- Email: [email protected]
Chest Tube Insertion
11
Chest Tube Insertion Aarti Mathur, MD and Stephen R. T. Evans, MD INTRODUCTION Drainage of the pleural space by means of tube thoracostomy is a common procedure performed for a variety of well-established indications. Although chest tube insertion is considered a simple procedure by experienced physicians, morbidity rates as high as 36% have been reported.1,2 Factors associated with a higher complication rate include technique of insertion, emergent placement of chest tube, operator performing the procedure, and the length of time that the tube is in place.2,3 In addition, increased severity of injury correlates with a higher complication rate, although the mechanism of chest injury, blunt versus penetrating, does not.2
INDICATIONS 1,4 A chest tube essentially functions to remove air, fluid, or pus from the intrathoracic space.
Place a gloved finger into the incision and sweep 360° Step 8 Advance a proximally clamped thoracostomy tube and direct it in the desired direction Step 9 Connect the end of the thoracostomy tube to an underwater-seal apparatus Step 10 Suture the tube in place and apply a dressing Step 11 Obtain a chest x-ray Step 7
OPERATIVE PROCEDURE Patient Positioning The ideal position for chest tube insertion is supine on a bed, slightly rotated, with the arm on the side of the lesion behind the patient’s head to expose the axillary area. This positioning exposes the “safe triangle” and reduces the risk of injuring underlying muscle and breast tissue.5
Choose Drain Insertion Site ● ● ● ● ● ●
Pneumothorax Tension pneumothorax Hemothorax Penetrating chest injury Drainage of malignant pleural effusion Parapneumonic effusions: simple or complicated with empyema ● Pleurodesis for intractable symptomatic effusions ● Chylothorax ● Bronchopleural fistula
OPERATIVE STEPS Step 1 Step 2
Step 3 Step 4 Step 5 Step 6
Position the patient Choose the drain insertion site—nipple level (fifth intercostal space) just anterior to the midaxillary line Prepare and drape the chest using sterile technique at the chosen site of insertions Anesthetize the skin and periosteum Skin incision and blunt dissection through subcutaneous tissue down to the rib Puncture the parietal pleura just above the rib
Diaphragmatic Perforation ● Consequence Placement of a chest tube outside of the thoracic cavity or a diaphragmatic injury will result in an iatrogenic pneumothorax, an unresolved pneumothorax, or a tension pneumothorax.6,7 Placement of the chest tube through or below the diaphragm will cause the tube to become lodged in the abdominal cavity, and the pulmonary pathology initially requiring the tube will persist. The consequences, repair, and prevention of intra-abdominal placement of a tube are discussed later. Grade 1/2 complication ● Repair A second chest tube must be placed into the pleural space and the initial tube removed. The diaphragm does not need to be repaired as long as a functional chest tube is present on that side. ● Prevention Insertion should be in the safe triangle bordered by the anterior border of the latissimus dorsi, the lateral
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Cupula (dome) of pleura
Apex of lung
Spleen Diaphragm
Liver Stomach Pancreas
Figure 11–1 During full expiration, the diaphragm rises to the fifth rib/fourth intercostal space. Therefore, identifying a site in the fourth intercostal space helps to avoid diaphragmatic and abdominal cavity penetration.
border of the pectoralis major muscle, a line superior to the horizontal level of the nipple, and an apex below the axilla.5 During full expiration, the diaphragm rises to the fifth rib/fourth intercostal space (Fig. 11–1). Identifying a site in the fourth intercostal space midaxillary line helps to avoid diaphragmatic and abdominal cavity penetration. The highest rib space in the axilla adjacent to the nipple is usually the fourth or fifth, or alternatively, the rib spaces may be counted down from the second rib at the sternomanubrial joint (Fig. 11–2; see also Fig. 11–1).8
Aseptic Technique/Surgical Preparation and Draping Wound Site Infection ● Consequence Infection of the wound site results in cellulitis, leukocytosis, and an increased risk of developing an empyema or necrotizing soft tissue infection. Necrotizing soft tissue infection typically presents with wound pain; crepitus; foul, watery wound discharge; skin blistering; and rapid progression to septic shock 3 to 5 days after insertion of a chest tube.9 A chest tube placed for an empyema is associated with an increased risk of developing a necrotizing chest wall infection. Grade 2/3 complication ● Repair A simple wound site infection typically consists of Staphylococcus aureus and responds to antibiotics. Necrotizing soft tissue infections are highly lethal and require aggressive surgical débridement and high-
dose antibiotics. Reconstructive surgery may eventually be required. ● Prevention A large area of skin cleansing using iodine or chlorhexidine should be undertaken.5 Prophylactic antibiotics do not reduce the incidence of wound infections in routine chest tube placement and are, therefore, not indicated.10,11 However, they may be considered in the setting of penetrating trauma. The wound site should be examined daily.
Thoracic Empyema ● Consequence An empyema may cause respiratory compromise/ failure. The incidence of this complication reported in the literature varies widely from 1% to 25%.12 The true source and route of infection may be difficult to determine; however, the rate of empyema is higher when a pleural effusion is present prior to tube insertion.12 Grade 2/3 complication ● Repair An empyema can be drained via closed tube thoracostomy and treated with intravenous antibiotics. However, if it continues to persist, a thoracotomy and decortication will be required. ● Prevention Although tube thoracostomy may lead to infectious complications by providing an entrance for contamina-
11 CHEST TUBE INSERTION
137
B
C
Figure 11–2 During inspiration, the diaphragm lies several rib spaces lower.
