fixing stitches are cut, patient takes deep inspiration, tube withdrawn, the track sealed rapidly with a gauze, the sealing stitch is tightened

If the lung fails to re-expand after ICT placement?

4 possibilities:
Wrong placement: correct Large leak: put on suction Pleural cortex (rim): decortication Endobronchial obstruction: bronchoscopy

If foaming (excess froth in the bottle) occurs ?

Occurs with high volume air leak Commonly occurs at start of suctioning Overcome by silicon antifoam spray or adding ethanol to the bottle

If the tube is blocked and stop function?

The tube will stop oscillation Check for kinking, if not(a possible clot) Milking: distal clamping and proximal milking Striping: proximal clamping and distal striping Clean with a sterile Fogarty catheter Change the tube if all fail

If surgical emphysema (SE) develops?

Means a poor functioning tube
SE may indicate tension pnx.

SE is disfiguring and annoying to the pt.

If pt. is stable: reassure and search for a block and correct If tube is working = a large leak; put on suction If pt. is distressed: release tension

If the seal bottle on suction suddenly bubbles furiously?

This means excessive air leak
3 possibilities:
1. Disconnected from the seal
2. Dislodgement of ICT from chest

3. A leak within the lung itself

st 1 check

the patient:

Stable and no manifestations of respiratory distress:

Check for tubing disconnection and reconnect Aseptically re-insert a dislodged tube Ask the pt to cough to expel any air entered the pleura

st 1 check

the patient:

Unstable with manifestations of

respiratory distress:
Give 100% O2 and monitor by oxymetry Support circulation if needed and monitor BP Examine chest for signs of tension pntx. Obtain X-ray chest to confirm Check tubing and do as before

 If the ICT tube is dislodged :

Continue pt. support and monitoring Swap the area of insertion and the exposed portion of the tube with Betadine Stop suction, cut the stay suture, re introduce tube till all holes are inside Make new stay sutures to fix the tube New X-ray chest to check position Give prophylactic antibiotics

IF lung air leak persist after one week on suction ?

These patients need VATS or open thoracotomy

If a sudden gush of blood appear in the drain bottle ?

3 possibilities:
1. Severe active bleeding: support circulation, call for thoracotomy 2. Mild active bleeding: wait and see under close observation

3. A collected blood passed a block: close observation

SPECIAL SITUATION ICT IN VENTILATED PATIENTS

ICT can cause:
1.Decrease Vt 2.Decrease oxygenation and CO2 removal 3.Inappropriate cycling of the ventilator 4. Persistence of air leak (BPF)

So, this situation is somewhat difficult

Ventilator management:
Minimize airway pressure:
1. Decrease Vt

2. Decrease respiratory rate

3. Decrease inspiratory time

4. Use least PEEP possible

Ventilator management:
DIFFERENTIAL VENTILATION Ventilate only the healthy side Ventilate both sides differently using Carlens tube Tube pressurization in expiration and occlusion during inspiration Make leak site more dependent High frequency ventilation