1Tubes, drains and Tubes, drains and catheterscatheters

How, when, which, whatHow, when, which, what

Alain Tremblay MDCM, FRCPC, FCCP

Tubes, drains and cathetersTubes, drains and catheters

AnatomyAnatomy IndicationsIndications InsertionInsertion TubesTubes DrainageDrainage ExamplesExamples

Dr. Ward Flemons Dr. Ward Flemons

diaphragm

lunglung

hilum

parietalpleura

visceralpleura

pleuralcavity

pleuralcavity

costodiaphragmatic

sulcus

costodiaphragmatic

sulcus

FRONTVIEW

LATERALVIEW

Anatomy of the pleural space

ribs

intercostalvessels

intercostalspace

diaphragmcollapsed lung

Anatomy of the pleural space

2IndicationsIndications

Drainage of airDrainage of air PneumothoraxPneumothorax

Primary or secondaryPrimary or secondary Spontaneous or traumatic /iatrogenicSpontaneous or traumatic /iatrogenic

Drainage of fluidDrainage of fluid Malignant pleural effusionMalignant pleural effusion ParapneumonicParapneumonic effusions / effusions / EmpyemaEmpyema HemothoraxHemothorax OthersOthers

Post operativePost operativeleft pneumothorax right empyema

Insertion techniqueInsertion technique

Varies withVaries with Type of tube chosenType of tube chosen IndicationIndication ExperienceExperience UrgencyUrgency

Insertion technique: Insertion technique: Factors to considerFactors to consider

PercutaneousPercutaneous SimpleSimple Less painfulLess painful Less traumaticLess traumatic QuickQuick

No inspection of pleural No inspection of pleural spacespace

Care / image guidance Care / image guidance required if required if loculatedloculatedpleural spacepleural space

SurgicalSurgical More complexMore complex More pain?More pain? IncisionIncision

Allows digital Allows digital examination of pleural examination of pleural spacespace

Allows placement of large Allows placement of large bore tubesbore tubes

Insertion technique: Insertion technique: Factors to considerFactors to consider

BlindBlind QuickQuick CheapCheap OK for most indicationsOK for most indications No need for radiologist or No need for radiologist or

special trainingspecial training

Watch out if Watch out if loculatedloculatedpleural spacepleural space

Image guided (U/S, CT)Image guided (U/S, CT) Accurate / optimal Accurate / optimal

placementplacement Useful in Useful in loculatedloculated or or

complex spacescomplex spaces

Move patientMove patient Equipment, training, Equipment, training,

expenseexpense

intercostal space

rib

intercostalnerves and vessels

intercostal muscles

lung

diaphragm

fluid (or air) free in thepleural cavity

diaphragm

intercostalspace

Anatomy of the pleural space

3Loculated vs free pleural effusion (air or liquid)

fluid (or air) free in thepleural cavity

pleural adhesions

loculatedeffusion

Loculated vs free pleural effusion (air or liquid)

pleural adhesions

loculatedeffusion

rib

lung

pleural adhesion

rib

lung

pleuraladhesions

LoculatedLoculated empyemaempyema Advantages

Simple and quick Cheap Allows drainage of large quantities

of fluid or air Single use

Drawbacks The rigid tube+guide may be

traumatic to the lung Pleural lavage or tube desosbstruction

needs disconnection of the circuit

Chest Tube inserted

with an inner rigid guide

Dangerous in case of loculatedeffusion (pleural adhesions) slide 29

TubesTubes

Classic PVC chest tubesClassic PVC chest tubes Sizes 14 Sizes 14 36 36 frenchfrench StiffStiff Inserted surgicallyInserted surgically Good forGood for

Thick fluid (blood, pus)Thick fluid (blood, pus) Large air leaksLarge air leaks

Bad forBad for Pain, wound infectionsPain, wound infections

4TubesTubes

Small bore tubesSmall bore tubes Pigtails (8Pigtails (8--14 Fr)14 Fr) Strait Strait pneumothoraxpneumothorax tubes (8 Fr.)tubes (8 Fr.)

PercutaneousPercutaneous With or w/o image guidanceWith or w/o image guidance More comfortable, less traumaticMore comfortable, less traumatic Plugs easily, need for flushingPlugs easily, need for flushing Good for Good for lighterlighter fluids, most fluids, most airleaksairleaks

Pneumothorax kitPneumothorax kit

Small pigtail catheter inserted over a guide wire -Seldinger technique (Fuhrman pleural drainage set)

intoducerneedle

multipurposetube adapter

pigtailcatheter

dilator

introducing wireguide

(in sterile sleeve)

Chest Tube inserted

over a guide wire (Seldinger technique)

Chest Tube inserted

over a guide wire (Seldinger technique) TubesTubes

TunneledTunneled pleural catheters (pleural catheters (PleurxPleurx)) Malignant effusionsMalignant effusions Long term useLong term use Intermittent home drainageIntermittent home drainage Low complication ratesLow complication rates Soft / ComfortableSoft / Comfortable

5TPCTPC InsertionInsertion

TPC SystemThe system consists of a catheter allowing intermittent home drainage of pleural fluid into plastic vacuum bottles.

