TO CHEST TUBE

THORACOSTOMY
1. Rahmi Noorhayati
2. Fadli Ashar
3. Maulana Iskandardinata
4. Ricard Hartanto
5. Luthfi Lazuardi

Bedah Dasar
 DEFINITION

Chest Tube Thoracostomy

commonly referred to as “putting in a chest tube”, is a procedure
that is done to drain fluid (pleural effusions, chylothorax) blood
(hematothorax), empyema, or air (pneumothorax) from the
space around the lungs.

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ANATOMY OF THORACIC CAGE

Posterior View
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MUSCLES OF THORACIC WALL

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Intercostal Muscles

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VASCULARIZATION OF THORACIC WALL

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 ANATOMY OF PLEURA

Each lung is invested by and enclosed in a serous pleural sac that consists of two
continuous membranes :
1. The visceral pleura, which invests all surfaces of the lungs forming their shiny
outer surface
2. The parietal pleura, which lines the pulmonary cavities
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 ANATOMY OF PLEURA

The pleural cavity or pleural sac —the

potential space between the layers of pleura
— contains a capillary layer of serous
pleural fluid that :

◦ Lubricates the pleural surfaces

◦ Provides the cohesion that keeps the

lung surface in contact with the thoracic
wall
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PHYSIOLOGY OF PLEURAL FLUID

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 PHYSIOLOGY OF PLEURAL FLUID

The total amount of fluid in each pleural cavity is

normally slight. : 0,3 cc/kg of body weight or about
25 cc/hour.

The excess fluid is pumped away by lymphatic

vessels opening directly from the pleural cavity
into :

1. The mediastinum

2. The superior surface of the diaphragm

3. The lateral surfaces of the parietal pleura.

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 PHYSIOLOGY OF PLEURAL FLUID

Tekanan di rongga pleura selalu bersifat negatif :

◦ Inspirasi : - 8 cmH2O
◦ Ekspirasi : - 4 cmH2O
Adanya akumulasi cairan , udara, atau darah mengurangi tekanan negatif dari rongga pleura  paru- paru kolaps
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PHYSIOLOGY OF RESPIRATION

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INDICATION

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CONTRAINDICATION

ABSOLUT

• Diaphragmatic hernia
• Pleural adhesion

RELATIVE

• Coagulopathy
• Lung bullae
• Pulmonal or thoracal adhesions
• Skin infections around chest tube insertion site
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 WOUND EXUDATE (DRAINAGE)

◦ Serous : clean, watery

◦ Sanguineous : bright red

◦ Serosanguineous : pale red, watery

mixture of serous, and
sanguineous

◦ Purulent : thick, yellow, green,

or brown

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 WATER SEALED DRAINAGE

◦ Drainage system that is water sealed  to remove air and/or fluid from pleural space.

◦ Goal : restore negative pressure in the pleural space to re-expand the lung.

◦ Conditions with positive intrapleural pressure :

> Pneumothorax
> Hematothorax
> Pleural effusions
> Empyema
> Post thoracotomy

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 PRINCIPLE OF WATER SEALED DRAINAGE

• Gravitation

• Negative pressure

• Suction

• Water sealed

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PRINCIPLE OF WATER SEALED DRAINAGE

One-bottle chest drainage system

◦ It consists of a bottle which collects and contains the
fluid and at the same time seals air leak (leakage barrier-
water seal).

◦ A rigid straw is immersed into the bottle, so that its tip is

located 2 cm below the surface of the saline solution,
which is put into the bottle.

◦ The other end of this rigid straw is connected to the

thoracic drainage tube placed in the pleural cavity.

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PRINCIPLE OF WATER SEALED DRAINAGE

Two-bottle chest drainage system

The first bottle (closer to the patient) collects
the drainage and the second bottle is the water
seal, which remains at

2 cm (water seal and air vent).

