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Lions and Tigers & Chest Tubes, oh my!

LT Dominique Ferguson, DO

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Chest Tubes 101

Chest Drainage System setup

General Management

Troubleshooting air leaks

Removal

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Anatomy of the Chest Drainage System

Specific device will vary hospital to hospital
The most common unit is the Pleur-evac® Chest Drainage System

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Chest Drainage System Setup

Activate swivel floor stand
Fill water seal chamber with pre-attached solution

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Chest Drainage System Setup

Activate swivel floor stand
Fill water seal chamber
Attach chest tube to drainage system tubing, secure with tape

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4. Connect to wall suction

Increase wall suction until the orange float appears in the indicator window. Pressure is regulated at the chest drainage device itself with standard set to -20 cm H2O.

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5. Keep upright & below level of patient

Chest drainage system must remain upright for the water-seal chamber to function correctly and must be lower than the chest to facilitate drainage and prevent back flow.

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Chest tube management

To wall suction

To water seal

Removal

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To wall suction

Ensure wall suction unit is turned on and orange float appears in the window.
Typical level is -10 to -20 cm H20

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Respiratory Tidaling

Water rises with inspiration and falls during expiration in spontaneous breathing patient.
No tidaling = occlusion of tubing (clot or kink) vs fully re-expanded lung

When the drainage system is functioning properly, the height of the fluid level in the drainage tube fluctuates with inspiration and expiration. The water level in the water-seal chamber should rise during inspiration and fall during expiration in a spontaneously breathing patient. A loss of this normal ‘‘respiratory variation’’ likely means that the tube is no longer exposed to intrathoracic pressures. Absence of respiratory fluctuation or a decrease in the drainage may indicate that the system is blocked or that the lung is fully expanded. The loss of respiratory variation suggests the importance of looking for external factors (eg, kinked tube) that might contribute to the apparent blunting of pleural pressure swings. In most cases, the chest tube is physically excluded from global pleural pressures by the anatomic location of the tube, normal pleural healing, or pathologic changes (eg, blood clots).

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Techniques for tubing occlusion

If visible clots, squeeze hand-over-hand along the tubing, AVOID stripping/milking maneuvers
Sterile saline irrigation (5-10 mL)
Alteplase (10 mg in 30mL of sterile water) and pulmozyme (5 mg in 30mL of sterile water), clamping of CXT for 4 hrs, and side to side rotation of patient.
Chest tube maneuvers under sterile conditions

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Checking for presence of an air leak

Bubbling in the water chamber = air leak
Causes: extra-pleural from penetrating injuries (rib fracture), alveolar-pleural fistula, bronchopleural fistula
Classify as continuous, intermittent, or with provocative maneuver (cough).
Determine severity of the leak

The water seal pictured allows air to escape through the chest tube without re-entering the thoracic cavity. Initially, intermittent bubbling is expected but should resolve as the lung re-expands. However, persistent bubbling of air through the water chamber of the collecting system indicates an air leak from the lung or thoracic cavity. A continuous air leak or a leak during inspiration indicates a larger and more significant lung injury.

Provocative maneuver such as coughing transiently increases pleural pressure and facilitates the evacuation of pleural air. Determine severity of the leak: the higher the bubbles are noted down the column, the greater degree of air leak.

The number of columns (eg, 1 to 7) that are bubbling in the air leak gauge of a wet suction-controlled, closed-drainage system provides a semiquantitative measure of the severity of the leak.

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Verify presence of Sentinel Hole on CXR

Inside or outside pleural cavity?

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Verify presence of Sentinel Hole on CXR

Inside or outside pleural cavity?

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Localize the Leak

Insertion Site – Inspect the dressing, look at the entry site. Plug insertion site with xeroform petroleum gauze dressing, cover with 4x4s, tape to chest.

Silk Tape

Foam Tape

Xeroform gauze

Connector and Connection Sites– Ensure chest tube and connector is secured with tape. Ensure all connector sites are secure.

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Criteria to change to water seal

WATER (fluid should be serous)�Stable clinical status�Expanded lung�Amount of fluid <200mL in 24 hr�Lack of air leak

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Pulling a chest tube 101

Varying practice on the duration of water seal prior to chest tube removal.
Clamping trial is unnecessary (Rasheed et al.)

There is no well-established standard of care regarding the time patients should be observed on water seal drainage to exclude the potential of prematurely removing a chest tube. Ensure after switching to water seal that there is complete resolution of pneumothorax and no evidence of ongoing air leak. Clamping trial is unnecessary prior to removal of tube thoracostomy in blunt and penetrating non-cardiac thoracic trauma in terms of recurrent pneumothorax (Rasheed et al.)

