1. Chest Tube Insertion and Needle Decompression AFAMS Resident Orientation April 8, 2012

2. Outline Needle Decompression Chest Tube Insertion – Indications / Contraindications – Equipment – Insertion – Confirming Placement Managing Chest Tubes – Toubleshooting

3. Needle Decompression Indications دیکمپریشن پلورا Emergency Use for Tension Pneumothorax Not indicated for simple pneumothorax, open pneumothorax or flail chest If done in a patient without pneumothorax, increased morbidity موارداستفاده موارداستفاده - کمک عاجل برای تنشن نموتوراکس - کمک عاجل برای تنشن نموتوراکس نوت نوت درحالاتی که مریض نموتوراکس ساده، نموتوراکس باز،هیموتوراکس یا درحالاتی که مریض نموتوراکس ساده، نموتوراکس باز،هیموتوراکس یا flail chest داشته باشد موثرواقع نمی ش

4. Tension Pneumothorax تنشن نموتوراکس Signs and Symptoms -Decreased or low breath sounds -Unequal chest rise -Dyspnea increases -Discomfort/anxiety -Signs and history of chest injury -Jugular veins inflated -Weakness of pulse pressure -Shock -Mediastinal shift (late) اعراض وعلایم اعراض وعلایم - صدای تنفس موجود نمی باشد یا تقلیل میابد - بلند شدن صدربه شکل غیرمساویانه -Dyspnea افزایش میابد - ناراحتی / اضطراب - نشانه ها یا تاریخچه جرحه غشای صدر - وریدهای عنق متورم میگردد - ضعیف شدن یا کم عرض شدن فشارنبض - شاک – mediastinal shift (late)

5. Locations for Needle Decompression انتخاب ناحیه Preferred Preferred – 2 nd or 3 rd intercostal space, mid clavicular line Alternative Alternative -5 th intercostal space, mid axillary line -For patient transportation, other sites are not recommended. Always place needle above the rib! Always place needle above the rib! ترجیح داده شده ترجیح داده شده – جوف دوم یا سوم بین الضلعی ، خط وسط clavicular الترنیتو الترنیتو - جوف بین الضلعی پنجم ، خط وسط axillary - برای انتقال دادن مریض ، ناحیه های دیگر توصیه نمی گردد

6. Chest Tube چست تیوب Indications – Drainage of fluid or air from pleural cavity – Is used to treat pneumothorax, heamothorax, hemopneumothorax, and empyema (pus) – Is effective to collect fluids. – Is helpful to support breathing موارد استعمال و هدف –دریناژ مایع و هوا ازجوف پلورا یا mediastinum –برای تداوی نموتوراکس ، هیموتوراکس ، هیمونموتوراکس و empyema (pus ) استفاده میشود –درجمع نمودن مایعات موثر میباشد –درحمایه تنفس کمک کننده میباشد.

7. Chest Tube Equipment Sterile gown, gloves, mask, drapes, and gauze Chlorhexidine or betadine 22 or 25 Gauge needle, 10 cc syringe, 1-2% Lidocaine Scalpel with 11 blade At least 4 Kelly curved clamps or artery forceps Strong, non-absorbable sutures size 1.0 or greater (silk or nylon) Sterile drainage system

8. Chest Tube Size Appropriate chest tube size – Chest tubes sized by internal diameter – Length marked on side of tube – Radiopaque strip runs length of tube and encircles the most proximal drainage hole Choosing appropriate size depends on clinical indication for chest tube – Stable patient with large pneumothorax: 16-22 French – Unstable patient, chronic lung disease, high air leak risk: 24-28 French – Empyema, pneumothorax in patient on ventilator: 28-32 French

9. Chest Tube Procedure Obtain and review a chest x- ray prior to procedure Occlude proximal free end of chest tube with forceps Occlude insertion end of tube with forceps, this will help with insertion of tube Place patient in supine position, move ipsilateral arm behind patient’s head

10. Locate Site of Entry Triangle of Safety – Lateral border of pectoral major muscle – Mid-axillary line – Horizontal line from the nipple 4 th or 5 th intercostal space

