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ByMARITES A. ROSAPAPAN, RN

Clinical Instructor

License No. 0274161

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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.

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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 under

-lying pathology

Numerous indications in which patients

are at great risk for major morbidity or

mortality

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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

pneumothoraxin

patients over 50

years

Rapidly

accumulating pleural

effusion

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Empyema

and complicated

parapneumonic effusion

Hemo or haemopneumothorax

Postoperative

(

in

cardiac & mediastinalsurgery)

Chylothorax

Chest trauma

When pleurodesis is needed

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Absolute: The need for emergent thoracotomy

Fused pleural space

Relative: include the following: Coagulopathy

Pulmonary bullae

Pulmonary, pleural, or thoracic adhesions Loculated pleural effusion orempyema

Skin infection over the chest tube insertion

site

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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 basaltube for fluid

3. For intra-thoracic extra pulmonaryoperations:only one basal tube ifpleura is opened

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Chest tube drainage device withunder 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

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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, 4x 4(10)

Sterile adhesive tape, 4wide

Chest tube of appropriate size :

=Man : 28-32F =Woman : 28F

=Child : 12-28F = Infant : 12-16F

=Neonate : 10-12F

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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

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Best is semi recumbent

at a 30- 45

The arm on the affected

side should be abductedand externally rotated

A soft restraint or silk

tape can be used tosecure the arm in this

location

Safe

Triangle

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Best positioning: 30 elevation,

45 rotation

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Give O2 IV line Observe Identify the 5th space and the

mid axillary line (MAL)

Clean the area (remove excess

hair)Mark the site of insertion (4thor

5thspace between MAL and AAL)

Wear sterile gloves, gown, haircover, and goggles or face shield

Apply sterile drapes to the area.

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Administera systemic analgesic(unless contraindicated).

Use the 25-ga needle to inject 5

mL of the local anesthetic

solution into the skin overlyingthe initial skin incision

Infiltrate the skin area of incision

by 5 ml of the anesthetic then

direct down to periosteum andinfiltrate with 10 ml

Advance the needle and aspirate

to confirm entry to pleura

If no air or fluidaspirated?

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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 therib itself.

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Use a hemostat or a

medium Kelly clamp

Bluntly dissect a tractin the subcutaneous

tissue by intermittently

advancing the closed

instrument and opening it

Dissect down to

intercostal muscles

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Further blunt dissection down tothe pleura

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Palpate the tract with a finger as shown, and make surethat the tract ends at the upper border of the rib underthe skin incision

Adding more local anesthetic to the intercostal muscles

and pleura at this time is recommended.

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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

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

possible adhesions

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Rotate the finger 360 to appreciate the presenceof dense adhesions that cannot be broken andrequire placement of the chest tube at anothersite

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The proximal end of the chest tube is held with aKelly clamp that guides the chest tube through thetract.

The distal end of the chest tube should always be

clamped until it is connected to the drainage device.

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Tube insertion guided

by a curved Kelly clamp

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Desired intra pleural length equals the

distance between incision and lung apex

Direct the tube upwards and posteriorly inpneumothorax and above the diaphragm in

effusionBefore securing the tube with stitches, look

for a respiration-related swing in the fluidlevel of the water seal

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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 severaltimes to cause slight indentation, and then tied

again

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Sealing suture: A central vertical mattress stitch withends left long and knotted together can be placed to

allow for sealing of the tract once the chest tube isremoved.

Place petrolatum (eg, Vaseline) gauze over the skinincision as shown

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Prepare a Y-shaped fenestrateddrain gauze from regular gauze(4 x 4 in).

Apply support gauze dressingaround the chest tube andsecure it to the chest wall with

4-in adhesive tape

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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 aschambers. Commercially prepared

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THORACOSTOMY TUBE

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THORACOSTOMY TUBECARE1. The amount of suction is regulated by the wallgauge in two-bottle.

2. The amount of suction is regulated by the depthof the tip of venting glass submerged in the waternot by the suction machine (continuous negative

pressure) in three-bottle.3. Water seal bottle fluctuates during:

inhalation = upexhalation = down (tidaling is a normal sign)

bubbling means persistent leak of air from thelungs or leak in the system

4. 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

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THORACOSTOMY TUBECARE

1. Emergency equipment must beavailable always in the bedsideextra bottlespetrolatum gauzeadhesive tapeclamp with rubberized tip

2. Milk the tube in the direction of thebottle.

3. Fluctuation/tidaling will stop when:lung has re expandeddependent loop develops and

suction is not working

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THORACOSTOMY TUBECARE

1. Always put the drainage system belowchest.

2. Never clamp the chest tube duringtransport or prolonged period of time.

3. Location of the tip of chest tube will beconfirmed by an X-ray and fullexpansion of the affected lung.

4. Chest tube is removed when the lungs

have re-expanded in 24 hours toseveral days.

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THORACOSTOMY TUBECARE

1. During tube removal avoid a sudden largeinspiration this may producepneumothorax.

2.

