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Technique for Chest Tube Insertion

Tuesday, April 4, 2017

Chest tube insertion is a procedure commonly performed by residents and fellows throughout their general and cardiothoracic surgical training. Proper placement of a chest tube can effectively evacuate air, fluid, and blood. In many cases, insertion of a chest tube can prevent more invasive procedures. This video will demonstrate tips and tricks for the successful insertion of a chest tube, whether on the floor or in the operating room.

Patient Considerations

  • Stability of the patient
  • Why is the tube being placed?
    • It is important to note whether the tube is being placed for fluid or air in order to appropriately direct the tube for maximum drainage
    • Tubes placed for fluid should be directed posteriorly, while tubes placed for air should always be directed apically
    • If the collection is loculated, imaging may be used as an adjunct to help plan the chest tube position and ensure that the tube is directed into a precise location
  • Factors that can make chest tube placement more difficult
    • Prior chest surgery, previous chest tube placement, prior chest irradiation can all result in adhesions that may complicate a tube thoracostomy, and make it more difficult to direct the tube to the desired location
  • Anticoagulation
    • If a patient is anticoagulated, it is preferable to reverse anticoagulation, if possible, prior to performing a procedure
  • Always consider your pain management plan ahead of time
    • A dose of pain medication 30 minutes before the procedure can significantly improve patient comfort
    • Liberal use of local with each layer particularly on awake patients

Positioning

  • Bump under the back with arm over the head and out of the procedural field
  • The chest should be as flat as possible or gently flexed to allow for maximum opening of the spaces between the ribs

Identify Landmarks

  • Even in an emergency situation, take a few moments to identify your important landmarks.  It is important for the tube to go into the correct location, particularly in an emergent situation, so taking time to ensure this will be the case is essential.
  • The authors spend some extra time during the video reviewing important anatomical landmarks that can be used to assist in tube placement, including:
    • Tip of the scapula
    • Nipple or infra-mammary or pectoral crease
    • Anterior inferior iliac spine
    • 12th rib
    • Mid-axillary line – it is ideal to place chest tubes in front of this line for patient comfort so that they are not laying on the tube
    • Approximate lie of the diaphragm
  • Plan your incision
    • It is helpful to use a marking pen to select your incision site prior to prepping and draping to make sure that you have a firm idea of where you plan to place your tube.
    • Always make an adequately sized incision, allowing adequate room to introduce a finger as well as the tube, to allow for the tube to be carefully directed into position.

Time out

  • Verify your patient, laterality, equipment, and that you have adequate help in the room
  • Have your assistant start setting up the atrium
  • Using the buddy system is always a good idea
    • An extra set of hands to prep, drape, hand you instruments, and hold the chest tube while tying into place is ideal.  Always take someone with you if you can!

Pain Management

  • For patients who are intubated and asleep you have the benefit of general anesthesia
  • For awake patients on the floor, chest tube insertion can be performed in a comfortable manner without the use of sedation team if the local is performed properly.
    • Have all 30 mL drawn ahead of time and ready to use
    • Begin with anesthetizing the skin and allow for adequate time for the agent to take effect  
    • As dissection is carried down to the chest wall, continue to anesthetize each layer encountered while allowing time for the local to take effect
    • It is essential to adequately anesthetize the pleural, as it is highly innervated and can be the most uncomfortable portion of the procedure for the patient

Dissection

  • Blunt dissection is carried down to the chest wall. Use your finger to identify the top part of the rib. 
  • Remember that the intercostal artery, vein, and nerve run on the underside of the rib, injury to these vessels can result in a significant amount of bleeding.
  • The chest should be entered bluntly with a hemostat or curved Kelly clamp
  • Brace your dominant hand with your second hand to avoid advancing the clamp too far into the chest and risking injuring the lung or the heart on the left side.
  • Dilate the track
  • Insert the chest tube using the Kelly clamp or your finger to guide the tube into the desired location
    • The video shows the chest tube advancing into the chest under VATS guidance for the intra-operative patient
    • Remember that there is the benefit of being able to drop the lung
    • In awake patients, a finger can be helpful to direct the chest tube away from the fissure

Secure the Tube

  • Secure the chest tube in place with a large silk suture (number 1 or 0)
    • Go around the chest tube several times
    • Cinch down to create a small waist on the chest tube
    • Tie many knots
    • Go around a second time and re-secure chest tubes should never accidentally fall out due to inadequately secured tube
  • A second suture should be used to close the incision, if there is additional space to avoid drainage or introduction of air

