1. CHEST TUBES

2. Chest tubes Indications Pleural effusions Pneumothorax Hydrothorax
Chylothorax
Hemothorax
Empyema
Pneumothorax

3. Pleural Effusions Fluid in the pleural space Two types Transudative
Exudative

4. Pleural Effusions Transudative
Accumulation of fluid when the integrity of the pleural space is intact
Less protein and inflammatory cells
Hydrostatic and osmotic pressures are abnormal

5. Pleural Effusions Exudative Inflammation of the lung or pleura
More protein and inflammatory cells
Types
Hemothorax
Chylothorax

6. Pleural Effusion Exudative Causes Neoplastic disease
Infectious disease PE
GI disease
Drugs

7. Sike! Someone thought this was a pleural effusion. Why isn’t it?
This elderly lady presented with delirium, but no other medical history could be obtained. The chest x-ray showed what was assumed (by the medical registrar) to be a right sided pleural effusion. He was keen to drain it. Luckily, the physician decided that he wanted a CT of the chest first, which revealed a large right-sided diaphragmatic hernia.
The scout image from the CT is shown, which demonstrates colonic bowel gas and soft-tissue density corresponding to the liver herniating into the right hemithorax. There is also Paget’s disease of the right humerus.
Incidentally-discovered posterior diaphragmatic hernias (Bochdalek hernias) are rare (0.17% of patients having an abdominal CT). Of these, right-sided hernias are more common (68%). The great majority are small, with only 27% containing abdominal organs such as bowel, spleen or liver.
Reference: Mullins ME, et al. Prevalence of Incidental Bochdalek’s Hernia in a Large Adult Population. AJR 2001; 177:
Credit: Dr Michael Tam
ANIMATION: SIKE

8. Now here’s a pleural effusion. Case Report
An eighteen year old male presented to the emergency department with rapidly progressive shortness of breath, chest tightness, and a physical exam significant for tracheal deviation. The patient had a past medical history significant only for tuberculosis diagnosed three years prior. A chest roentgenogram revealed a massive right side pleural effusion with significant tracheal and mediastinal shift (Fig. 1).
An attempt to drain this effusion with a thoracostomy tube was not successful in resolving the patient's symptoms and was cytologically non-diagnostic.
Video assisted thoracoscopy was performed. Three large cystic masses were seen within the right chest. Due to their massive nature the decision was made to perform a standard posterolateral thoracotomy. The superior cystic mass was found to arise from the superior mediastinum, the middle mass was adherent to the pericardium, and the inferior mass arose from the posterior mediastinum, entering the abdomen at its lower border.
A second thoracostomy tube was placed and the surgical incision closed. The patient's postoperative course was uneventful. He was discharged home on the fifth day following surgery. Histopathology confirmed the diagnosis of cystic hygroma (Fig. 3).
In an eighteen month period following discharge the patient has required two hospital admissions for chest tube drainage of symptomatic right pleural effusions.
Discussion
Occult cystic hygroma represent a variant type of cystic hygroma that remains hidden within the thoracic or abdominal cavities. They eventually present in adolescence or adulthood and may grow to enormous size prior to becoming symptomatic 4 . Many are discovered incidentally as abnormal radiographic findings.

9. Pneumothorax Air in the pleural space Can be Traumatic Spontaneous
Tension

10. The symptoms of tension pneumothorax tend to be severe with sudden onset (beginning). They include anxiety, swollen neck veins, weak pulse, and decreased breathing sounds from the lung
Chest X ray showing a collapsed right lung (the left side of the image). (© Reproduced by permission of Custom Medical Stock Photo .)

11. Chest tubes Small bore 7 French shown Heimlich valve
What is the size range for children and adults?
Heimlich valve
Used for pneumothorax mostly

12. Chest tube
Insertion
2nd or 3rd intercostal space
Midclavicular level

13. Chest Tube Large bore Up to 40 French
For pleural effusions and pneumothorax
Use local anesthetic and dissect to the parietal pleura
Finger sized hole

14. Chest Tube Large Bore Insertion Suture into place, use petroleum gauze
4th to 6th intercostal space
Midaxillary line
Suture into place, use petroleum gauze
Get x-ray
Hook to drainage system

15. Drainage systems Gravity Positive pressure Suction
Affects air and fluid
Positive pressure
Increased positive pressure from the air or fluid will try to relieve itself to lower pressure
Suction
Sub-atmospheric pressure
Gravity: self-explanatory
Increased positive pressure from the air or fluid will try to relieve itself to lower pressure (in the water)
Suction: Use of vacuum speeds the movement of air and fluid

16. Drainage systems One bottle system Contains 100ml of sterile water
Airtight cap
Two vent tubes

17. Drainage systems Two bottle system 1st bottle = drainage
2nd bottle = water seal

18. Drainage systems Three bottle system 1st bottle = drainage
2nd bottle = water seal
3rd bottle = suction

19. Drainage systems Trouble shooting Excessive bubbling No bubbling
Leak in system
No bubbling
Re-expansion or occlusion
Milk the tubes…maybe

20. Drainage systems Pleur-evac
Three bottle concept in one lightweight, plastic unit
Easy to transport
Difficult to break
Easy to exchange when full
Will hold up to 2500 mL of fluid

21. Drain systems Pleur-evac
Right side – calibrated for measurement of fluid evacuation
Middle – water seal chamber
Left side – suction control

22. What constitutes stable??
Chest tube removal
Requirements
No air leak
< 100 mL drained in hours
Stable respiratory status
What constitutes stable??

23. Chest tube removal Patient in semi-fowlers Premedicate
D/C suction, clamp tube
Prep 4x4 gauze of Jelonet and elastoplast tape

24. Chest tube removal Remove current dressing and remove sutures
Clean site with antiseptic solution
Patient deep breath, pull out
Should come out easily!!!!!!
Secure site with the gauze and elastoplast

25. Chest tube removal
Watch patient for signs/symptoms of respiratory distress
Get chest x-ray