A
tion, the true route and source of infection for development of an empyema are difficult to determine.12 The best way to prevent empyema is by use of the aseptic technique. Prophylactic antibiotics have not been shown to reduce the incidence and, therefore, are not recommended for routine use of chest tube placement.10,11,13
Anesthesia/Analgesia14 Lack of Appropriate Analgesia ● Consequence Lack of appropriate analgesia creates a mobile patient, which increases the difficulty of the procedure. This
increases the likelihood of most of the complications discussed in this chapter. Grade 1 complication ● Repair If the patient is experiencing pain causing her or him to move, the procedure should be placed on hold until adequate analgesia or sedation is administered. ● Prevention Providing the patient with adequate analgesia aids in ease of performing the procedure. It has been recommended to use about 10 to 20 ml of lidocaine to first create a dermal bleb and then to direct the needle perpendicular to the skin to infiltrate the muscles of the
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chest wall. This includes the intercostal muscles, down to the rib, injecting around the periosteum of the rib. The needle is then angled above the rib until air is aspirated. The remaining 5 ml can be injected into the pleural space.
Incision and Blunt Dissection Damage to Intercostal Artery or Vein ● Consequence Damage to an intercostal vessel may cause an iatrogenic hemothorax. In rare instances, it may result in an arteriovenous fistula either between an intercostal artery and a subcutaneous vein or from an internal thoracic artery draining into a lobar pulmonary artery.15 The clinical manifestations of a fistula may be immediate or delayed. Grade 2/3 complication
Intercostal v. Intercostal a. Intercostal n.
Kelly clamp parallel to body
● Repair The hemothorax is best treated by adequate pleural drainage with the chest tube; however, if it is massive, a thoracotomy may be required. Treatment of arteriovenous fistulas is based on clinical symptoms, and options range from surgical removal of the fistula to transcatheter embolization.15 ● Prevention A transverse incision is made parallel to and along the upper border of the rib below the intercostal space to be used. The size of the incision should be slightly larger than the operator’s finger and the tube. Blunt dissection using a Kelly clamp is carried out until the surface of the rib is encountered. A drain track is then created cranially using a Kelly clamp and blunt finger dissection so that it is directed over the top of the rib. This avoids the intercostal vessels lying below each rib.1 Excessive bleeding during insertion of a chest tube should raise the possibility of development of a fistula.15
Figure 11–3 The Kelly clamp should be directed immediately above the rib to avoid injury to the intercostal neurovascular bundle.
Damage to the Intercostal Nerve16
Lung Laceration
● Consequence Neuritis/neuralgia from intercostal nerve damage can present with pain, numbness, tingling, and muscle atrophy. Grade 1 complication
● Consequence A lung laceration may manifest in several different ways including bleeding; development of a new, iatrogenic, or unresolving persistent pneumothorax; and in severe cases, a bronchopleural fistula (BPF) or bronchocutaneous fistula.17,18 A BPF typically presents with suddenonset dyspnea, hypotension, subcutaneous emphysema, and cough with expectoration of purulent fluid. Although rare, BPF presents a challenging management problem and is associated with high morbidity and mortality.17 A bronchocutaneous fistula slowly develops after a chest tube has been in place for a longer period of time and is diagnosed with radiography after that tube is removed. Grade 3/4 complication
● Repair The mainstay in treatment is analgesia, physiotherapy, and occasionally, topical capsaicin. ● Prevention The intercostal nerve runs with the artery and vein below each rib. Thus, in attempting to prevent injury to the vessels, the nerve will be preserved as well (Fig. 11–3).
Fingersweep
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Lung
Adhesions from lung to chest wall
Gloved hand is left of nipple
Diaphragm
Figure 11–4 A fingersweep is performed by rotating a finger 360 degrees inside the pleural cavity to break down any pleural adhesions to avoid lung laceration, pneumothorax, bronchocutaneous fistula, and bleeding.
● Repair Pneumothorax, bronchocutaneous fistula, and bleeding will require tube thoracostomy drainage. A thoracotomy is indicated for massive hemothorax. Initial management of a patient with a BPF includes continued chest drainage and positioning of the patient on his or her side, with the side of the BPF being down. Long-term management involves various procedures including bronchoscopy with different glues, coils, and sealants.17 ● Prevention The thoracic cavity is entered using the clamp immediately above the rib. Excessive force is not necessary and may cause a lung laceration. Once the cavity is punctured, the clamps should be spread open widely to allow insertion of a finger and the tube. A finger is then inserted and rotated around 360°. This allows breakdown of any pleural adhesions that may position the lung against the chest wall and make it prone to injury (Fig. 11–4).8
Intra-Abdominal Placement ● Consequence Intra-abdominal placement of a chest tube has a wide variety of sequelae ranging from laceration of the spleen or liver, resulting in bleeding, to avulsion injury or perforation of stomach or colon, resulting in
peritonitis.7 In addition, the primary pulmonary pathology requiring the tube remains untreated.8 Grade 3/4 complication ● Repair Intra-abdominal placement can be confirmed by a plain film. Another chest tube must be placed in the chest, the intra-abdominal tube should be removed, and the patient should be closely monitored. In the case of a liver or splenic laceration, serial hematocrits and followup imaging should be obtained to ensure cessation of bleeding. Peritonitis may result from perforated viscus. Hemodynamic instability and peritonitis necessitate operative intervention. ● Prevention Initial choice of an appropriate drain site is critical to prevent intra-abdominal placement, as described earlier. The fingersweep confirms placement into the thoracic cavity. The first solid organ felt after a gloved finger is inserted should be the lung. The surface of the diaphragm may also be felt when the finger is rotated inferiorly to ensure placement into the thoracic cavity and evaluate for a diaphragmatic laceration.1,6 Although placement into the chest may be confirmed, injury to intra-abdominal organs may also result from emergent chest tube placement in a patient with an unrecognized diaphragmatic hernia (Fig. 11–5).6
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Finger sweep below diaphragm
track into the pleural cavity until the last hole of the drain is inside of the cavity. The tube should slide in easily; if excessive force is required, the tube should be taken out and another attempt made to slide it in the pleural cavity opening.
