Assisting with Chest Tube Insertion

EQUIPMENT

 Tube thoracostomy tray

 Syringes
 Needles/trocar
 Basins/skin germicide
 Sponges
 Scalpel, sterile drape, and gloves
 Two large clamps
 Suture material
 Local anesthetic
 Chest tube (appropriate size); connector
 Chest drainage system-connecting tubes and tubing, collection bottles or commercial system,
vacuum pump (if required)
 Sterile water
 Procedure

PROCEDURE
Nursing Action Rationale
Preparatory phase
1.Assess patient for pneumothorax, hemothorax,  
presence of respiratory distress.
2.Obtain a chest X-ray. Other means of localization of 2.To evaluate extent of lung collapse or
pleural fluid include ultrasound or fluoroscopic amount of bleeding in pleural space.
localization.
3.Assemble drainage system.  
4.Reassure the patient and explain the steps of the 4.The patient can cope by remaining immobile
procedure. Tell the patient to expect a needle prick and and doing relaxed breathing during tube
a sensation of slight pressure during infiltration insertion.
anesthesia.
5.Position the patient as for an intercostal nerve block or 5.The tube insertion site depends on the
according to physician preference. substance to be drained, the patient's
mobility, and the presence of coexisting
conditions.
Performance phase
Needle or intracath technique
1.The skin is prepared and anesthetized using local 1.The area is anesthetized to make tube
anesthetic with a short 25G needle. A larger needle is insertion and manipulation relatively
used to infiltrate the subcutaneous tissue, intercostal painless.
muscles, and parietal pleura.
2.An exploratory needle is inserted. 2.To puncture the pleura and determine the
presence of air or blood in the pleural cavity.
3.The IntraCath catheter is inserted through the needle  
into the pleural space. The needle is removed, and the
catheter is pushed several centimeters into the pleural
space.
4.The catheter is taped to the skin. 4.To prevent it from being pushed out of the
 chest during patient movement or lung
expansion.
5.The catheter is attached to a connector/tubing and  
attached to a drainage system (underwater-seal or
commercial system).

Trocar technique for chest tube insertion

A trocar catheter is used for the insertion of a large-bore  
tube for removal of a modest to large amount of air leak
or for the evacuation of serous effusion.
1.A small incision is made over the prepared, 1.To admit the diameter of the chest tube.
anesthetized site. Blunt dissection (with a hemostat)
through the muscle planes in the interspace to the
parietal pleura is performed.
2.The trocar is directed into the pleural space, the 2.There is a trocar catheter available equipped
cannula is removed, and a chest tube is inserted into with an indwelling pointed rod for ease of
the pleural space and connected to a drainage system. insertion.

Hemostat technique using a large-bore chest tube

A large bore chest tube is used to drain blood or thick  
effusions from the pleural space.
1.After skin preparation and anesthetic infiltration, an 1.The skin incision is usually made one
incision is made through the skin and subcutaneous interspace below proposed site of
tissue. penetration of the intercostal muscles and
pleura.
2.A curved hemostat is inserted into the pleural cavity 2.To make a tissue tract for the chest tube.
and the tissue is spread with the clamp.
3.The tract is explored with an examining finger. 3.Digital examination helps confirm the
presence of the tract and penetration of the
pleural cavity.
4.The tube is held by the hemostat and directed through  
the opening up over the ribs and into the pleural
cavity.
5.The clamp is withdrawn and the chest tube is 5.The chest tube has multiple openings at the
connected to a chest drainage system. proximal end for drainage of air or blood.
6.The tube is sutured in place and covered with a sterile  
dressing.

Follow-up phase
1.Observe the drainage system for blood and air. 1.If a hemothorax is draining through a
Observe for fluctuation in the tube on respiration. (See thoracostomy tube into a bottle containing
page 278.) sterile normal saline, the blood is available
for autotransfusion.
2.Secure a follow-up chest X-ray. 2.To confirm correct chest tube placement and
reexpansion of the lung.
3.Assess for bleeding, infection, leakage of air and fluid  
around the tube.
A chest tube (chest drain or tube thoracostomy) is a flexible plastic tube that is inserted through the
side of the chest into the pleural space. It is used to remove air (pneumothorax) or fluid (pleural
effusion, blood, chyle), or pus (empyema) from the intrathoracic space. It is also known as a
Bülau drain or an intercostal catheter.

