Chest Tube Insertion

Chest tube insertion

Definition

A chest tube insertion is a procedure to place a flexible, hollow drainage tube into the chest in order to remove an abnormal collection of air or fluid from the pleural space (located between the inner and outer lining of the lung).

Purpose

Chest tube insertions are usually performed as an emergency procedure. Chest tubes are used to treat conditions that can cause the lung to collapse, which occurs because blood or air in the pleural space can hamper the ability of a patient to breath.

There are four common conditions than can require surgical chest tube insertion, including:

• pneumothorax (air leak from the lung into the chest)
• hemothorax (bleeding into the chest)
• empyema (lung abscess or pus in the chest)
• pneumothorax or hemothorax after surgery or from trauma to the chest

Demographics

There is no available data concerning the demographics of chest tube insertion since this is a common procedure performed in emergency rooms and surgical departments. However, pneumothorax seems to occur most often in males 25–40 years of age.

Description

The point of insertion in the chest most commonly occurs on the side (lateral thorax), at a line drawn from the armpit (anterior axillary line) to the side (lateral) of the nipple in males, or to the side (about 2 in [5 cm]) above the sternoxiphoid junction (lower junction of the sternum, or chest bone) in females. The skin is sterilized with antiseptic solution covering a wide area, and local anesthesia is administered to minimize discomfort. At the rib chosen for insertion, the skin over the rib is anesthetized with lidocaine (a local chemical anesthetic agent) using a 10-cc syringe and 25-gauge needle. At the rib below the rib chosen for pleural insertion, the tissues, muscles, bone, and lining covering the lung are also anesthetized using a 22-gauge needle.

All health-care providers will take precautions to keep the procedure sterile, including the usage of sterile gown, facemask, and eye protection. All equipment must be sterile as well and universal precautions are followed for blood and body fluids. Chest tube size is selected depending on the problem; an 18–20 F(rench) catheter is used for pneumothorax, a 32–26 F catheter for hemothorax, and trauma patients usually require a 38–40 F catheter size; children generally require smaller tube sizes.

The patient's arm is placed over the head with a restraint on the affected side. For an insertion line down the armpit (axillary line insertion), the patient's head is elevated from the bed 30–60°. Using the anesthetic needle and syringe, the physician will insert a needle (aspirate) into the pleural cavity to check for the presence of air or fluid. Then, an incision is made and a clamp is used to open the pleural cavity. At this stage, either air or fluid will rush out when the pleural cavity is opened. The chest tube is positioned for insertion with a clamp and attached to the suction-drain system. A silk suture is used to hold the tube firmly in place. The area is wrapped and an x ray is taken to visualize the status of the tube placement.

Diagnosis/Preparation

The diagnosis for chest tube insertion depends on the primary cause of fluid or air in the pleural cavity. For malignancy (cancer)-causing pleural effusion (fluid in the pleural space filled with malignant cells), the diagnosis can be established with positive cytopathology (cancer cell visualization and analysis) and a chest x ray that shows fluid accumulation.

The typical diagnostic signs and symptoms of empyema (lung infection) include fever, cough, and sputum discharge as well as the development of pleural effusion (causing chest pain and shortness of breath). This type of lung infection can progress to systemic disease with such signs as weakness, and loss of appetite (anorexia). Chest x rays can readily allow the clinician to view the pleural effusion and can also help to detect pneumothorax, since there is visual proof in the displacement of the tissues covering the lungs as a result of air in the pleural cavity. Additionally, during physical examinations, people with pnemothorax have diminished breath sounds, hyperesonance on percussion (a highly resonating sound when the physician taps gently on a patient's back), and diminished ability to expand the chest. Computed axial tomography (CAT) scans can be used to visualize and analyze complicated cases that may require chest tube insertion.

Aftercare

The chest tube typically remains secure and in place until imaging studies such as x rays show that air or fluid has been removed from the pleural cavity. This removal of air or fluid will allow the affected lung to fully re-expand, allowing for adequate or improved breathing. After chest tube insertion, the patient will stay in the hospital until the tube is removed. It is common to expect complete recovery from chest tube insertion and removal. During the stay, the medical and nursing staff will carefully and periodically monitor the chest tube for air leaks or if the patient is having breathing difficulties. Deep breathing and coughing after insertion can help with drainage and lung re-expansion.

Aftercare should also include chest tube removal and follow-up care. The patient is placed in the same position in which the tube was inserted. Using precautions to maintain a sterile field, the suture holding the tube in place is loosened and the chest is prepared for tying the insertion-point wound. The chest tube is then clamped to disconnect the suction system. At this point, the patient will be asked to hold his or her breath, and the clinician will remove the tube with a swift motion. After the suture is tied, dressing (gauze with antibiotic ointment) and tape is securely applied to close the wound. A chest x ray should be repeated soon after tube removal and, within 48 hours, a routine wound care clinic follow-up is advised to remove the dressing and to further assess the patient's medical status and condition.

Risks

Although chest tube insertion is a commonly used as a therapeutic measure, there are several complications that can develop, including:

• bleeding from an injured intercostal artery (running from the aorta)
• accidental injury to the heart, arteries, or lung resulting from the chest tube insertion
• a local or generalized infection from the procedure
• persistent or unexplained air leaks in the tube
• the tube can be dislodged or inserted incorrectly
• insertion of chest tube can cause open or tension pneumothorax

Normal results

Chest tube insertion is a commonly used procedure, and it is typical for patients to recover fully from insertion and removal. If no complications develop, the procedure can relieve air or fluid accumulation in the pleural cavity that caused breathing impairment. Breathing is usually improved, and follow-up within the immediate 48 hours after hospital discharge is advised so that the patient can be further assessed with x rays and in the wound care clinic.

Morbidity and mortality rates

Mortality and morbidity for chest tube insertion is not strongly associated with the procedure itself. The primary cause responsible for fluid or air accumulation in the pleural cavity is related to continued illness and outcome such as pleural effusions caused by cancer (malignant pleural effusions). Cancer, and not the insertion of a chest tube, determines a patient's sickness and outcome. Chest tube insertion may be problematic in persons affected with certain connective tissue diseases.

Alternatives

The diagnosis, indications, and procedure for chest tube insertion are specific and unambiguous. There is no other alternative to rapidly remove accumulation of fluid or air within the pleural cavity.

Resources

books

Pfenninger, John. Procedures for Primary Care Physicians, 1st Edition. St Louis: Mosby-Year Book, Inc., 1994.

Townsend, Courtney. Sabiston Textbook of Surgery, 16th Edition. St. Louis: W. B. Saunders Company, 2001.

organizations

American Thoracic Society Homepage. <http://www.thoracic.org>.

Laith Farid Gulli, MD Nicole Mallory, MS, PA-C Alfredo Mori, MBBS

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

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The procedure is simple and widely utilized. Chest tube insertion is performed in a hospital, usually in the emergency department by an emergency room doctor, resident-in-training, or medical house officer. The medical and nursing team will monitor the patient at the hospital until the tube is removed.

QUESTIONS TO ASK THE DOCTOR

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• How is the procedure performed?
• Why do I need this procedure?
• Will I need to be sedated?
• When will I be able to resume normal activities?
• What aftercare is recommended?