Chest Drainage

Chest Drain/Tube Thoracotomy/Intercostal Chest Drain/Chest Tube Insertion/Chest Catheter Insertion

Definition: A chest tube inserted to drain the contents of the pleural space, be it air, blood or other fluid (e.g. pus).

Rationale behind a chest tube/Why insert it?

Recall Badariah’s Lecture on Mechanics of Breathing: When air/fluid enters pleural cavity, outside (atmospheric) pressure = inside (pleural cavity) pressure --> pleural cavity pressure = lung pressure --> pressure difference destroyed --> lung collapses

By draining the air/fluid out of cavity --> pressure difference restored --> re-expansion of lung

In order to do this, you must prevent entry of air/drained fluid back into the chest, and hence, a chest drain must have three components:

• An unobstructed chest drain
• A collecting container below chest level
• A one-way mechanism such as water seal or Heimlich valve

Indications for Chest Drain
(should wait for confirmation via X-Ray/ultrasound before proceeding)

Pneumothorax (pleural space filled with air) (tension, spontaneous, traumatic)
Haemothorax (pleural space filled with blood)
Empyema (pleural space filled with pus) and other Pleural effusion (pleural space filled with fluid)
Post-operative- thoracotomy, oesophagectomy and cardiac surgery

Emergency Circumstances:
Traumatic Arrest (with no cardiac output)
Patients in shock, or hypoxic due to penetrating trauma
Traumatic haemopneumothorax

Chest drain can be diagnostic and/or therapeutic

Therapeutic (as above)

Diagnostic:
Feel the texture of lung surface (for contusions)
Feel surface of diaphragm (for lacerations)
Feel heart (for presence of tamponade)

Examine material being drained:
Bright red/arterial blood – patient requires a thoracotomy
Intestinal contents – oesophageal injury or stomach/bowel injury
Persistent air leak – lung laceration
Large leaks – bronchial disruption

Contraindications

Infection over insertion site
Bleeding

Pre-procedure Patient Education

Obtain informed consent
Inform the patient of the possibility of major complications and their treatment
Explain the major steps of the procedure, and necessity for repeated chest radiographs

Procedure

1. Get materials ready, determine size of chest tube
2. Confirm site of insertion
3. Maintain sterile environment
4. Position patient
5. Anesthesia/Analgesia
6. Insertion

Materials

Chest tube
Chest tube suction unit
Chest tube tray to include scalpel blade and handle, large clamps of choice, needle driver, scissors
Packet of 0 or 1.0 silk suture on a curved needle
Tape, gauze
Anaesthesia of choice, 20cc syringe, 23-gauge needle for infiltration
Sterile prep solution; mask, gown and gloves

Selection of Chest Tube (measurement is Frenches: Fr/F)

Small, medium, large Chest Tube
Depends on what is being drained (larger for blood)
Depends on age (larger for older people)

Confirm Site of Insertion

Mid- or anterior- axillary line
Behind Pectoralis Major (to avoid having to dissect through this thick muscle)
Line lateral to the nipple (On expiration, the diaphragm rises to the 5th rib at the level of the nipple, and thus chest drains should be placed above this level)
Between 4^th or 5^th rib (highest rib space that can be easily felt in the axilla)

Sterile Environment/Position Patient

Don mask, gown, gloves.
Prep and drape area of insertion.
Position the patient. Have patient place arm over head to “open up” ribs.

Anesthesia/Analgesia

Chest tube insertion is a painful procedure, especially in muscular individuals; usually a combination of anaesthesia and analgesia is used.

Intravenous analgesia:

Opiods e.g. Morphine
Ketamine (alternative to opiods) (20mg)

Widely anesthetize area of insertion with local anaesthesia. Infiltrate skin, muscle tissues, and right down to pleura.

Local anaesthesia:

2% lidocaine (10-20ml)

Insertion

1. Make a 3-4 cm incision through skin and subcutaneous tissues between the 4^th and 5^th ribs, parallel to the rib margins.

2. Continue incision through the intercostal muscles, and right down to the pleura.

3. Insert Kelly clamp (or other curved clamp) through the pleura and open the jaws widely again parallel to the direction of the ribs (blunt dissection).

4. Insert finger through your incision and into the thoracic cavity. Make sure you are feeling lung (or empty space) and not liver or spleen.

5. Grasp end of chest tube with the Kelly forceps (convex angle towards ribs), and insert chest tube through the hole you have made in the pleura. Direct the tube over the top of the lower rib to avoid the intercostal vessels lying below each rib.

6. After tube has entered thoracic cavity, remove Kelly, and manually advance the tube in.

7. Suture/secure the tube in place. Certain closure sutures can be used in anticipation of removal.

8. Connect the tube to the drainage unit.

9. The chest is re-examined to confirm effect.

10. A chest X-ray is taken to confirm placement & position.

Drainage Unit

All chest tubes should be connected to a single flow (one direction of flow) drainage system e.g. underwater seal bottle or flutter valve.

A closed underwater seal bottle is one in which the tube is placed underwater (distilled water) at a depth of approximately 3 cm with a side vent which allows escape of air.

The drainage bottle should always be kept below the level of the patient, otherwise its contents will siphon back into the chest cavity.

The bottle may also be connected to a suction pump (when suction is turned on, air and fluid are pulled out of the pleural space and into the drainage collection bottle).

In basic terms:

Drainage occurs during expiration when pleural pressure is positive
Fluid within pleural cavity drains into water seal
Air bubbles through water seal to outside world

Complications

Tube placed subcutaneously: tube goes along chest wall instead of into chest cavity
Tube inserted too deep (lung laceration), or not deep enough (holes in tube sticking out)
Tube inserted too low: diaphragm and abdominal cavity penetration; puncture liver or spleen
Bleeding (usually ceases)
Pneumothorax after removal

Removal

Remove drain as soon as it has served it purpose
To remove drain ask patient to perform a Valsalva manoeuvre
Remove drain at the height of expiration
Tie pre-inserted closure suture.
Perform a post-procedure chest x-ray.

Documentation

1. Consent if obtained

2. Indications and contraindications for the procedure on this patient

3. Procedure used (trocar vs. non-trocar)

4. Any complications, or “none”

5. Who was notified of any complication (family, attending physician)

6. Patient education materials on chest drainage

Sources:

http://apps.med.buffalo.edu/procedures/chesttube.asp?p=7
http://www.nlm.nih.gov/medlineplus/ency/article/002947.htm
http://www.cssolutions.biz/cts.html
http://thorax.bmjjournals.com/cgi/reprint/58/suppl_2/ii53.pdf (fantastic article for everything one needs to know about chest drains)
http://www.surgical-tutor.org.uk/default-home.htm?specialities/cardiothoracic/chest_drains.htm~right
http://www.trauma.org/index.php/main/article/400/