Complication
No.
%
Unsuccessful insertion
10
4
Symptomatic loculation
21
8.4
Asymptomatic loculation
10
4
Empyema
8
3.2
PTX, SQ Air/BPF
6
2.4
Cellulitis
4
1.6
Recurred fluid
4
1.6
Dislodged
3
1.2
Bleeding
2
0.8
Tumor seeding
1
0.4
Pain requiring removal
1
0.4
Extrapleural catheter
1
0.4
Once the chest tube has been placed, there are a number of daily assessments that must be performed. Patient symptoms, pain management, respiratory variation, degree and duration of air leak, amount of drainage output per 24 h, character of output, chest tube entry site, radiographic imaging, and timing of tube removal are indicators as to whether the chest tube is optimally managed. While there may be controversy in the literature regarding some of these factors, we will review practical clinical pearls regarding these aspects. If there is a persistent air leak, assess all of the chest tube connections by removing the dressing to assure that the chest tube has not migrated out resulting in air entering into the pleural space from one of the open side ports. Proceed from the chest wall along all of the tubing to assure that all of the connections are sealed. If you do not identify a leak in the system, consider replacing the pleural drain tubing as small punctures in the tubing are difficult to isolate. If there is still an ongoing air leak, then there is most likely a bronchopleural fistula. If there is no respiratory variation with deep inspiration or cough, this could suggest that the chest tube may be occluded with fibrin or clot. Manual milking of the chest tube and adjacent tubing can remedy this; however, saline or fibrinolytics may be required. The chest tube or connector tubing could be kinked due to patient positioning but can be easily identified and corrected at the bedside. This can be recognized when drainage output markedly decreases, or there is evidence of reaccumulation of a pneumothorax. Lastly, it could signify that the lung has now fully expanded and is now occluding the chest tube. Criteria for determining the timing of chest tube removal vary in the literature. For pneumothorax , it is the resolution of a visible air leak in the drainage system and radiographic resolution. Generally, once this is established the chest tube is placed to water seal for 12–24 h, and if there is no recurrence, then the tube can be clamped for several hours and then removed.
Most would maintain a functioning chest tube while a patient is receiving positive pressure with mechanical ventilation when used to treat a pneumothorax; however, similar steps for standard removal as previously described may be considered as well. When treating empyema , the chest tubes are maintained until there is no spontaneous output, clinical status has improved, and chest imaging confirms resolution of the fluid collection. In the setting of malignant pleural effusion and pleurodesis, the chest tube may be removed with drainage output of <150 mL in a 24-h period without consequence.
Review of Technique
Pre-procedure preparation of the patient is fundamental. After consent has been obtained, platelet count, PT, INR, and PTT should be assessed. Current medications should be checked, specifically screening for antiplatelet agents or other anticoagulants. Discontinuation of the medication and reversal of the effect of these agents whenever possible is required. The patient should be placed in the supine position or decubitus position dependent on the chest tube site location with elevation of the head of bed approximately 30 °. For example, with a pneumothorax the second intercostal space along the midclavicular line is recommended. In the setting of pleural effusion , placing the patient with the noninvolved side down in the decubitus position placing the chest tube in the fourth or fifth intercostal space in the midaxillary line is recommended. Locating the xiphoid process and drawing a mental line at that level to the midaxillary line is a practical way to find this location. Physical exam, chest imaging review, and thoracic ultrasound are utilized to confirm the location for chest tube entry followed by marking the site. Universal protocol is exercised with final verbal confirmation of the correct anatomic side by the medical team. Intravenous analgesia and/or anxiolytics are recommended prior to chest wall preparation to alleviate patient symptoms in addition to topical anesthetic with 1% lidocaine. The site is then cleaned with chlorhexidine followed by placement of a sterile drape. Topical 1% lidocaine (not exceeding 5–7 mg/kg) is generously introduced subcutaneously, intercostally, and along the periosteum. Often pleural fluid or air (in the setting of pneumothorax) will be identified during this process, confirming entry into the pleural space. There are two basic techniques for chest tube placement defined as operative or the wire-guided modified Seldinger technique. The trocar method will not be discussed as it is not recommended. The operative technique requires a 1–2 cm intercostal incision parallel to the rib just above the rib that is the desired point of entry.
Using a sterile clamp applying steady controlled pressure over the rib, a tactile “pleural pop” will be felt. Once the pleural space has been entered, the clamp is spread apart to dilate an entry tract. The operative method allows for placement of a gloved sterile finger into this entry to perform a 360 ° finger sweep to remove any fibrous adhesions and to manually confirm that the lung is not against the chest wall.
The wire-guided modified Seldinger technique is less tactile; however, it is equally effective in placing a chest tube. The manufactured kits include the addition of a guidewire with one to three sequential dilators to gently dissect the intercostal muscles creating the entry tract for the chest tube and introducer. The available chest tube sizes range from 8 to 36 Fr using the Seldinger technique (Figs. 30.1, 30.2, and 30.3).