Indications

 Pneumothorax: accumulation of air in the pleural space

 Pleural effusion: accumulation of fluid in the pleural space
 Chylothorax: a collection of lymphatic fluid in the pleural space
 Empyema: a pyogenic infection of the pleural space
 Hemothorax: accumulation of blood in the pleural space
 Hydrothorax: accumulation of serous fluid in the pleural space
Contraindications
Contraindications to chest tube placement include refractory coagulopathy, lack of cooperation by the
patient, and diaphragmatic hernia. Additional contraindications include scarring in the pleural space
(adhesions)

Technique

The insertion technique is described in detail in an article of the NEJM. The free end of the tube is usually
attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the
pleural space, and prevents anything returning to the chest. Alternatively, the tube can be attached to
a flutter valve. This allows patients with pneumothorax to remain more mobile.

British Thoracic Society recommends the tube is inserted in an area described as the "safe zone", a
region bordered by: the lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior
border of latissimus dorsi and a horizontal line superior to the nipple[citation needed]. More specifically, the tube
is inserted into the 5th intercostal space slightly anterior to the mid axillary line.

Chest tubes are usually inserted under local anesthesia. The skin over the area of insertion is first
cleansed with antiseptic solution, such as iodine, before sterile drapes are placed around the area. The
local anesthetic is injected into the skin and down to the muscle, and after the area is numb a small
incision is made in the skin and a passage made through the skin and muscle into the chest. The tube is
placed through this passage. If necessary, patients may be given additional analgesics for the procedure.
Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied to the
area. Once the drain is in place, a chest radiograph will be taken to check the location of the drain. The
tube stays in for as long as there is air or fluid to be removed, or risk of air gathering.

Chest tubes can also be placed using a trocar, which is a pointed metallic bar used to guide the tube
through the chest wall. This method is less popular due to an increased risk of iatrogenic lung injury.
Placement using the Seldinger technique, in which a blunt guidewire is passed through a needle (over
which the chest tube is then inserted) has been described.

Chest Drainage Canister

A chest drainage canister device is typically used to drain chest tube contents (air, blood, effusions).
There are generally three chambers. The first chamber is a collecting chamber. The second is the "water
seal" chamber which acts as a one way valve. Air bubbling through the water seal chamber is usual when
the patient coughs or exhales but may indicate, if continual, a pleural or system leak that should be
evaluated critically. It can also indicate a leak of air from the lung. The third chamber is the suction control
chamber. The height of the water in this chamber determines the negative pressure of the system.
Bubbling should be kept a gentle bubble to limit evaporating the fluid. Increased wall suction does not
increase the negative pressure of the system. Newer systems are designed not to need the water seal
chamber, so there is not a column of water that can spill and mix with blood, mandating the replacement
of the canister. Even newer systems are small and portable so the patient can be sent home for drainage
if indicated.

Complications
Major complications are hemorrhage, infection, and reexpansion pulmonary edema. Chest tube clogging
can also be a major complication if it occurs in the setting of bleeding or the production of significant air or
fluid. When chest tube clogging occurs in this setting, a patient can suffer from pericardial tamponade,
tension pneumothorax, or in the setting of infection, an empyema. All of these can lead to prolonged
hospitilization and even death. To minimize potential for clogging, surgeons often employ larger diameter
tubes. These large diameter tubes however, contribute significantly to chest tube related pain. Even larger
diameter chest tubes can clog. In most cases, the chest tube related pain goes away after the chest tube
is removed, however, chronic pain related to chest tube induced scarring of the intercostal space is not
uncommon.

In recent years surgeons have advocated using softer, silicone Blake drains rather than more traditional
PVC conventional chest tubes to address the pain issues. Clogging and chest tube occlusion issues have
been a problem, including reports of life threatening unrecognized bleeding that occurs in the chest due to
an occluded or clogged drain. Thus when a chest tube is inserted for whatever reason, maintaining
patency is critical to avoid complications.

Injury to the liver, spleen or diaphragm is possible if the tube is placed inferior to the pleural cavity.
Injuries to the thoracic aorta and heart have also been described.

Minor complications include a subcutaneous hematoma or seroma, anxiety, shortness of breath

(dyspnea), and cough (after removing large volume of fluid).

Subcutaneous emphysema indicates backpressure created by a clogged drain or insufficient negative

pressure.