1. CHEST TUBE INSERTION Dr. Gwen Hollaar

2. Chest Cavity Punctured lung from rib fracture or penetrating injury to chest causes air &/or blood in space between lung and chest pleura --> lung collapses Normal lungs: No space between lung pleura and chest wall pleura

3. Why put in a chest tube? –To drain fluid or air in the pleural space so that the lung can re-expand When does a patient need a chest tube? –Large pneumothorax –Tension pneumothorax Air continues to leak into pleural space It pushes mediastinum and trachea to contralateral side –Traumatic hemothorax –Acute empyema

4. Clinical Signs PneumothoraxHemothorax InspectionPossible chest bruising Tracheal deviation (if tension pneumothorax) Possible chest bruising PalpationSubcutaneous emphysema Possible tenderness or crepitus over chest wall PercussionHyperresonantDull over fluid AuscultationAbsent breath soundsAbsent or Decreased

5. Where do we place a chest tube? –Anterior to mid-axillary line –4th to 5th intercostal space Level of nipple

6. Things to Remember Neurovascular bundle is under the rib –Intercostal vein, artery, nerve –Must enter the chest OVER the rib, not under Long thoracic nerve (goes to muscles controlling position of scapula) travels in posterior axillary line –Must make incision in anterior or mid axillary line

7. Things to Remember If you make incision too low, you will enter abdominal cavity (i.e. liver) –This is especially true on the right side because the right hemidiaphragm is just inferior to the level of the nipple Liver

8. Material required Sterile gloves and drapes Antiseptic for skin Needle driver, forceps, curved clamp Syringe / Needle Local anaesthetic Scalpel Chest tube Connecting tubing Closed drainage system with sterile water for under water seal Dry gauze and tape

9. Bottle must have lid Bottle must have 2 tubes going thru lid - one tube extends under water (allows air and fluid in pleural space to bubble out, but does not let air enter pleural space) - one tube lets the air empty out of the bottle Tubing connects to patient’s chest tube Open to air Commercial bottles are available, but it is easy to make your own.

10. Step by Step 1.Prepare all your materials, including chest tube, closed draining system, and tubing 2.Abduct and externally rotate patient’s arm 3.Landmark where you will make the incision

11. Step by Step 4.Clean and drape 5.Local anaesthesia (i.e. 1% lidocaine) - Infiltrate the skin with 5 ml - Infiltrate 10 - 15 ml into rib periosteum (if bone encountered), intercostsal muscle, and pleura - Aspiration of air, blood or pus confirms entrance into chest cavity

12. Step by Step 6. Make approximately 3 cm incision just above rib at approximately the level of the nipple (4th to 6th intercostal space)

13. Step by Step 7. Bluntly dissect through subcutaneous tissue and intercostal muscles immediately OVER the rib with a curved clamp - Technique of blunt dissection: Advance closed clamp and open

14. Step by Step 8. Palpate tract - check you are over rib - check how deep 9. Add more local anaesthesia to intercostal muscle and pleura

15. Step by Step 10. When you are almost through intercostal muscle, twist and push tip of closed clamp into chest cavity over rib - Do NOT plunge forward as you could injure lung or diaphragm - When you enter chest, you will should get gush of air or blood or pus

16. Step by Step 11. Open curved clamp inside chest to enlarge tract so you can insert the chest tube

17. Step by Step 12. Palpate the tract and rotate finger 360º to make sure there are no attachments of the lung to the inside chest wall

18. Step by Step 13. Estimate distance between skin incision and lung apex to see how far tube needs to be inserted 14. Grasp end of chest tube between tip of curved clamp and guide into chest cavity 15. Advance tube posteriorly and superiorly the appropriate distance 16. Make sure all of the chest tube holes are inside the chest cavity or you will have a leak!

19. Step by Step 17. Connect chest tube to drainage system with tubing - Good idea to tape all tubing connections so that they do not come apart - Water level should go up and down with respiration - If pneumothorax, air bubbles will pass into water in the bottle when the patient coughs

20. Step by Step 18. Tie chest tube to skin on both sides using 1 or 0 suture (silk or nylon) - Skin should be tightly closed around chest tube

21. Step by Step 19. Can wrap small gauze around drain or use sterile vaseline to make sure no air leaks around tube

22. Step by Step 20. Apply air-tight dressing around chest tube

23. Good position of chest tube

24. Tension Pneumothorax If patient is in acute respiratory distress and has subcutaneous emphysema and deviated trachea to contralateral side – To immediately relieve the tension, insert needle into 2nd intercostal space in mid clavicular line – Then put in chest tube

25. Chest Tube Removal Must be cautious and prevent air from entering chest through incision. –Place suture at site of incision (not tied yet) –Have patient take full inhalation and hold it Patient cannot suck air in through incision –Remove chest tube and immediately tie down suture. –Place gauze and tape over incision