Placement Too Far into Apex or Mediastinum
Figure 11–5 A fingersweep will aid in detection of intraabdominal penetration and avoid incorrect placement of a chest tube.
Placement of Tube and Position of Tube Tip Placement into Subcutaneous Tissue8 ● Consequence Placement of a chest tube outside the thoracic cavity in the subcutaneous tissues will result in an unresolved pnemothorax or effusion. In addition, it may cause a tension pneumothorax because air has been allowed to enter the thoracic cavity from the initial puncture site. These complications may also be noted in a chest tube that has been placed inside the correct cavity when all of the holes of the tube are not inside the cavity. ● Repair Subcutaneous chest tube placement can be confirmed by chest x-ray and/or worsening clinical symptoms. An intra-thoracic chest tube must be immediately placed. After confirmation of correct placement of the second chest tube, the first tube may be removed. ● Prevention The actual placement of the tube into the puncture site created by the Kelly clamp can often be difficult and challenging. However, an appropriate-sized track and a large enough opening into the thoracic cavity will make this step of the procedure easier and reduce the risk of subcutaneous tissue placement. The blunt dissection should be minimal, creating a single track until the pleural cavity is punctured. A track that is too wide or has gone more superior than the puncture site may make it easier to miss the opening into the thoracic cavity. This can also occur if the entrance to the cavity is not wide enough. Once the thoracic cavity is punctured, the Kelly clamp should be widely opened to provide a large enough space to accommodate the chest tube and a clamp. Before the tube is inserted, it should be mounted on a clamp and passed along the
● Consequence A variety of complications have been reported from chest tubes that have been placed too far into the lung apex or that abut the mediastinum. The tube may abut major vascular structures such as the subclavian artery and cause an obstruction or even disruption.19,20 Direct injury to the artery is unlikely at the time of insertion; however, it may occur secondary to vessel erosion from direct contact with the tube over a period of time. Rarer complications include brachial plexus compression causing pain, sudden death from vagus nerve irritation, extubation failure secondary to phrenic nerve injury, partial aortic obstruction, contralateral pneumothorax, and esophageal perforation.19,21 Grade 3/4 complication ● Repair A chest radiograph should be obtained immediately after insertion, and any tube that is found to be in a dangerous position, too far into the apex, or abutting the mediastinum should be repositioned immediately. If profuse bleeding is noted from a chest tube, thoracotomy is indicated to determine the source and control the bleeding. Cessation of bleeding may be managed with careful repositioning of the chest tube and subsequent radiographic confirmation. ● Prevention The tip of any intrathoracic tube should not rest in either the apex of the thorax or the mediastinum. The final resting place of the tube is determined in part by the direction of the track it follows through the chest wall. If a drain is to lie anteriorly in the chest, the track should be developed in a slightly anterior direction. Typically, a chest tube is placed apically for a pneumothorax and basally for drainage of an effusion.5 Placement should not require excessive force. Because most chest tubes placed too far into the apex cause symptoms related to the duration of placement of the tube, the best way to prevent these complications is to check a chest film immediately after the tube has been placed and to reposition any suspicious tube.
Placement Abutting Mediastinum ● Consequence If a chest tube is placed with excessive force, perforation of the left ventricle or right atrium may occur, resulting in cardiac tamponade.22,23 Cardiogenic shock
11 CHEST TUBE INSERTION and various arrhythmias, especially rapid atrial fibrillation, may result if a tube abuts and irritates the mediastinum.24 Rarely, in patients who have had a previous coronary bypass, vein compression can produce myocardial ischemia.19 Rarely, the phrenic nerve may be injured where it runs over the mediastinum.19,25 Patients with cardiomegaly are at increased risk for these complications. Grade 3/4/5 complication ● Repair If the chest radiograph obtained after insertion of the chest tube shows the tube to abut the cardiac silhouette, the tube should be repositioned and placement confirmed with x-ray. If cardiac tamponade or perforation is suspected, an echocardiogram may confirm the diagnosis. However, operative intervention is necessary. ● Prevention Simple pneumothorax causes mediastinal shift toward the affected side, making the pericardium prone to laceration. Therefore, no excessive force should be used to place a chest tube. Placement of a chest tube ideally should be performed under electrocardiographic monitoring to assess for mediastinal irritation. If electrocardiographic changes are present during the procedure or if resistance is met while inserting the tube, it should be repositioned. In addition, a chest radiograph should be checked immediately after placement; if the tube appears to be abutting the mediastinum, it should be repositioned.