11. Preparation of the Incision Site Clean region with betadine or chlorhexidine Apply analgesia – 25G needle form superficial wheel – Inject subcutaneous tissue Using longer needle inject lidocaine into – Deeper subcutaneous tissue – Numb the periostium of the rib below insertion site

12. Preparation of Insertion Site After anesthetizing the periostium advance needle overtop of the rib Aspirate every 1-2 cm and inject lidocaine Using scalpel make 2 cm incision parallel but just above the rib

13. Formation of Tract Insert Kelly clamp through incision Use blunt dissection technique and advance over rib Kelly clamp will “pop” through parietal pleura

14. Formation of Tract Use index finger to trace tract created by Kelly clamp Using forceps direct tube through tract using finger as guide

15. Advancing Tube Advance tube toward lung apex in patients with pneumothorax Advance tube toward base in patients with hemothorax, chylothorax or pleural effusion Advance tube until you are sure all drainage holes are inside parietal pleura

16. Securing Chest Tube Secure tube to skin using heavy suture Mattress or several simple interrupted sutures to close the hole around the tube Use the free ends of the suture to wrap around the tube several times Tie the free ends of the suture around the tube

17. Preventing Air Leak Surround the tube with petroleum based sterile gauze Cover the gauze with several pressure dressings

18. Confirming Placement Confirm proper placement of chest tube with chest x- ray. Using the radio opaque stripe, make sure all drainage holes are contained inside the pleura. If they are not, replace the tube, DO NOT ADVANCE existing tube

19. Proper and Improper Chest Tube Placement Improper Placement Proper Placement

20. Connecting the Chest Tube to Drainage Connect the chest tube to a sterile draining system Unclamp the tube Place drainage system at least 40 inches below the patient

21. Complications Bleeding Traumatic organ injury or perforation Intercostal neuralgia from damage to intercostals neurovascular bundle Subcutaneous emphysema Re-expansion pulmonary edema Infection of the drainage site Empyema

22. Managing Chest Tubes Pain – Often referred to ipsilateral shoulder Pain Control – Epidural – Toradal IV

23. Managing Chest Tubes: Drainage System Three functional chambers to a drainage system 1 st Chamber: collects fluid/air from patient – Fluid accumulates in 1 st Chamber 1

24. Managing Chest Tubes: Drainage System 2 nd Chamber: Air rises from 1 st chamber enters 2 nd chamber from below – Water seal will “bubble” – Height of water in 2 nd chamber indicates amount of suction 2

25. Managing Chest Tubes: Drainage System 3 rd Section is an atmospheric vent Manually venting through a pressure relief valve It equilibrates collection chamber with atmospheric pressure 3

26. Example of Drainage System 1 3 2

27. Managing Chest Tubes: Suction Amount of suction depends on indication – Spontaneous air leak: start at -10 cm water and use least amount needed to maintain full expansion – Collapsed lung due to PTX: use low gradient to avoid re-expansion pulmonary edema – Fluid Drainage: start at - 20 cm of water

28. Troubleshooting: Air Leak Continuous bubbling in water seal chamber Leak is between patient and water seal Actions: – Tighten loose connections – Locate Leak If that doesn’t work …

29. Troubleshooting: Air Leak Clamp tube near chest wall – If bubbling stops then leak is inside thorax Get CXR Call Attending Physician – If bubbling continues then air leak is between clamp and drainage system Slowly move the clamp from the thorax to the collection system – If bubbling stops at any point in time you have found the leak in the tube Replace Tube – If bubbling doesn’t stop, leak is in collection system Replace collection system

30. Troubleshooting: Tension Pneumothorax Patient is in respiratory distress even with chest tube in place First: make sure chest tube is not obstructed – Clamped – Occluded – Kinked

31. Troubleshooting: Tension Pneumothorax Drain tubing contents into a separate drainage bottle Make sure water seal is connected Make sure water-seal is not broken If patient has signs of tension PTX, call attending and prepare for a second chest tube placement

32. Conclusions Tension Pneumothorax is a life threatening event that can be quickly treated with needle decompression Chest tubes are used to treat many pulmonary conditions Proper technique will minimize complications Careful management of chest tubes will expedite their removal and improve patient status