Chest Tube (Thoracostomy, Intercostal Catheter, ICC, Chest Drain)

Last updated 10.08.13

 

Definition

-  Placement of an intercostal catheter into the pleural space  

 

Drain

 

Features

-  Despite local anaesthetic is still a painful procedure

- Consider use of a pigtail drain instead if appropriate

 

Indications

-  Pneumothorax

- Haemothorax

- Pleural effusion (large)

- Empyema (large)

- Chylothorax

- Post intrathoracic surgery

 

Contraindications

-  Bleeding diathesis (relative containdication)

 

Equipment

-  Preparation: Chlorhexidine

- Drape

- LA: 1% Lidocaine with Adrenaline

- Syringe 10ml

- Needles: 21G &/or 25G

- Scalpel size 11 blade

- Sterile gauze

- Artery forceps

- Intercostal catheter/tube

-  Stable patient: 16-22F

- Unstable patient, underlying lung disease, mechanically ventilated: 24-28F

- Tube has radio-opaque stripe to allow visualisation CXR

- Tube has several holes to allow drainage

- Most proximal hole interrupts radio-opaque stripe so you can tell where it is sitting on CXR

- Kelly curved clamps x4

- Sterile gloves, gown, mask

- Suture: strong, non-absorbable: 1-0 silk or nylon

- Needle holder

- Scissors

- Tegaderm

- Underwater drain

 

Chest Tube

Chest Tube

 

Insertion Procedure

- Explanation & consent

- CXR prior to insertion

- Choose tube size

- Patient position should be comforrtable and relaxed

-  Supine/semirecumbent

-  Ipsilateral arm behind head (abducted)

-  Locate insertion site

- Triangle of safety: lateral border of Lat Dorsi, lateral border of Pec Major, apex at axilla

-  5th intercostal space (nipple level)

-  Slightly anterior to midaxillary live

- Effected side of chest

- Use sterile marker

-  Sterile preparation & drape

- LA to insertion site

- Infiltrate to skin, subcutaenous tissue, muscle &pleural layers

- Wheal of anaesthetic wtih small needle

- Use larger needle through wheal

- Aspirate periodically

- 2-3cm transverse incision

- Centre to inferior aspect of intercostal space

- Blunt dissection with artery forceps through subcutaneous tissue over superior aspect of inferior rib

- Muscle splitting technique appropriate to orientation to muscle fibers

- Rotate forceps 90o to split muscles of external & internal oblique muscles

- If pneumothorax is present there may be a escape of air from the chest

- Puncture parietal pleura with tip of clamp

- Insert gloved finger into incision & clear lung parenchema from adhesions, clots, etc.

- Clamp proximal end of thoracostomy tube

- Advance tube into pleural space to desired length

-  Direct tube posteriorly along chest wall

- Apically for pneumothorax

- Posteriorly for fluid

- Confirm placement of tube

-  Fogging of tube on expiration

- Listen for air movement

- Connect tube to underwater-seal +/- wall suction (high flow, low pressure ~20cm H2O)

- Serves as one way valve

- Unclamp tube

- Suture

- Wound closed around tubing with simple interupted or continuous

- Roman sandle suture to secure tubing

- Apply dressing:

- CXR to confirm placement & state of chest pathology

- Radio-opaque strip has interuuption where proximal hole sits, should be within chest

- +/- ABG

- +/- O2Sat

 

Complications

-  Laceration or puncture of intrathoracic organs

- Empyema

- Damage to intercostal nerve, artery or vein

- Creation of haemothorax

- Incorrect tube placement

- Persistent pneumothorax

- Air leak

- Subcutaneous emphysema

 

Removal Procedure

- Only removed when all air & fluid drainage has ceased evidence by full chest expansion on CXR

- Patient asked to breathe in maximally while tube is briskly removed

- Immediately cover wound with occlusive dressing and pressure dressing

- Repaet CXR in 12-24hrs

 

 

 

References

 

ATLS Student Course Manual 2008

Textbook of Surgery 3rd Ed, Tjandra et al, Blackwell Publishing, 2006

YouTube: Chest Tube Insertion NEJM 2010

Pic (Chest Tube)

Pic (Patient)