Drain Becomes Nonfunctional (Kink/Clot)7,19 ● Consequence A nonfunctional drain will result in an undrained effusion, hemothorax, unresolved pneumothorax, or in extreme instances, a tension pneumothorax. A tube typically becomes nonfunctional once it is filled with clot, debris, or lung tissue, which can result in infarction of lung tissue. Grade 3/4 complication ● Repair Once a nonfunctional drain is identified, a second drain needs to be placed and, after radiographic confirmation of successful placement, the first drain should be removed. ● Prevention Key to preventing clotting of a chest tube is to choose the appropriate drain size. Smaller drains tend to kink/ clot easier than larger drains, especially when used in the setting of trauma because of the high incidence of hemothorax.26 The major determinant to size selection is the flow rate of either the air or the liquid that can
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accommodated by the tube. The internal diameter (bore) of the tube and, less so, the tube length are the critical flow determinants. Twenty percent of patients with chest trauma have accompanying hemothorax and pneumothorax. Therefore, given the potential need for evacuation of both air and blood, a large-bore (28– 36 Fr) chest tube is recommended. In hemodynamically stable, nonmechanically vented patients with primary or secondary spontaneous pneumothorax, a small-bore chest tube (16 or 22 Fr) may be placed. A mechanically vented patient with an iatrogenic pneumothorax or a patient who needs fluid drained should have a tube greater than 28 Fr placed.13,27–29 The inadvertent occlusion of drains by normal patient positioning can be potentially life-threatening. Because the tubing is soft and elastic, it is predisposed to frequent bending and kinking, which if done at right angles, has the effect of clamping outflow. This can be minimized by frequent monitoring of the tube and appropriate taping. It has been suggested that fitting a standard corrugated ventilator circuit over the drain can provide an outer support layer to stiffen the tubing.30 The drain may also be blocked with lung tissue. If a track is directed posteriorly, the drain can fall back to lie in the oblique fissure where it may become blocked. Chest radiographs must be checked, and this blockage can be suspected in a patient who is clinically deteriorating with no chest tube output.
Secure Drain Pneumothorax or Effusion ● Consequence A pneumothorax or effusion may persist if the tube starts to come out of or fall out of the thoracic cavity, and in severe cases, a tension pneumothorax may result.19 Subcutaneous emphysema may be noted around the skin site. Grade 1/2 complication ● Repair A second chest tube needs to be placed for a nonfunctional chest drain in the setting of a persistent effusion, pneumothorax, or tension pneumothorax. ● Prevention Once a chest tube is placed, ensuring that the last hole of the drain is inside of the thoracic cavity, it should be appropriately sutured and a sterile dressing placed.
Complications of Chest Tube Insertion Reexpansion Pulmonary Edema31–33 This refers to a unilateral pulmonary edema that can rarely occur on either the ipsilateral or the contralateral side after evacuation of a pleural effusion or pneumothorax. This is
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a rare but serious complication that carries a mortality rate as high as 20%. Although the pathophysiology remains obscure, both mechanical and inflammatory processes are believed to contribute to its development. The risk of developing reexpansion pulmonary edema is associated with duration and severity of lung collapse and the rate of reexpansion.
REFERENCES 1. Millikan JS, Moore EE, Steiner E. Complications of tube thoracostomy for acute trauma. Am J Surg 1980;140:738–741. 2. Etoch SW, Bar-Natan MF, Miller FB, Richardson JD. Tube thoracostomy. Factors relating to complications. Arch Surg 1995;130:521–525. 3. Resnick DK. Delayed pulmonary perforation: a rare complication of tube thoracostomy. Chest 1993;103:311– 313. 4. Miller KS, Sahn SA. Chest tubes: indications, technique, management and complications. Chest 1987;91:258–264. 5. Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax 2003;58(suppl II):ii53– ii59. 6. Hyde J. Reducing morbidity from chest drains. BMJ 1997;314:914–915. 7. Bailey RC. Complications of tube thoracostomy in trauma. Emerg Med J 2000;17:111–114. 8. Advanced Trauma Life Support Team Manual. Chest trauma management. In American College of Surgeons Advanced Trauma Life Support for Doctors, 7th ed. Chicago: First Impression, 2004; p 125. 9. Urschel JD, Takita H, Antkowiak JG. Necrotizing soft tissue infections of the chest wall. Ann Thorac Surg 1997; 64:276–279. 10. Luchette FA, Barrie PS, Oswanksi MF, et al. Practice management guidelines for prophylactic antibiotic use in tube thoracostomy for traumatic hemothorax: the EAST Practice Management Guidelines Work Group. J Trauma 2000;48:753–757. 11. Wilson RF, Nichols RL. The EAST practice management guidelines for prophylactic antibiotic use in tube thoracostomy for traumatic hemothorax: a commentary. J Trauma 2000;48:758–759. 12. Chan L, Reilly KM, Henderson C. Complication rates of tube thoracostomy. Am J Emerg Med 1997;15:368–370. 13. Baumann MH. What size chest tube? What drainage system is ideal? And other chest tube management questions. Curr Opin Pulm Med 2003;9:276–281. 14. Luketich JD, Kiss MD, Hershey J, et al. Chest tube insertion: a prospective evaluation of pain management. Clin J Pain 1998;14:152–154. 15. Coulter TD, Maurer JR, Miller MT, Mehta AC. Chest wall arteriovenous fistula: an unusual complication after chest tube placement. Ann Thorac Surg 1999;67:849– 850.
