Chest Tube Insertion and Needle Decompression

AFAMS Resident OrientationApril 8, 2012

Outline

• Needle Decompression• Chest Tube Insertion

– Indications / Contraindications– Equipment– Insertion– Confirming Placement

• Managing Chest Tubes– Toubleshooting

Needle Decompression Indications پلورا دیکمپریشن

• Emergency Use for Tension Pneumothorax

• Not indicated for simple pneumothorax, open pneumothorax or flail chest

• If done in a patient without pneumothorax, increased morbidity

موارداستفاده موارداستفاده •تنشن- • برای عاجل تنشن- کمک برای عاجل کمک

نموتوراکس نموتوراکس نوتنوت•

مریض که مریض درحاالتی که درحاالتینموتوراکسساده، نموتوراکسساده،

نموتوراکس نموتوراکس یا یا باز،هیموتوراکس flailباز،هیموتوراکس

chest باشد داشتهنمیش موثرواقع

Tension Pneumothoraxنموتوراکس تنشن

Signs and Symptoms- Decreased or low breath

sounds- Unequal chest rise - Dyspnea increases - Discomfort/anxiety - Signs and history of chest

injury- Jugular veins inflated - Weakness of pulse pressure - Shock - Mediastinal shift (late)

اعراضوعالیم اعراضوعالیم نمی - تنفسموجود صدای

میابد تقلیل یا باشدشکل - صدربه شدن بلند

غیرمساویانه -Dyspnea افزایشمیابداضطراب / - ناراحتیتاریخچه - یا ها نشانه

صدر غشای جرحهمتورم - عنق وریدهای

میگرددعرض - کم یا ضعیفشدن

فشارنبض شدن شاک-–mediastinal shift (late)

Locations for Needle Decompressionناحیه انتخاب

• Preferred Preferred – 2nd or 3rd intercostal space,

mid clavicular line

• Alternative Alternative - 5th intercostal space, mid

axillary line- For patient transportation,

other sites are not recommended.

• Always place needle Always place needle above the rib!above the rib!

شده • داده شده ترجیح داده ترجیحبین – سوم یا دوم جوف

وسط خط ، الضلعیclavicular

الترنیتوالترنیتو •- ، پنجم الضلعی بین جوف

وسط axillaryخط- ، مریض دادن انتقال برای

توصیه دیگر های ناحیهگردد نمی

Chest Tubeتیوب چست

Indications– Drainage of fluid or air from

pleural cavity– Is used to treat

pneumothorax, heamothorax, hemopneumothorax, and empyema (pus)

– Is effective to collect fluids.– Is helpful to support

breathing

هدف و استعمال موارد

پلورا – ازجوف هوا و مایع دریناژmediastinumیا

– ، نموتوراکس تداوی برای ، هیموتوراکس

و empyemaهیمونموتوراکس(pus ) میشود استفاده

موثر – مایعات نمودن درجمعمیباشد

کننده – کمک تنفس درحمایهمیباشد .

Chest Tube Equipment• Sterile gown, gloves, mask,

drapes, and gauze• Chlorhexidine or betadine• 22 or 25 Gauge needle, 10

cc syringe, 1-2% Lidocaine• Scalpel with 11 blade• At least 4 Kelly curved

clamps or artery forceps• Strong, non-absorbable

sutures size 1.0 or greater (silk or nylon)

• Sterile drainage system

Chest Tube Size• Appropriate chest tube size

– Chest tubes sized by internal diameter

– Length marked on side of tube– Radiopaque strip runs length of

tube and encircles the most proximal drainage hole

• Choosing appropriate size depends on clinical indication for chest tube– Stable patient with large

pneumothorax: 16-22 French– Unstable patient, chronic lung

disease, high air leak risk: 24-28 French

– Empyema, pneumothorax in patient on ventilator: 28-32 French

Chest Tube Procedure• Obtain and review a chest

x-ray prior to procedure

• Occlude proximal free end of chest tube with forceps

• Occlude insertion end of tube with forceps, this will help with insertion of tube

