Chest tube insertion lab

Tube placement sites Depends on purpose Anterior (triangle of safety) Pneumothorax Low lateral (Ultrasound guidance really helps) Fluid drainiage

Indications

Triangle of Safety

Incision and Insertion Sites

Dissection OVER rib

Chest tube size Air: small Fluid: medium Blood: Large Pus: Large

Alternate procedures Underwater seal jar Heimlich valve Simple needle aspiration and recheck For simple pneumothorax only: Small No tension Underwater seal jar Heimlich valve

Tube removal criteria Pneumothorax: no bubbling and lung expanded Consider an interval of tube clamping before removal Probably best to not remove while on mechanical ventilation, especially with PEEP Drainage: less than 200 cc/24 hours Take care to seal hole during and after removal! Follow-up chest x-ray

Complications Bleeding and hemothorax due to intercostal artery perforation Perforation of visceral organs (lung, heart, diaphragm, or intra-abdominal organs) Perforation of major vascular structures such as the aorta or subclavian vessels Intercostal neuralgia due to trauma of neurovascular bundles, Subcutaneous emphysema, Re-expansion pulmonary edema Infection of the drainage site Pneumonia, and empyema Technical problems such as intermittent tube blockage from clotted blood, pus, or debris, or incorrect positioning of the tube, which causes ineffective drainage.