16. Verdigo RJ, Cea JG, Campero M, Castillo JL. Pain and temperature. In Goetz CG, Pappert EJ (eds): Textbook of Clinical Neurology, 2nd ed. Philadelphia: Saunders, 2003; p 351. 17. Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest 2005;128:3955–3965. 18. John S, Jacob S, Piskonowski T. Bronchocutaneous fistula after chest-tube placement: a rare complication of tube thoracostomy. Heart Lung 2005;34:279–281. 19. Taub PJ, Lajam F, Kim U. Erosion into the subclavian artery by a chest tube. J Trauma 1999;47:972–979. 20. Moskal TL, Liscum KR, Mattox KL. Subclavian artery obstruction by tube thoracostomy. J Trauma 1997;43: 368–369. 21. Shapira OM, Aldea GS, Kupferschmid J, Shemin RJ. Delayed perforation of the esophagus by a closed thoracostomy tube. Chest 1993;104:1897–1898. 22. Abad C, Padron A. Accidental perforation of the left ventricle with a chest drainage tube. Tex Heart Inst J 2002;29:143. 23. Hesselink DA, Van Der Klooster JM, Bac EH, et al. Cardiac tamponade secondary to chest tube placement. Eur J Emerg Med 2001;8:237–239. 24. Barak M, Iaroshevski D, Ziser A. Rapid atrial fibrillation following tube thoracostomy insertion. Eur J Cardiothorac Surg 2003;24:461–462. 25. Williams O, Greenough A, Mustafa N, et al. Extubation failure due to phrenic nerve injury. Arch Dis Child Fetal Neonatal Ed 2003;88:72–73. 26. Collop NA, Kim S, Sahn S. Analysis of tube thoracostomy performed by pulmonologists at a teaching hospital. Chest 1997;112:709–713. 27. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax. An American College of Chest Physicians Delphi consensus statement. Chest 2001; 119:590–602. 28. Antony VB, Loddenkemper R, Astoul P, et al. Management of malignant pleural effusions. Am J Respir Crit Care Med 2000;162:1987–2001. 29. Colice GL, Curtis A, Deslaurier B, et al. Medical and surgical treatment of parapneumonic effusions. An evidence-based guideline. Chest 2000;118:1158– 1171. 30. Konstantakos AK. A simple and effective method of preventing inadvertent occlusion of chest tube drains: the corrugated tubing splint. Ann Thorac Surg 2005;79:107– 111. 31. Gordon AH, Grant GP, Kaul SK. Reexpansion pulmonary edema after resolution of tension pneumothorax in the contralateral lung of a previously lung injured patient. J Clin Anesth 2004;16:289–292. 32. Sherman SC. Reexpansion pulmonary edema: a case report and review of the current literature. J Emerg Med 2003; 24:23–27. 33. Mahfood S, Hix WR, Aaron BL, et al. Reexpansion pulmonary edema. Ann Thorac Surg 1988;45:340– 345.
Chest Tube Insertion Aarti Mathur, MD and Stephen R. T. Evans, MD INTRODUCTION Drainage of the pleural space by means of tube thoracostomy is a common procedure performed for a variety of well-established indications. Although chest tube insertion is considered a simple procedure by experienced physicians, morbidity rates as high as 36% have been reported.1,2 Factors associated with a higher complication rate include technique of insertion, emergent placement of chest tube, operator performing the procedure, and the length of time that the tube is in place.2,3 In addition, increased severity of injury correlates with a higher complication rate, although the mechanism of chest injury, blunt versus penetrating, does not.2
INDICATIONS 1,4 A chest tube essentially functions to remove air, fluid, or pus from the intrathoracic space.
Place a gloved finger into the incision and sweep 360° Step 8 Advance a proximally clamped thoracostomy tube and direct it in the desired direction Step 9 Connect the end of the thoracostomy tube to an underwater-seal apparatus Step 10 Suture the tube in place and apply a dressing Step 11 Obtain a chest x-ray Step 7
OPERATIVE PROCEDURE Patient Positioning The ideal position for chest tube insertion is supine on a bed, slightly rotated, with the arm on the side of the lesion behind the patient’s head to expose the axillary area. This positioning exposes the “safe triangle” and reduces the risk of injuring underlying muscle and breast tissue.5
Choose Drain Insertion Site ● ● ● ● ● ●
Pneumothorax Tension pneumothorax Hemothorax Penetrating chest injury Drainage of malignant pleural effusion Parapneumonic effusions: simple or complicated with empyema ● Pleurodesis for intractable symptomatic effusions ● Chylothorax ● Bronchopleural fistula
OPERATIVE STEPS Step 1 Step 2
Step 3 Step 4 Step 5 Step 6
Position the patient Choose the drain insertion site—nipple level (fifth intercostal space) just anterior to the midaxillary line Prepare and drape the chest using sterile technique at the chosen site of insertions Anesthetize the skin and periosteum Skin incision and blunt dissection through subcutaneous tissue down to the rib Puncture the parietal pleura just above the rib
Diaphragmatic Perforation ● Consequence Placement of a chest tube outside of the thoracic cavity or a diaphragmatic injury will result in an iatrogenic pneumothorax, an unresolved pneumothorax, or a tension pneumothorax.6,7 Placement of the chest tube through or below the diaphragm will cause the tube to become lodged in the abdominal cavity, and the pulmonary pathology initially requiring the tube will persist. The consequences, repair, and prevention of intra-abdominal placement of a tube are discussed later. Grade 1/2 complication ● Repair A second chest tube must be placed into the pleural space and the initial tube removed. The diaphragm does not need to be repaired as long as a functional chest tube is present on that side. ● Prevention Insertion should be in the safe triangle bordered by the anterior border of the latissimus dorsi, the lateral
136
SECTION II: BEDSIDE PROCEDURES
Cupula (dome) of pleura
Apex of lung
Spleen Diaphragm
Liver Stomach Pancreas
Figure 11–1 During full expiration, the diaphragm rises to the fifth rib/fourth intercostal space. Therefore, identifying a site in the fourth intercostal space helps to avoid diaphragmatic and abdominal cavity penetration.