Dressing

  • Chest tube dressing should maintain the tube in a neutral position to prevent kinking at the level of the skin

Comments

Nice explanation. But here in our common practice we also take purse string suture for future closure of skin incision when tube is out.
I would advise against putting the arm behind the as it pulls the chest wall skin superiorly and when the arm goes back to its normal position the suture securing the drain to the chest tube will cause the drain to migrate inferiorly from its original position in the chest. When anesthetizing it is helpful to aspirate on the syringe as you will know that you just passed the pleura when you get air or effusion back and you can pull the needle slightly back before depositing a generous amount of LA on the pleura. It is advisable to have a subcutaneous tunnel one ribspace up as this ensure less chance of pneumothorax upon drainremoval as the tunnel can be compressed by a finger on the skin closing it to prevent airentry. A finger through the whole confirms intrathoracic location and free pleural space. A trocar slightly pulled back and used gently can be very helpful for placing the drain. When the patient experiences neckpain, you know you reach the apex. Vicryl is better for securing drain as the suture doesn't snap as easily as silk. I prefer using a horizontal matress suture evened out with a knot on the two suture ends about 10 cm from where it exits the skin. After exiting the skin you wrap the suture around the drain before pulling it through the loop above the skin of the matress suture, making sure the knot is pulled through the loop. Then the two suture ends encircle the drain clockwise and anticlockwise2 times before you tie the knot securing the drain. When you want to remove the suture you just cut the suture below the knot that was pulled through the loop and you now have 2, 10 cm long suture ends exiting from the matress suture you can tie to close the hole. Thus one suture both the secure the drain and is already in place to close the hole upon drain removal. With a pneumothorax it is advisable to warn the patient that the lung re-expansion is going to be temporary painful specially if suction is applied because of stretch of the visceral pleura. Otherwise this can cause the patient to panic.
Apologize for typo errors as the preview function didn´t work on the website. Putting the arm behind the head jeopardize the intended drain postion beause of skin movement, specially in women and the obese. One suture can both secure the drain and be used for hole closure with this technique.
it is common practice as already mentioned in the previous comment that an additional suture is placed to close the wound during the time of removal of the chest tube..
Dear honored colleagues in Mayo Clinic: Congratulations for such a great illustrative video. Preoperative planning, the incision, disection and digital thoracostomy were all great. However, I found som issues concerning the following: 1. ANESTHESIA: I do not think that this short needle used in the video is long enough to penetrate a thoracic chest wall in our common patients (Scandinavian-although we are not so fatty in general !). I could see that the operator neither penetrated the parietal pleura nor confirmed the pleural content whether air, blood or effusion. It has been said but not done in the video . INSERTION TECHNIQUE: Using a Kelly Clamp guiding the tube inside the chest is not always safe. It is almost (but not) like a trocar that is obsolete nowadays. This definitely could penetrate the inflated lung during insertion although didgital thoracostomy has confirmed no adhesions but usually air and or blood comes out once we entered the chest giving a great chance for the lung to inflate With the risk of penetration/injury. Therefore, any clamps are not recommended to insert the tube with. In my technique addressed below. I usually use my non-harmful fingers if I must. Furthermore, Planning the size of the incision (bredth of tube+finger) was good intention just for using the finger not the clamp as said in the video. So I Wonder, why you did not use the finger as you perfectly planned it preoperatively? Accordingly, the incision would be much smaller when using the clamp as shown (probably only 1 cm if we follow such a preoperative precaution). SECURING THE TUBE: I found it inadequate. The edges of the incision were not perfectly co-adapted, and this will predispose to air leakage once suction is instituted. Moreover, a new suture that needs again local anesthesia must be used to close the incision once the tube is removed. VASELINE GAUZE: Such a gauze is never a good alternative for securing an air-tight incision compared with a perfectly closed incision, with the risk of infection by keeping the incision around the tube moisty, particularly in trauma. We use a Tegaderm that is transparent (see wound changes towards infection) and even air tight following meticulous wound closure. I recommend therefore, more rigorous technique to anchoring the tube in case of trauma (50% unconscious with easy dislogement of the tude), elective and urgent cardiothoracic procedures in adults and in pediatric practices. This is basically a technique that I developed as a student and used it since the end of Eighties in my early cardiothoracic training in Sweden and became well known in the rest of Scanjdinavian countries. Here is Rashid`s technique, where 3 sutures just for trauma patients and spontaneous pneumothiorax, but only one (the horizontal mattress suture) for drains as part of surgery. http://www.jctt.org/text.asp?2016/1/1/12/194053 Welcome with your comments on this simple and modest technique.

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