1. Chest tube insertion and pleural ultrasound
Prepared by Shane Barclay MD

2. Objectives 1. Review lung and pleural ultrasound.
2. Review the indications for chest tubes.
3. Review the technique for chest tube and pigtails.
4. Review chest tube removal.

3. Lung ultrasound
The next slide is an excellent video by Dr. Bret Nelson of Mt. Sinai Medical Center in New York. It covers ultrasound for detecting pneumothorax but also covers congestive heart failure.

4. Pleural Ultrasound

5. Indications for a chest tube
Absolute indications: 1. Pneumothorax (tension, simple or open) - Depending on size and whether Pt is to be air-evaced. 2. Hemothorax Relative indications: 1. Rib fractures with positive pressure ventilation. 2. Hypoxia/shock with penetrating chest injury.

6. Some points on Needle Thoracostomy
The standard ‘ATLS’ protocol for tension pneumothorax is to first do a needle thoracostomy then insert a chest tube. However, you should be aware of the efficacy of Needle Thoracostomy

7. Some points on Needle Thoracostomy
J Trauma Acute Care Surg Dec;73(6):1412-7
Using a swine model: All NTs were patent on initial placement, but 5 (26%) demonstrated mechanical failure (due to kinking, obstruction, or dislodgment) within 5 minutes of placement
Among those that remained patent at 5 minutes, 43% failed to relieve tension physiology for an overall failure rate of 58%.

8. Some points on Needle Thoracostomy
J Trauma Acute Care Surg Dec;73(6):1412-7
Using a swine model: The NT failed to restore perfusion in nine events (64%), whereas Thoracostomy Tube was successful in 100% of events as a primary intervention and restored perfusion as a rescue intervention in eight of the nine NT failures (88%).

9. Some points on Needle Thoracostomy
But:
J Trauma Acute Care Surg Feb; 80(2): 272–277. Needle Thoracostomy: Clinical Effectiveness is Improved Using a Longer Angiocatheter.
Compared using a 5 cm versus an 8 cm angiocath
Patients who underwent NT using 8 cm compared to 5 cm were significantly more effective (83% VS 41% respectively)

10. Needle Thoracostomy versus a finger thoracostomy
Using a #10 scalpel, a large curved forcep and your finger, generally you can open the chest for decompression in well under a minute. Perhaps slightly longer then a needle thoracostomy, but not much, and much more accurate/reliable for decompression.

11. Do you need CXR or ultrasound evidence of a pneumo/hemothorax to place a chest tube? NO

12. If you have a clinical story and findings suggestive of a pneumothorax or hemothorax and the patient is ‘crashing’ (traumatic arrest, no cardiac output, penetrating chest injury) do not waste time doing a CXR or lung ultrasound.

13. techniques for a chest tube
There are subtle variations on chest tube placement. The first one presented here is the ‘standard’ technique.

14. techniques for a chest tube
Location: (is the same for all techniques) - “4th intercostal space (nipple line), mid axillary line”. The diaphragm can rise to the 5th rib at the level of the nipple therefore chest tubes should be above this level. Or pick the highest rib space felt in the axilla.

15. technique for a chest tube

16. technique for a chest tube
Analgesia: If the patient is conscious you should use both IV (fentanyl, morphine) and local anesthesia ( cc xylocaine). For local anesthesia: 10-20mls of local anesthetic is required.

17. Local Anesthetic
1. 10 – 20 mls local anesthetic will be needed. 2. Infiltrate under the skin along the line of the incision. 3. Then direct the needle perpendicular to the skin infiltrate through the layers of the chest wall down on to the rib below the actual intercostal space. 4. Inject around the periosteum of the rib. 5. The needle is then directed up over the rib and advanced slowly until air is aspirated. 6. The last few mls of anesthetic can be injected into the pleural space.

18. technique for a chest tube
Have your pleur-evac set up. See video on this web page.

19. technique for a chest tube
Procedure: 1. Prep and draped the area appropriately 2. Using #10 blade make an incision is made along the upper border of the rib below the intercostal space to be used. The drain track will be directed over the top of the lower rib to avoid the intercostal vessels lying below each rib. The incision should easily accommodate the operator's finger. 3. Using a curved clamp the track is developed by blunt dissection only. The clamp is inserted into muscle tissue and spread to split the fibers. The track is developed with the operator's finger. 4. Once the track comes onto the rib, the clamp is angled just over the rib and dissection continued until the pleural is entered

20. technique for a chest tube
Procedure: 5. A finger is inserted into the pleural cavity and the area explored for pleural adhesions. 6. A large-bore (32 or 36F) chest tube is mounted on the clamp and passed along the track into the pleural cavity. 7. Insert the tube so ALL holes in the tube are inside the chest cavity. However they should not abut against the mediastinum as this is quite painful.

21. technique for a chest tube
Procedure: 8. The tube is connected to an underwater seal and sutured / secured in place. 9. The chest is re-examined to confirm effect. 10. A chest X-ray is taken to confirm placement & position.

22. technique for a chest tube
Procedure: Using a Bougie 1. Steps as outlined in previous up to step 5 – finger inserted into the chest cavity. 2. At this point you can insert a bougie into the chest cavity. 3. As long as you use a # 24 Fr. tube or larger, it will fit over the bougie. Advantage of this technique is you can use a much smaller incision in the chest wall to insert the tube.

23. Mayo clinic video on Chest Tube insertion

24. Second video on chest tube placement

25. Pigtail Catheter Insertion
Pigtail catheters are used for pneumothorax and should not be used for trauma patients. Their advantage is small diameter and less trauma to the chest wall than a regular chest tube.

26. Pigtail Catheter Insertion

27. The next video is on how to remove a chest tube.

28. Chest tube removal

29. Chest tube removal
Do you have the patient inhale or exhale during removal? One study of chest tube removal randomized patients to removal at end inspiration versus end expiration, demonstrating that the rate of recurrent pneumothorax between the two groups was similar (8% versus 6%).

30. Chest tube removal
There is some debate as to whether a chest tube hole should be sutured after tube removal. Most now do not suture, but merely apply the occlusive dressing.

31. The end.