• Place patient in supine position, move ipsilateral arm behind patient’s head

Locate Site of Entry• Triangle of Safety

– Lateral border of pectoral major muscle

– Mid-axillary line– Horizontal line from the

nipple

• 4th or 5th intercostal space

Preparation of the Incision Site• Clean region with

betadine or chlorhexidine• Apply analgesia

– 25G needle form superficial wheel

– Inject subcutaneous tissue• Using longer needle inject

lidocaine into– Deeper subcutaneous

tissue– Numb the periostium of

the rib below insertion site

Preparation of Insertion Site

• After anesthetizing the periostium advance needle overtop of the rib

• Aspirate every 1-2 cm and inject lidocaine

• Using scalpel make 2 cm incision parallel but just above the rib

Formation of Tract

• Insert Kelly clamp through incision

• Use blunt dissection technique and advance over rib

• Kelly clamp will “pop” through parietal pleura

Formation of Tract

• Use index finger to trace tract created by Kelly clamp

• Using forceps direct tube through tract using finger as guide

Advancing Tube

• Advance tube toward lung apex in patients with pneumothorax

• Advance tube toward base in patients with hemothorax, chylothorax or pleural effusion

• Advance tube until you are sure all drainage holes are inside parietal pleura

Securing Chest Tube• Secure tube to skin using

heavy suture

• Mattress or several simple interrupted sutures to close the hole around the tube

• • Use the free ends of the

suture to wrap around the tube several times

• Tie the free ends of the suture around the tube

Preventing Air Leak

• Surround the tube with petroleum based sterile gauze

• Cover the gauze with several pressure dressings

Confirming Placement• Confirm proper placement

of chest tube with chest x-ray.

• Using the radio opaque stripe, make sure all drainage holes are contained inside the pleura.

• If they are not, replace the tube, DO NOT ADVANCE existing tube

Proper and Improper Chest Tube Placement

Improper Placement

Proper Placement

Connecting the Chest Tube to Drainage

• Connect the chest tube to a sterile draining system

• Unclamp the tube

• Place drainage system at least 40 inches below the patient

Complications• Bleeding• Traumatic organ injury or

perforation• Intercostal neuralgia from

damage to intercostals neurovascular bundle

• Subcutaneous emphysema • Re-expansion pulmonary

edema• Infection of the drainage

site• Empyema

Managing Chest Tubes

• Pain– Often referred to

ipsilateral shoulder

• Pain Control– Epidural– Toradal IV

Managing Chest Tubes: Drainage System

• Three functional chambers to a drainage system

• 1st Chamber: collects fluid/air from patient– Fluid accumulates in 1st

Chamber1

Managing Chest Tubes: Drainage System

• 2nd Chamber: Air rises from 1st chamber enters 2nd chamber from below

– Water seal will “bubble”

– Height of water in 2nd chamber indicates amount of suction

2

Managing Chest Tubes: Drainage System

• 3rd Section is an atmospheric vent

• Manually venting through a pressure relief valve

• It equilibrates collection chamber with atmospheric pressure

3

Example of Drainage System

1

3

2

Managing Chest Tubes: Suction

• Amount of suction depends on indication– Spontaneous air leak:

start at -10 cm water and use least amount needed to maintain full expansion

– Collapsed lung due to PTX: use low gradient to avoid re-expansion pulmonary edema

– Fluid Drainage: start at -20 cm of water

Troubleshooting: Air Leak• Continuous bubbling in

water seal chamber

• Leak is between patient and water seal

• Actions:– Tighten loose connections– Locate Leak

• If that doesn’t work …

Troubleshooting: Air Leak• Clamp tube near chest wall

– If bubbling stops then leak is inside thorax

• Get CXR• Call Attending Physician

– If bubbling continues then air leak is between clamp and drainage system

• Slowly move the clamp from the thorax to the collection system– If bubbling stops at any point in

time you have found the leak in the tube

• Replace Tube– If bubbling doesn’t stop, leak is

in collection system• Replace collection system

Troubleshooting: Tension Pneumothorax

• Patient is in respiratory distress even with chest tube in place

• First: make sure chest tube is not obstructed– Clamped– Occluded– Kinked

Troubleshooting: Tension Pneumothorax

• Drain tubing contents into a separate drainage bottle

• Make sure water seal is connected

• Make sure water-seal is not broken

• If patient has signs of tension PTX, call attending and prepare for a second chest tube placement

Conclusions

• Tension Pneumothorax is a life threatening event that can be quickly treated with needle decompression

• Chest tubes are used to treat many pulmonary conditions

• Proper technique will minimize complications

• Careful management of chest tubes will expedite their removal and improve patient status