Fig. 30.1
(a) Thal-Quick introducer needle. (b, c) Wayne trocar
Fig. 30.2
Insertion kit: trocar and catheters
Fig. 30.3
Thal-Quick chest tube
Description of Technique (Figs. 30.4, 30.5, 30.6, 30.7, 30.8, 30.9, and 30.10)
After informed consent is obtained from the patient, the patient is placed in a supine or decubitus position with the affected side slightly elevated. Thoracic ultrasound is employed in all cases to verify the point of entry and to ensure there is a safe pocket of fluid for TPC insertion. The correct site is marked as “yes” in the visible field of the operator, and a time-out is called where patient name, medical record number, and date of birth are verified. The skin is then prepped with chlorhexidine and covered with a large sterile drape. The patient is connected to a telemetry monitor and continuous pulse oximetry monitoring as well as placement of a peripheral IV in the event of any need for medication administration. The skin is anesthetized with 1% lidocaine at both the insertion site and the planned tunneling site. The pleural fluid pocket is accessed with the needle using Seldinger technique , and the guide wire is inserted through the needle and directed into the largest fluid collection seen on the ultrasound examination. A small incision (0.5 cm) is made at the guidewire entry to facilitate the insertion of the dilating trocar. A small incision (1 cm) is made at the skin level a few centimeters anterior to the insertion site with the catheter tunneled subcutaneously until the polyester cuff is buried 0.5 cm underneath the skin and catheter exits from the guidewire insertion site. Gentle dilatation with the sequential dilators is performed over the guidewire with eventual insertion of the trocar and removal of the guidewire. The catheter is then fed through the breakaway trocar which is peeled until the catheter is fully inserted into the pleural space. The catheter is then secured with sutures and drained to ensure proper function and provide the patient with immediate relief of dyspnea. A follow-up CXR is ordered to confirm proper placement. The patient is scheduled for follow-up visit in 7–10 days for suture removal and to review the drainage data.
Fig. 30.4
Pleural catheter and equipment needed
Fig. 30.5
Pleural catheter kit
Fig. 30.6
Preparing the patient for TPC insertion and accessing the pleural space
Fig. 30.7
Patient positioning and local anesthesia
Fig. 30.8
Guidewire insertion, followed by pleural catheter tunneling
Fig. 30.9
Trocar insertion followed by feeding the catheter into trocar and finally peeling off the trocar
Application by Disease Process
Pneumothorax
Chest tube placement in this setting will be directed anteriorly and apically in the supine patient. The anterior second intercostal space along the midclavicular line is the standard location. The exception to this would be in the setting of the iatrogenic pneumothorax from cardiac pacemaker or defibrillator placement. In order to avoid the risk of possible subcutaneous chest wall infection in a newly placed device, it is recommended to place the chest tube along the fourth or fifth intercostal space in the midaxillary line. If the patient is noted to have a loculated pneumothorax with varying pleural adhesions, then CT guidance for chest tube placement would be advised. With the availability of smaller-bore chest tubes and literature supporting that these are as effective and better tolerated by the patient, the larger-bore tubes have been replaced by the smaller-bore tubes ranging from 8 to 14 Fr. At the time of chest tube placement, manual aspiration of the pneumothorax with a luer lock syringe until resistance is met can result in a quicker resolution of the pneumothorax.
Empyema
When a diagnosis of pneumonia is made and a pleural effusion is identified, a thoracentesis should be performed immediately with complete evacuation and analysis of the pleural fluid. This may prevent the need for further intervention. However, if the fluid reaccumulates and the patient does not demonstrate clinical improvement with antibiotics or the initial pleural fluid analysis diagnosis an empyema, then a chest tube should be placed. There is evidence that small-bore chest tubes defined as <14 Fr are as effective as the traditional larger-bore chest tubes for evacuating pleural space infections.
The smaller tubes are better tolerated by the patients. The British Thoracic Society guidelines also suggest that to prevent premature clogging of the smaller-bore tubes, routine saline flushes 30–50 mL every 6–8 h is effective. We recommend the use of the 14 Fr catheter due to its resilience and lower incidence of fibrin clogging as compared to the smaller-bore tubes. Fibrinolytics can be utilized such at tissue plasminogen activator (TPA) (2–50 mg) instilled at varying intervals to further maintain an existing chest tube. If the patient has clear evidence of multiple loculations from the outset, then image-guided placement of more than one chest tube may be required, and thoracic surgical consult would also be recommended in the event that surgical decortication is required.
Hemothorax
This is most often associated with thoracic trauma or iatrogenic thoracic complications. It is recommended to utilize a 28–32 Fr chest tube due to the viscosity of the hemothorax, and there is a higher risk for occlusion with a smaller tube. It is critical in this scenario to be able to have a patent tube in order to accurately assess the rate of output as this would determine the need for surgical intervention.
Malignant Pleural Effusion
Malignant pleural effusion is common in lung cancer, breast cancer, and lymphoma. This impacts patient’s quality of life. After the initial pleural diagnosis is made, a definitive management plan to prevent recurrence should follow. This will be fully discussed later with the indwelling pleural catheter. TPC is typically done in a patient with MPE who has poor performance status indicated by Karnofsky score less than 60% (Table 30.2). Patients with known MPE and a good performance status may elect for TPC rather than medical thoracoscopy and pleurodesis to further minimize hospitalization.
Table 30.2
Karnofsky score
Able to carry on normal activity and to work; no special care needed | 100 | Normal, no complaints, no evidence of disease |
90 | Able to carry on normal activity, minor signs or symptoms of disease | |
80 | Normal activity with effort, some signs or symptoms of disease | |
Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed | 70 | Cares for self, unable to carry on normal activity or to do active work
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