When tube is accidentally disconnected.What to do?Place the distal-end tube in a containerwith sterile water

3. When tube is accidentally pulled-out fromthe chest

Ask client to do valsalvas maneuver thenapply an occlusive dressing

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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 thepleura

Check for optimal position of the tube insidethe chest by X-ray

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Left side chest tube

in a good position

Right side chest tube

in a wrong position

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Complications are reduced whendone by experienced operators

Good experience is gained after doing

at least 10SUPERVISED 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

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1.ImproperplacementHorizontal (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

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2.Bleeding Local -Usually responds to direct

pressure Hemothorax (lung vs IC artery

injury)- Might requirethoracotomy if it does not resolvespontaneously

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3.Organ penetration and injury: Lung -Occurs as a result of pleuraladhesions or use of a thoracostomy tube

trocar Liver or spleenwith hemoperit-

oneum -Requires emergent laparotomy

Stomach, colon, or diaphragm -Occursas a result of unrecognized diaphragmatichernia

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4. Dislodgement:Due to accidental pull re-introduce

a sterile tube5. Pleural infection and empyema:If sterilization is poor

6.Mal or non function:replace

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The tube must be sealed after insertion Sealing is by underwater systemor

Heimilch valve

Underwater seal is the most commonlyused

It is either single bottle, two bottles or three

bottles system

The seal is a straw that pass through thebottle cap and settle 2-3 cm below water

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When intrapleural pressure rises above 3cm water contents of pleura are expelledbut 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)

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CONCEPT

Most basic concept

Just like a straw ina drink, air can be

pushed through the

straw, but air cantbe drawn back up

the straw

Tube fromthe patient

Straw conceptTube open toatmospherevents air

UNDER WATER SEAL

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UNDER WATER SEAL

1 2

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3

Trap Seal Manometer

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Disposable 3 bottle one unit system (Pleuro-Evac)

H i li h Fl tt V l

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Heimlich Flutter Valve

One way flutter valve

Used for ambulant patients withpneumothorax

Must be placed in a correct position otherwisewill be fatal

When functioning makes a duck like quacks

Inspiration

Expiration

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Proper connection to the seal

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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

Two loops nearthe patient

Dependent loop Wrongconnection

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The following can significantly restrict

tube function and could be dangerous:

A full bottle with glass straw tip deep underthe fluid surface.

Too narrow or too soft tubing may spontaneou-

sly 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 willobstruct flow and create back pressure,especially to an air leak

P i b h

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Patient must be taught:

To keep the bottle down

To have good inspirations toinflate the lungs

To observe any change in the

bottleand to call for helpwhen:

Develops respiratorydistress

Excess bubbling occurs Excess blood seen Oscillation stops The tube move from place

100 cm

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Morning Evening 24 hour total

Date Air Fluid Others Air Fluid Others

CHEST TUBE FOLLOW UP CHART

WALL

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Use of suction to chestbottles is somewhatcontroversial

When properly applied,chest tube suction is veryuseful

There are different ways:thoracic pumps or wallsuction

WALL

PUMP

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Conditions where

Suction is Useful:1. Pneumothorax: Persistent leak after 18-24 hrs

A defect in seal system that cannotbe corrected

2. Effusion:When thick and not easily drained

3. Hemothorax:Unless active bleeding is present

4. After open heart surgery

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Clamping the tube is indicated in:

1. During insertion and if signs ofREPE develops

2. During transportation3. During seal changing4. As a test for leaking connections

5. After introducing pleural sclerosant6. After pneumonectomy: controlled7. For milking and striping

8. Before removal

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A chest tube can be safely removed

when:1. Patient clinically well2. X-ray shows fully expanded lung

3. In pneumothorax: no leak for 24 hrs4. In effusion: less than 50-80 ml ( some: 200-

300 ml) fluid gain/24 hrs

The fixing stitches are cut, patient takes deepinspiration, tube withdrawn, the track sealedrapidly with a gauze, the sealing stitch is

tightened

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f h l f il d

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4 possibilities:

Wrong placement: correctLarge leak: put on suctionPleural cortex (rim): decorticationEndobronchial obstruction:

bronchoscopy

If the lung fails to re-expand

after ICT placement?

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Occurs with high volume air leakCommonly occurs at start of suctioning

Overcome by silicon antifoam spray oradding ethanol to the bottle

If foaming (excess froth in

the bottle) occurs ?

If th t b i bl k d d

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The tube will stop oscillation

Check for kinking, if not(a possible clot)

Milking: distal clamping and proximalmilking

Striping: proximal clamping and distalstriping Clean with a sterile Fogarty catheter

Change the tube if all fail

If the tube is blocked and

stop function?

If i l h

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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 onsuction

If pt. is distressed: release tension

If surgical emphysema

(SE) develops?

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3 possibilities:

1. Disconnected from the seal

2. Dislodgement of ICT from chest

3. A leak within the lung itself

This means excessive air leak

If the seal bottle on suction

suddenly bubbles furiously?

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1stcheck the patient:Stable and no manifestations of

respiratory distress:

Check for tubing disconnectionand reconnect

Aseptically re-insert a dislodged

tube Ask the pt to cough to expel any

air entered the pleura

st

h k th ti t

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1stcheck the patient:

Unstable with manifestations ofrespiratory 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 :

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If the ICT tube is dislodged :

Continue pt. support and monitoring

Swap the area of insertion and theexposed 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 tubeNew X-ray chest to check position

Give prophylactic antibiotics

l l k

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These patients need VATS

or open thoracotomy

IF lung air leak persist

after one week onsuction ?

If a sudden gush of blood

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3 possibilities:

1. Severe active bleeding: support

circulation, call for thoracotomy2. Mild active bleeding: wait and see under

close observation

3. A collected blood passed a block: closeobservation

If a sudden gush of blood

appear in the drain bottle ?

SPECIAL SITUATION

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ICT IN VENTILATED PATIENTSICT can cause:

1.Decrease Vt2.Decrease oxygenation and CO2 removal

3.Inappropriate cycling of the ventilator

4. Persistence of air leak (BPF)

So, this situation is somewhat difficult

SPECIAL SITUATION

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Ventilator management:

Minimize airway pressure:

1. Decrease Vt

2. Decrease respiratory rate

3. Decrease inspiratory time

4. Use least PEEP possible

V til t t

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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

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