15.5 F silicone tube with

fenestrations and a one way drainage

valve

Polyester cuff that holds the tunneled portion just beneath the skin and acts as a barrier to infection

One way valve accessed

using drainage kit into 600ml

drainage bottle

Photo compliments of Dave Lowery

Photo compliments of Dave Lowery Photo compliments of Dave Lowery

Photo compliments of Dave Lowery Photo compliments of Dave Lowery

6Photo compliments of Dave Lowery

Drainage systemsDrainage systems

What, and how much are you draining?What, and how much are you draining? Air?Air?

Simple aspirationSimple aspiration Massive Massive airleakairleak

Liquid?Liquid?Bags, BottlesBags, Bottles

Both?Both? 3 bottle / 3 bottle / PleurevacPleurevac systemssystems

PneumothoraxPneumothoraxdrainage optionsdrainage options

Heimlich ValveHeimlich Valve can use perforated rubber glove finger fastened can use perforated rubber glove finger fastened

to a tubeto a tube

3 bottle systems3 bottle systemsChest Tube adapter

three waystop cockchest tube

suction tube

connectingports

(luer lock)

slide 48

7Chest Tube adapter

chest tube

instillation of talc slurry

slide 49

AdvantagesAdvantages allowsallows continuouscontinuous accessaccess to to thethe pleural drainage circuit pleural drainage circuit

withoutwithout anyany tube tube disconnectiondisconnection for:for: pleural lavagepleural lavage desobstructiondesobstruction of of thethe chestchest tubetube intraintra--pleural instillation of:pleural instillation of:

fibrinolyticfibrinolytic agentsagents talc talc slurryslurry

GettingGetting pleural pleural fluidfluid samplessamples

closedclosed system (system ( riskrisk of infection)of infection) cancan bebe connectedconnected to to mostmost types of types of chestchest tubestubes

Chest Tube adapter

PneumothoraxPneumothoraxTreatment optionsTreatment options

ObservationObservation Simple aspirationSimple aspiration Chest tube Chest tube -- Tube Tube thoracostomythoracostomy Small strait tubes usually adequateSmall strait tubes usually adequate Rare need for image guidanceRare need for image guidance Attached to Heimlich valve or underwater sealAttached to Heimlich valve or underwater seal

Surgical tubes only if large Surgical tubes only if large airleakairleak suspected or suspected or documenteddocumented

EmpyemaEmpyemaTreatment optionsTreatment options

Image guided tubes bestImage guided tubes best Larger bore Larger bore 1212--14 Fr pigtails ok14 Fr pigtails ok

Flush tubes regularlyFlush tubes regularly May need multiple tubesMay need multiple tubes Consider Consider thrombolyticsthrombolytics,, surgical optionssurgical options

MPE Treatment:MPE Treatment:PleurodesisPleurodesis

No advantage of large bore tubeNo advantage of large bore tubeChest 2001;120:19-25

49%49%55%55%Large (n=44)Large (n=44)47%47%55%55%Small (n=58)Small (n=58)

4 months4 months6 weeks6 weeksGroupGroup\\SuccessSuccess

MPE MPE Proposed Proposed AlgorithmAlgorithm

Known MalignancySymptomatic Effusion

No Known MalignancySymptomatic Effusion

Therapeutic Thoracentesis and

Referral for Pleurx Placement

Referral for Pleurx Placement

Diagnostic/Therapeutic Thoracentesis

Ancillary Investigations

NonMalignant

Malignant Effusion

882 82 y.oy.o. engineer with previous . engineer with previous asbestos exposure asbestos exposure MPEMPE

A)A) Repeated Repeated thoracentesisthoracentesis

B)B) Thoracoscopic Thoracoscopic talc poudragetalc poudrage

C)C) Chemical Chemical pleurodesis via pleurodesis via chest tubechest tube

D)D) OpiatesOpiates

How would you manage this symptomatic patient?

Pleurx PatientsPleurx Patients

82 y.o. engineer with previous asbestos exposure

April 2002 -Closed pleural Bx-Pleurx placement

MesotheliomaMesothelioma

July 2002-Spontaneous pleurodesis-Pleurx removed

MesotheliomaMesothelioma

June 2003-Patient passes away-No recurrence of effusion-Hospital days: 0

Trauma / Surgical optionTrauma / Surgical option

Trauma / resuscitation / Trauma / resuscitation / hemothoraxhemothorax Post thoracic surgeryPost thoracic surgery

Large PVC tubes best approachLarge PVC tubes best approach

Thank You!