border of the pectoralis major muscle, a line superior to the horizontal level of the nipple, and an apex below the axilla.5 During full expiration, the diaphragm rises to the fifth rib/fourth intercostal space (Fig. 11–1). Identifying a site in the fourth intercostal space midaxillary line helps to avoid diaphragmatic and abdominal cavity penetration. The highest rib space in the axilla adjacent to the nipple is usually the fourth or fifth, or alternatively, the rib spaces may be counted down from the second rib at the sternomanubrial joint (Fig. 11–2; see also Fig. 11–1).8
Aseptic Technique/Surgical Preparation and Draping Wound Site Infection ● Consequence Infection of the wound site results in cellulitis, leukocytosis, and an increased risk of developing an empyema or necrotizing soft tissue infection. Necrotizing soft tissue infection typically presents with wound pain; crepitus; foul, watery wound discharge; skin blistering; and rapid progression to septic shock 3 to 5 days after insertion of a chest tube.9 A chest tube placed for an empyema is associated with an increased risk of developing a necrotizing chest wall infection. Grade 2/3 complication ● Repair A simple wound site infection typically consists of Staphylococcus aureus and responds to antibiotics. Necrotizing soft tissue infections are highly lethal and require aggressive surgical débridement and high-
dose antibiotics. Reconstructive surgery may eventually be required. ● Prevention A large area of skin cleansing using iodine or chlorhexidine should be undertaken.5 Prophylactic antibiotics do not reduce the incidence of wound infections in routine chest tube placement and are, therefore, not indicated.10,11 However, they may be considered in the setting of penetrating trauma. The wound site should be examined daily.
Thoracic Empyema ● Consequence An empyema may cause respiratory compromise/ failure. The incidence of this complication reported in the literature varies widely from 1% to 25%.12 The true source and route of infection may be difficult to determine; however, the rate of empyema is higher when a pleural effusion is present prior to tube insertion.12 Grade 2/3 complication ● Repair An empyema can be drained via closed tube thoracostomy and treated with intravenous antibiotics. However, if it continues to persist, a thoracotomy and decortication will be required. ● Prevention Although tube thoracostomy may lead to infectious complications by providing an entrance for contamina-
11 CHEST TUBE INSERTION
137
B
C
Figure 11–2 During inspiration, the diaphragm lies several rib spaces lower.
A
tion, the true route and source of infection for development of an empyema are difficult to determine.12 The best way to prevent empyema is by use of the aseptic technique. Prophylactic antibiotics have not been shown to reduce the incidence and, therefore, are not recommended for routine use of chest tube placement.10,11,13
Anesthesia/Analgesia14 Lack of Appropriate Analgesia ● Consequence Lack of appropriate analgesia creates a mobile patient, which increases the difficulty of the procedure. This
increases the likelihood of most of the complications discussed in this chapter. Grade 1 complication ● Repair If the patient is experiencing pain causing her or him to move, the procedure should be placed on hold until adequate analgesia or sedation is administered. ● Prevention Providing the patient with adequate analgesia aids in ease of performing the procedure. It has been recommended to use about 10 to 20 ml of lidocaine to first create a dermal bleb and then to direct the needle perpendicular to the skin to infiltrate the muscles of the
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chest wall. This includes the intercostal muscles, down to the rib, injecting around the periosteum of the rib. The needle is then angled above the rib until air is aspirated. The remaining 5 ml can be injected into the pleural space.
Incision and Blunt Dissection Damage to Intercostal Artery or Vein ● Consequence Damage to an intercostal vessel may cause an iatrogenic hemothorax. In rare instances, it may result in an arteriovenous fistula either between an intercostal artery and a subcutaneous vein or from an internal thoracic artery draining into a lobar pulmonary artery.15 The clinical manifestations of a fistula may be immediate or delayed. Grade 2/3 complication
Intercostal v. Intercostal a. Intercostal n.
Kelly clamp parallel to body
● Repair The hemothorax is best treated by adequate pleural drainage with the chest tube; however, if it is massive, a thoracotomy may be required. Treatment of arteriovenous fistulas is based on clinical symptoms, and options range from surgical removal of the fistula to transcatheter embolization.15 ● Prevention A transverse incision is made parallel to and along the upper border of the rib below the intercostal space to be used. The size of the incision should be slightly larger than the operator’s finger and the tube. Blunt dissection using a Kelly clamp is carried out until the surface of the rib is encountered. A drain track is then created cranially using a Kelly clamp and blunt finger dissection so that it is directed over the top of the rib. This avoids the intercostal vessels lying below each rib.1 Excessive bleeding during insertion of a chest tube should raise the possibility of development of a fistula.15
Figure 11–3 The Kelly clamp should be directed immediately above the rib to avoid injury to the intercostal neurovascular bundle.
