Chest Tubes and Drainage

Insertion

Absolute  sterile technique

Adequate local anesthesia.

Position patient for tube as needed:

• Pneumothorax
  • Anterior for pneumothorax-recumbent position
• Pleural effusion
  • Axillary line-decubitus position for fluid drainage
  • Avoid posterior position (patient unable lay on back)
  • Position patient upright so diaphragm is as low as possible.

Technique of Chest tube insertion:

• Trocar Tube Thoracostomy: Incision parallel to rib; tube clamped on insertion.
  • Stylet inside trocar cannula; followed by tube placement. Relatively fast, danger of impaling the lung or another organ. Therefore, carefully control depth of penetration.
  • Chest tube with Trocar inside: Same risks as above.
• Operative Tube Thoracostomy: Incision, blunt dissection into pleura, with digital inspection of space and guidance of tube placement by finger and large hemostat. Probably safer than trocar method, somewhat more involved. Suture tube into place.
• Seldinger (guide-wire) Technique: fast, quite safe, least painful. Difficult to control direction tube goes into pleura. Difficult if adhesions are expected.

Drainage

• Air Alone-Flutter Valve: atmospheric pressure provides seal of flutter valve, and allows air to escape from pleura. Generally with a small tube. Simple, no bulky drainage apparatus.
• Fluid and/or Air: Suction and the three bottle collection system.
  Example: Pleura-evac
  • Fluid Collection Chamber
  • Water Seal Chamber
  • Suction Control Chamber

Chest Tube Care (3 daily questions and removal)

• Does the water seal chamber bubble? Find the leak: tube system or the patient. Is the tube completely into the pleura?
• Does the tube function properly? Water seal level fluctuation with respiration (easier to see off suction). Fluctuation means tube is patent and functions well. If not functioning, restore its function or remove it. Stripping, Streptokinase.
• How much drainage is there and what does it look like?

Removal:

• When drainage has stopped or pneumothorax is gone, and there is no air leak.
• Snip and remove sutures.
• Petrolatum gauze is used to close opening immediately after tube is pulled during Valsalva maneuver.
• Occlusive dressing is applied.