How To Do Tube and Catheter Thoracostomy

• Pneumothorax that is recurrent, persistent, traumatic, large, under tension, or bilateral

• Pneumothorax in a patient on positive-pressure ventilation

• Symptomatic or recurrent large pleural effusion

• Empyema or complicated parapneumonic effusion

• Hemothorax

• Chylothorax

Absolute contraindications

• None

Relative contraindications

• Coagulopathy or bleeding disorder (may require blood products or coagulation factors)

• Skin or soft tissue infection at the site (a different site without infection should be used if possible)

• Malpositioning of the tube in the lung parenchyma, in the lobar fissure, under the diaphragm, or subcutaneously

• Blockage of the tube due to blood clots, debris, or kinking

• Dislodgement of the tube, requiring replacement

• Re-expansion pulmonary edema

• Subcutaneous emphysema

• Infection of residual pleural fluid or recurrent effusion

• Pulmonary or diaphragmatic laceration

• Intercostal neuralgia due to injury of the neurovascular bundle below a rib

• Bleeding

• Rarely, perforation of other structures in the chest or abdomen

• Elective chest tube insertion is best done by a physician trained in the procedure. Other physicians can relieve a tension pneumothorax with needle thoracostomy.

• Chest tube placement is an inpatient procedure. If done in the emergency department, the patient is then admitted to the hospital.

• Catheter thoracostomy is being used increasingly for pneumothoraces or free-flowing effusions; because smaller diameter catheters more easily clog and kink, larger diameter tubes are preferred for purulent effusions and hemothoraces. The main advantages of smaller diameter catheters are less pain and no need for sutures after catheter removal.

• Neurovascular bundles are located at the lower edge of each rib. Therefore, the tube must be placed over the upper edge of the rib to avoid damage to the neurovascular bundle.

Rib Anatomy

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• In a spontaneously breathing patient, the head of the bed is elevated 30 to 60° to limit the elevation of the diaphragm that occurs during expiration and thus decrease the risk of inadvertent intra-abdominal tube placement.

• The arm of the affected side can also be placed in a position over the patient’s head or otherwise abducted.

• The hand can be placed behind the head.

How To Do Tube Thoracostomy

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• Connect a water seal suction apparatus sealed with sterile water to a source of suction. Usually, a commercially available apparatus that connects to wall suction and the thoracostomy tube with plastic connectors is used.

• The insertion site can vary based on whether air or fluid is being drained. For pneumothorax, the tube is usually inserted in the 4th intercostal space, and for other indications in the 5th intercostal space, in the mid-axillary or anterior axillary line.

• Mark the insertion site.

• Drape the area.

• Estimate how deep the tube needs to be inserted so that all of the tube’s holes are inside the pleural space, accounting for all subcutaneous and fat tissue, particularly in obese patients. Note or record the mark on the tube that should be then visible at the skin.

For chest tube placement ( ≥ 16 Fr):

• Make a 1.5- to 2-cm skin incision, and then bluntly dissect the intercostal soft tissue down to the pleura by advancing a clasped hemostat or Kelly clamp and opening it. Identify the rib below the insertion site and move over the rib to find the pleural space above the rib. Then perforate the pleura with the clamped instrument (usually indicated by a pop and/or sudden decrease in resistance) and open in the same way.

• Use a finger to widen the tract and confirm entry into the pleural space and the absence of adhesions.

• Clamp the chest tube on the outside end.

• Insert the chest tube, with another clamp grasping the tip, through the tract and direct it inferoposteriorly for effusions, or apically for pneumothorax, until all of the tube’s holes are inside the chest wall.

For chest catheter placement (≤ 14 Fr):

• Insert the needle along the upper border of the rib while aspirating and advance it into the effusion or pneumothorax.

• When fluid or air is aspirated, remove the syringe from the needle and pass the guidewire enough to clear the needle.

• Remove the needle, leaving the wire in place.

• Make a skin nick using a scalpel.

• Pass the dilator over the wire and into the pleural space.

• Place the catheter and its trocar over the wire, making sure that the last side hole is within the pleural space.

• Remove the trocar and guidewire.

For both chest tube and catheter, after placement:

• Suture the chest tube to the skin of the chest wall using one of many suture methods. One way is to use a purse-string suture. In addition, place an interrupted suture next to the tube across the incision and tie the suture around the tube. Another method is to substitute a second interrupted suture across the incision on the other side of the tube for the purse string suture and tie that suture to the tube as well.

• Place a sterile dressing with petroleum gauze to help seal the wound over the site.

• Cut 2 sterile gauze pads halfway across and place them around the tube.

• Remove the draping.

• Tape the dressing in place using pressure dressings. To increase stability, consider taping the outside part of the tube to the dressing or the patient separately.

• Connect the tube to the water seal suction apparatus to prevent air from entering the chest through the tube and to allow drainage with or without suction.

• An anteroposterior chest x-ray should be obtained at the bedside to check the tube’s position. If there are concerns about positioning or functioning of the chest tube, posteroanterior and lateral x-rays or chest CT should be done.

• The chest tube is removed when the condition for which it was placed resolves. With a pneumothorax, suction is stopped and the tube is placed on just water seal for several hours to ensure that the air leak has stopped and that the lung remains expanded. Chest x-ray is often repeated 12 to 24 hours after the last evidence of an air leak before removing the tube. For pleural effusions or hemothorax, the tube is typically removed when the drainage is < 100 to 200 mL/day of serous fluid.

• Removal of a chest tube in patients on mechanical ventilation, especially those with high oxygen requirements, positive pressure ventilation, chronic lung disease, or increased risk of recurrent pneumothorax, should be done only after consultation with the pulmonary specialist.

• To remove the tube, the patient should be semi-erect. After removal of the sutures, at the moment of removal, the patient is asked to take a deep breath and then to forcibly exhale; the tube is removed during exhalation and the site is covered with petroleum gauze, a sequence that reduces the chance of pneumothorax during removal.

• The purse-string suture, if inserted during tube insertion, is closed, and/or additional sutures may be needed to close the incision.

• A chest x-ray should be done several hours after chest tube removal. If no pneumothorax is seen on the x-ray after chest tube removal, there is no need for further chest x-rays except as dictated by clinical changes in the patient's condition.

• Do not use a small chest catheter (≤ 14 Fr) if there is a bloody effusion because clots can clog the catheter.

• The water seal suction apparatus must be kept 100 cm (40 inches) below the patient to avoid retrograde flow of fluid or air back into the pleural space.

• Some clinicians recommend draining no more than 1.5 L of pleural fluid in 24 hours due to a concern about causing re-expansion pulmonary edema. However, there is little evidence that the risk of re-expansion pulmonary edema is directly proportional to the volume of fluid removed (1). Thus, it is reasonable to completely drain effusions at the time of chest tube insertion in properly monitored patients.

• If the chest x-ray shows that the chest tube is not far enough into the chest and the aspiration holes in the tube are not in the chest cavity, the chest tube will need to be replaced. Simply advancing the chest tube can introduce non-sterile tubing into the chest.

• Common insertion errors include inadequate quantities of local anesthetic and an initial incision that is too small.

• Lock the stretcher before inserting the tube because insertion may take significant force and move the stretcher.

• Conscious sedation prior to the procedure can be used in selected cases.

• When marking the insertion point, use a skin marking pen or make an impression with a pen so that the skin cleansing preparation will not remove the mark.

1. 1. Feller-Kopman D, Berkowitz D, Boiselle P, et al: Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thoracic Surg 84:1656–1662, 2007.