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PRINCIPLE OF WATER SEALED DRAINAGE

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 EQUIPMENT

◦ Aquabides
◦ Sarung tangan steril sesuai ukuran
◦ Duk bolong/duk steril
◦ Kassa steril dan hipafix
◦ Povidone Iodine 10%
◦ Lidokain 2% (dosis max 3 mg/kgBB)
◦ Spuit 10cc
◦ Chest tube set  klem kelly, kom, needle holder,
pinset, gunting benang, mosquito
◦ CTT No.28F – 32F
◦ Bisturi No.21 atau No.23
◦ Benang silk 0

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TYPES OF CHEST TUBE

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 PROCEDURE

◦ Perkenalkan diri
◦ Informed consent, surat ijin operasi (SIO)
◦ Ukur chest tube
◦ O2 dan IV line
◦ Pemasangan monitor
◦ Posisikan pasien : setengah duduk dengan sudut antara 30 sampai 60  bila sulit dapat supine

◦ Lengan pada sisi yang akan dipasang ‘chest tube’ diangkat ke atas kepala pasien untuk membuka
ICS

◦ Tentukan ICS 5 dengan cara menghitung dari angulus Ludovici (ICS 2) sampai ke ICS 5

◦ Tentukan tempat insersi, pada ICS 5, anterior linea midaksilaris

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 PROCEDURE

◦ Daerah yang akan diinsisi dan sekitarnya di

sterilkan dengan cairan antiseptik (povidone
iodine) sampai sternum, klavikula, posterior hingga
batas bed

◦ Kemudian ditutup dengan duk steril

◦ Suntikkan anestesi lokal di sekitar tempat yang

akan diinsisi secara antegrade

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 PROCEDURE

◦ Lakukan aspirasi terlebih dahulu untuk melihat

adanya cairan atau isi rongga pleura

◦ Dengan bisturi dibuat sayatan sesuai desain insisi

sejajar dengan costa, lalu dilakukan diseksi untuk
memisahkan jaringan di sekitar costa

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 PROCEDURE

◦ Selanjutnya dilakukan insersi klem Kelly

menembus fascia yang menutupi
m.intercosta dengan arah superior dari
costa, (untuk menghindari pembuluh
darah dan saraf yang terletak di sisi
inferior tiap costa).

◦ Pastikan klem selalu menempel dengan

costa.

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 PROCEDURE

◦ Ketika klem berada tepat di tepi superior

costa, dengan posisi klem tertutup, doronglah
klem ke dalam dada dengan tekanan yang
cukup sampai menembus pleura parietal

◦ Setelah klem menembus rongga pleura, isi

rongga tersebut mungkin mengalir keluar saat
pasien melakukan ekspirasi

◦ Lebarkan lubang dengan membuka klem

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 PROCEDURE

◦ Masukkan jari telunjuk operator untuk

memperlebar saluran yang baru dibuat

◦ Kemudian dilakukan eksplorasi dengan

menyapukan jari mengelilingi lubang yang
telah dibuat untuk meyakinkan bahwa
rongga tersebut betul rongga pleura serta
meyakinkan tidak adanya adhesi/ massa
dalam rongga pleura

◦ Finger decompression

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 PROCEDURE

◦ Setelah eksplorasi jari telunjuk tetap di dalam

rongga sebagai patokan penempatan tube. Tube
dijepit dengan klem dengan ujung tube, kemudian
dimasukan ke dalam rongga pleura mengikuti jari.

◦ Klem dilepaskan, tube didorong dengan arah cranio

posterior

◦ Semua lubang yang ada di bagian proksimal chest

tube harus berada di dalam rongga pleura.

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 PROCEDURE

◦ Perhatikan adanya ‘fogging’ pada chest tube

saat ekspirasi, atau dengarkan adanya aliran
udara. Untuk cairan, perhatikan cairan yang
mengalir dan undulasi

◦ Hubungkan chest tube dengan botol WSD.

◦ Jahit chest tube ke kulit dinding dada, matras

horizontal dari inferior – superior - inferior.
Surgical notch, 7 kali keliling, simple notch,
simpul tali sepatu

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PROCEDURE

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COMPLICATION
EARLY
• Reexpansion pulmonary edema
• Hematothorax
• Lung laseration
• Abdominal cavity/diaphragm penetration
• Subcutanoues emphysema
• Pneumothorax
• Pain
DELAYED
• Obstruction
• Empyema
• Pneumothorax after tube removal
• Infection
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• Persistent hematothorax
FOLLOW UP TUBE REMOVAL

1. Production The lungs have re-rexpanded clinically and

radiologically :
2. Undulation
◦ Difficulty of breathing (-)
3. Air bubble
◦ Fluid production < 100 cc/24 hours  in
pleural effusion or hematothorax

◦ Air bubble (-)  in pneumothorax

◦ X-Ray Thorax : no fluid/air, maximal

lung expasion

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 REMOVAL OF TUBE

◦ Deep inspiration

◦ Pull the tube quickly

◦ Cover the wound with occlucive dressing over the gauze

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THANK YOU

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