Damage to the Intercostal Nerve16
Lung Laceration
● Consequence Neuritis/neuralgia from intercostal nerve damage can present with pain, numbness, tingling, and muscle atrophy. Grade 1 complication
● Consequence A lung laceration may manifest in several different ways including bleeding; development of a new, iatrogenic, or unresolving persistent pneumothorax; and in severe cases, a bronchopleural fistula (BPF) or bronchocutaneous fistula.17,18 A BPF typically presents with suddenonset dyspnea, hypotension, subcutaneous emphysema, and cough with expectoration of purulent fluid. Although rare, BPF presents a challenging management problem and is associated with high morbidity and mortality.17 A bronchocutaneous fistula slowly develops after a chest tube has been in place for a longer period of time and is diagnosed with radiography after that tube is removed. Grade 3/4 complication
● Repair The mainstay in treatment is analgesia, physiotherapy, and occasionally, topical capsaicin. ● Prevention The intercostal nerve runs with the artery and vein below each rib. Thus, in attempting to prevent injury to the vessels, the nerve will be preserved as well (Fig. 11–3).
Fingersweep
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Lung
Adhesions from lung to chest wall
Gloved hand is left of nipple
Diaphragm
Figure 11–4 A fingersweep is performed by rotating a finger 360 degrees inside the pleural cavity to break down any pleural adhesions to avoid lung laceration, pneumothorax, bronchocutaneous fistula, and bleeding.
● Repair Pneumothorax, bronchocutaneous fistula, and bleeding will require tube thoracostomy drainage. A thoracotomy is indicated for massive hemothorax. Initial management of a patient with a BPF includes continued chest drainage and positioning of the patient on his or her side, with the side of the BPF being down. Long-term management involves various procedures including bronchoscopy with different glues, coils, and sealants.17 ● Prevention The thoracic cavity is entered using the clamp immediately above the rib. Excessive force is not necessary and may cause a lung laceration. Once the cavity is punctured, the clamps should be spread open widely to allow insertion of a finger and the tube. A finger is then inserted and rotated around 360°. This allows breakdown of any pleural adhesions that may position the lung against the chest wall and make it prone to injury (Fig. 11–4).8
Intra-Abdominal Placement ● Consequence Intra-abdominal placement of a chest tube has a wide variety of sequelae ranging from laceration of the spleen or liver, resulting in bleeding, to avulsion injury or perforation of stomach or colon, resulting in
peritonitis.7 In addition, the primary pulmonary pathology requiring the tube remains untreated.8 Grade 3/4 complication ● Repair Intra-abdominal placement can be confirmed by a plain film. Another chest tube must be placed in the chest, the intra-abdominal tube should be removed, and the patient should be closely monitored. In the case of a liver or splenic laceration, serial hematocrits and followup imaging should be obtained to ensure cessation of bleeding. Peritonitis may result from perforated viscus. Hemodynamic instability and peritonitis necessitate operative intervention. ● Prevention Initial choice of an appropriate drain site is critical to prevent intra-abdominal placement, as described earlier. The fingersweep confirms placement into the thoracic cavity. The first solid organ felt after a gloved finger is inserted should be the lung. The surface of the diaphragm may also be felt when the finger is rotated inferiorly to ensure placement into the thoracic cavity and evaluate for a diaphragmatic laceration.1,6 Although placement into the chest may be confirmed, injury to intra-abdominal organs may also result from emergent chest tube placement in a patient with an unrecognized diaphragmatic hernia (Fig. 11–5).6
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Finger sweep below diaphragm
track into the pleural cavity until the last hole of the drain is inside of the cavity. The tube should slide in easily; if excessive force is required, the tube should be taken out and another attempt made to slide it in the pleural cavity opening.
Placement Too Far into Apex or Mediastinum
Figure 11–5 A fingersweep will aid in detection of intraabdominal penetration and avoid incorrect placement of a chest tube.
Placement of Tube and Position of Tube Tip Placement into Subcutaneous Tissue8 ● Consequence Placement of a chest tube outside the thoracic cavity in the subcutaneous tissues will result in an unresolved pnemothorax or effusion. In addition, it may cause a tension pneumothorax because air has been allowed to enter the thoracic cavity from the initial puncture site. These complications may also be noted in a chest tube that has been placed inside the correct cavity when all of the holes of the tube are not inside the cavity. ● Repair Subcutaneous chest tube placement can be confirmed by chest x-ray and/or worsening clinical symptoms. An intra-thoracic chest tube must be immediately placed. After confirmation of correct placement of the second chest tube, the first tube may be removed. ● Prevention The actual placement of the tube into the puncture site created by the Kelly clamp can often be difficult and challenging. However, an appropriate-sized track and a large enough opening into the thoracic cavity will make this step of the procedure easier and reduce the risk of subcutaneous tissue placement. The blunt dissection should be minimal, creating a single track until the pleural cavity is punctured. A track that is too wide or has gone more superior than the puncture site may make it easier to miss the opening into the thoracic cavity. This can also occur if the entrance to the cavity is not wide enough. Once the thoracic cavity is punctured, the Kelly clamp should be widely opened to provide a large enough space to accommodate the chest tube and a clamp. Before the tube is inserted, it should be mounted on a clamp and passed along the
● Consequence A variety of complications have been reported from chest tubes that have been placed too far into the lung apex or that abut the mediastinum. The tube may abut major vascular structures such as the subclavian artery and cause an obstruction or even disruption.19,20 Direct injury to the artery is unlikely at the time of insertion; however, it may occur secondary to vessel erosion from direct contact with the tube over a period of time. Rarer complications include brachial plexus compression causing pain, sudden death from vagus nerve irritation, extubation failure secondary to phrenic nerve injury, partial aortic obstruction, contralateral pneumothorax, and esophageal perforation.19,21 Grade 3/4 complication ● Repair A chest radiograph should be obtained immediately after insertion, and any tube that is found to be in a dangerous position, too far into the apex, or abutting the mediastinum should be repositioned immediately. If profuse bleeding is noted from a chest tube, thoracotomy is indicated to determine the source and control the bleeding. Cessation of bleeding may be managed with careful repositioning of the chest tube and subsequent radiographic confirmation. ● Prevention The tip of any intrathoracic tube should not rest in either the apex of the thorax or the mediastinum. The final resting place of the tube is determined in part by the direction of the track it follows through the chest wall. If a drain is to lie anteriorly in the chest, the track should be developed in a slightly anterior direction. Typically, a chest tube is placed apically for a pneumothorax and basally for drainage of an effusion.5 Placement should not require excessive force. Because most chest tubes placed too far into the apex cause symptoms related to the duration of placement of the tube, the best way to prevent these complications is to check a chest film immediately after the tube has been placed and to reposition any suspicious tube.
