Tube Thoracostomy

Dr.Faisal Alruways

PYG4 - EM - PMAH

What is thoracostomy ?

Tube thoracostomy is a procedure used to evacuate an abnormal accumulation of fluid or air from the pleural space and can be performed on an elective, urgent, or emergency basis.

Indications for tube thoracostomy

Contraindications for tube thoracostomy

Absolute

None

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Relative

1. Presence of multiple pleural adhesions
2. Presence of emphysematous blebs
3. Coagulopathy

Complications !

1. Infection
2. Laceration of an intercostal vessel
3. Pulmonary injury
4. Intraabdominal or solid organ tube placement
5. Failure of re-expansion of pneumothorax
6. Re expansion pulmonary edema

Equipment !

Patient preperation

• Start oxygenating and monitoring the patient continuously with cardiac and pulse oximetry.

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• Elevate the head of the bed 30 to 60 degrees, to lower the diaphragm and decrease the risk for injury to the diaphragm, spleen, and liver.

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• Clean the skin with a standard surgical scrub and drape the field with sterile towels.

Site of insertion

• Insert the tube over the top of the rib rather than near the bottom to avoid the neurovascular structures located on the inferior aspect of the ribs.

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• The most common location for a chest tube is the midaxillary to anterior axillary line, usually in the fourth or fifth intercostal space.

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• Hold the tube next to the chest wall with the tip of the tube at the level of the clavicle to estimate the distance that the tube needs to be advanced from the incision site to the apex of the lung.

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• Confirm that the last drainage hole is within the pleural space at the level of the insertion site to ensure that the tube has been advanced sufficiently far.

Anesthesia

• Parenteral analgesics or procedural sedation to stable patients before the procedure.

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• A common problem is inadequate systemic analgesia and local anesthesia.

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• Use generous local anesthesia, such as up to 5 mg/kg of locally injected 1% lidocaine with or without epinephrine.

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• Slowly inject local anesthetic over the superior aspect of the rib; through the muscle, periosteum, and parietal pleura; and along the entire anticipated tract of passage of the tube.

Insertion

• The incision site should be lateral to the edge of the pectoralis major and breast tissue and not through these structures.

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• Make sure that the incision is no less than 3 to 5 cm long.

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• Make a transverse incision through the skin and subcutaneous tissue with a No. 10 blade over the rib.

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• After the incision is made, insert a large Kelly clamp to push and spread the deeper tissues.

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• Bluntly dissect a tract over the rib while avoiding the inter- costal vessels and nerve on the inferior margin of each rib.

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• Firm resistance will usually be felt when the tough parietal pleura is met.

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• Close the clamp and push it forward with firm pressure to penetrate the pleura and enter the cavity.

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• Penetrating the pleura is usually the most painful portion of the procedure

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• On entering the pleural cavity, a palpable pop may be felt and a rush of air or fluid may occur.

• With only the tips of the clamp in the pleural cavity, spread the clamp to make an adequate hole in the pleura and then withdraw it.

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• Make the opening in the parietal pleura wide enough to comfortably insert both a finger and the tube, but avoid a larger pleural opening to reduce the risk for an air leak.

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• Slide a sterile gloved finger over the clamp and into the pleura before withdrawing the clamp.

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• This is done to further define the tract and to verify that the pleura has been entered and that no solid organs have been penetrated.

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• Ensure that all the holes in the tube are within the pleural space.

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• Rotate the tube 360 degrees to reduce the likelihood of kinking.

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• Attach the tube to the water seal or suction before releasing the clamp.

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• Look for bubbles in the water seal chamber to check for patency of the system.

Confirmation of tube placement

1. Slide a finger along the tube to verify that it has entered the pleural cavity.

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• Look for condensation on the inside of the tube and listen for air movement, which is audible during respirations.

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• Observe free low of blood or fluid.

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• A chest radiograph is used for definitive assessment of tube placement.

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Securing the tube

Drainage and suction system

All drainage systems have two essential components:

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1. One-way valve to allow air or fluid to drain out of the pleural space without allowing air back into the pleural space.

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• Suction mechanism to increase the rate of drainage.

• Use suction initially to treat patients with pneumothorax or hemothorax, but replace it with a water seal once drainage and expansion are satisfactory and no persistent air leaks are present.

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• The suction device should have high suction low (≤20 L/min) and be able to keep the suction constant.

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• Wall suction of 10 to 20 cm H2O is normally used.

Thank you