Schulman et al: Conclusion: 119 pts, A normal chest radiograph obtained 3 hours after placing a chest tube on water seal effectively excludes development of a clinically significant pneumothorax.

Sweet et al: Conclusion: In nonventilated patients, one in ten developed recurrent pathology after chest tube removal and almost a quarter of them underwent reintervention. However, current literature remains insufficient to draw definitive conclusions on this matter, and future studies are needed.

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Pulling a Chest Tube

What to avoid: recurrent pneumothorax
Pull at end inspiration or end expiration
Ensure removal is swift and speedy
Have your dressing ready with your pull
Acquire post-pull CXR in 4 hours or sooner depending on clinical status of patient

Opinions are divided between discontinuation of tube thoracostomies at the end of inspiration or expiration (Bell et al. 2001: equally safe; Thitivaraporn et al. 2017: Valsalva maneuver + full inspiration). Both methods of removal can be rationalized on the basis of pulmonary mechanics. At the end of inspiration, the lung is maximally expanded, and the parietal and visceral pleura are most closely opposed. At the end of expiration, the pressure difference between the atmosphere and the intrapleural space is minimized so the risk of inadvertent airflow into the chest cavity during tube removal is limited. (If on ventilator, can do an inspiratory pause).

Per Robert and Hedges: “it has traditionally been advised to ask the patient to inhale fully and perform a mild Valsalva maneuver”

Bell at al: 102 chest tubes in 69 trauma patients; Discontinuation of chest tubes at the end of inspiration or at the end of expiration has a similar rate of post removal pneumothorax. Both methods are equally safe

Thitivaraporn et al: Randomize controlled trial of 48 tube thoracostomies; Performing the Valsalva maneuver correctly during full inspiration may be the method of choice for removing thoracostomy tubes. Using a party balloon forces the patient perform the Valsalva maneuver adequately and is simpler to explain.

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EAST Guidelines OCT 2022

In adult trauma patients who require tube thoracostomy insertion, we conditionally recommend antibiotic prophylaxis be given at the time of insertion to reduce incidence of empyema.

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References

Thomsen. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Seventh edition. Philadelphia, PA: Elsevier, 2019.
UpToDate: Thoracostomy tubes and catheters: Management and removal
Mentzer SJ, Tsuda A, Loring SH. Pleural mechanics and the pathophysiology of air leaks. J Thorac Cardiovasc Surg. 2018 May;155(5):2182-2189. doi: 10.1016/j.jtcvs.2017.12.062. Epub 2017 Dec 23. PMID: 29397977; PMCID: PMC7263434.
Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management of Persistent Air Leaks. Chest. 2017 Aug;152(2):417-423. doi: 10.1016/j.chest.2017.02.020. Epub 2017 Mar 4. PMID: 28267436; PMCID: PMC6026238.
Paydar S, Ghahramani Z, Ghoddusi Johari H, Khezri S, Ziaeian B, Ghayyoumi MA, Fallahi MJ, Niakan MH, Sabetian G, Abbasi HR, Bolandparvaz S. Tube Thoracostomy (Chest Tube) Removal in Traumatic Patients: What Do We Know? What Can We Do? Bull Emerg Trauma. 2015 Apr;3(2):37-40. PMID: 27162900; PMCID: PMC4771264.
Rasheed MA, Majeed FA, Ali Shah SZ, Naz A. Role Of Clamping Tube Thoracostomy Prior To Removal In Non-Cardiac Thoracic Trauma. J Ayub Med Coll Abbottabad. 2016 Jul-Sep;28(3):476-479. PMID: 28712216.
Heimes J, Copeland H, Lulla A, Duldulao M, Bahjri K, Zaheer S, Wallen JM. The use of thrombolytics in the management of complex pleural fluid collections. J Thorac Dis. 2017 May;9(5):1310-1316. doi: 10.21037/jtd.2017.04.56. PMID: 28616283; PMCID: PMC5465141.
Thitivaraporn P, Narueponjirakul N, Samorn P, et al. Randomized controlled trial of chest tube removal aided by a party balloon. Asian Cardiovascular and Thoracic Annals. 2017;25(7-8):522-527. doi:10.1177/0218492317721412
Mohammed H. Chest tube care in critically ill patient: A comprehsensive review. Egyptian Journal of Chest Diseases and Tuberculosis. 2015; 64 (4): 849-855.

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Media References

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Quiz

https://docs.google.com/forms/d/e/1FAIpQLSeqI34K0yhanEsla-FqQ1u7pknly9ymv3nExFFXeEbMAEgg9Q/viewform?usp=sf_link