Placement Abutting Mediastinum ● Consequence If a chest tube is placed with excessive force, perforation of the left ventricle or right atrium may occur, resulting in cardiac tamponade.22,23 Cardiogenic shock
11 CHEST TUBE INSERTION and various arrhythmias, especially rapid atrial fibrillation, may result if a tube abuts and irritates the mediastinum.24 Rarely, in patients who have had a previous coronary bypass, vein compression can produce myocardial ischemia.19 Rarely, the phrenic nerve may be injured where it runs over the mediastinum.19,25 Patients with cardiomegaly are at increased risk for these complications. Grade 3/4/5 complication ● Repair If the chest radiograph obtained after insertion of the chest tube shows the tube to abut the cardiac silhouette, the tube should be repositioned and placement confirmed with x-ray. If cardiac tamponade or perforation is suspected, an echocardiogram may confirm the diagnosis. However, operative intervention is necessary. ● Prevention Simple pneumothorax causes mediastinal shift toward the affected side, making the pericardium prone to laceration. Therefore, no excessive force should be used to place a chest tube. Placement of a chest tube ideally should be performed under electrocardiographic monitoring to assess for mediastinal irritation. If electrocardiographic changes are present during the procedure or if resistance is met while inserting the tube, it should be repositioned. In addition, a chest radiograph should be checked immediately after placement; if the tube appears to be abutting the mediastinum, it should be repositioned.
Drain Becomes Nonfunctional (Kink/Clot)7,19 ● Consequence A nonfunctional drain will result in an undrained effusion, hemothorax, unresolved pneumothorax, or in extreme instances, a tension pneumothorax. A tube typically becomes nonfunctional once it is filled with clot, debris, or lung tissue, which can result in infarction of lung tissue. Grade 3/4 complication ● Repair Once a nonfunctional drain is identified, a second drain needs to be placed and, after radiographic confirmation of successful placement, the first drain should be removed. ● Prevention Key to preventing clotting of a chest tube is to choose the appropriate drain size. Smaller drains tend to kink/ clot easier than larger drains, especially when used in the setting of trauma because of the high incidence of hemothorax.26 The major determinant to size selection is the flow rate of either the air or the liquid that can
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accommodated by the tube. The internal diameter (bore) of the tube and, less so, the tube length are the critical flow determinants. Twenty percent of patients with chest trauma have accompanying hemothorax and pneumothorax. Therefore, given the potential need for evacuation of both air and blood, a large-bore (28– 36 Fr) chest tube is recommended. In hemodynamically stable, nonmechanically vented patients with primary or secondary spontaneous pneumothorax, a small-bore chest tube (16 or 22 Fr) may be placed. A mechanically vented patient with an iatrogenic pneumothorax or a patient who needs fluid drained should have a tube greater than 28 Fr placed.13,27–29 The inadvertent occlusion of drains by normal patient positioning can be potentially life-threatening. Because the tubing is soft and elastic, it is predisposed to frequent bending and kinking, which if done at right angles, has the effect of clamping outflow. This can be minimized by frequent monitoring of the tube and appropriate taping. It has been suggested that fitting a standard corrugated ventilator circuit over the drain can provide an outer support layer to stiffen the tubing.30 The drain may also be blocked with lung tissue. If a track is directed posteriorly, the drain can fall back to lie in the oblique fissure where it may become blocked. Chest radiographs must be checked, and this blockage can be suspected in a patient who is clinically deteriorating with no chest tube output.
Secure Drain Pneumothorax or Effusion ● Consequence A pneumothorax or effusion may persist if the tube starts to come out of or fall out of the thoracic cavity, and in severe cases, a tension pneumothorax may result.19 Subcutaneous emphysema may be noted around the skin site. Grade 1/2 complication ● Repair A second chest tube needs to be placed for a nonfunctional chest drain in the setting of a persistent effusion, pneumothorax, or tension pneumothorax. ● Prevention Once a chest tube is placed, ensuring that the last hole of the drain is inside of the thoracic cavity, it should be appropriately sutured and a sterile dressing placed.
Complications of Chest Tube Insertion Reexpansion Pulmonary Edema31–33 This refers to a unilateral pulmonary edema that can rarely occur on either the ipsilateral or the contralateral side after evacuation of a pleural effusion or pneumothorax. This is
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a rare but serious complication that carries a mortality rate as high as 20%. Although the pathophysiology remains obscure, both mechanical and inflammatory processes are believed to contribute to its development. The risk of developing reexpansion pulmonary edema is associated with duration and severity of lung collapse and the rate of reexpansion.
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