HISTORY
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Hippocrates was the first to describe drainage of the pleural space with metal tubes for empyema drainage.
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Playfair was the first to use an underwater seal with a drainage tube in 1872.
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Hewitt described closed drainage of empyemas in 1876, but it was not commonly employed until 1917 to drain postinfluenza epidemic empyemas.
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The use of chest tubes postoperatively for thoracic procedures was not common until reported by Lilienthal in 1922.
INDICATIONS
Chest tubes are used to drain the pleural space in both emergent and non-emergent settings (also see Chapters 47 and 49 on pleural effusions and pneumothorax). A variety of conditions can require drainage including pneumothorax (air), hydrothorax (fluid), hemothorax (blood), chylothorax (lymph), and (empyema or infection). Placement of a chest tube is indicated either acutely, when a patient is experiencing respiratory distress or is septic, or subacutely, when the patient is not in any distress, but the lung is prevented from fully expanding.
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Pneumothorax
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Tension pneumothorax: Ideally, there should never be an x-ray study documenting a tension pneumothorax. This is a clinical diagnosis based on respiratory distress with or without hemodynamic compromise and unilaterally decreased breath sounds. Tracheal deviation may be present, but it is often difficult to confirm. In this scenario, if the patient is truly unstable and a tension pneumothorax is suspected, needle decompression should be performed promptly with a large-bore angiocath in the second intercostal space anteriorly followed by a chest tube.
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Nontension pneumothorax: A stable pneumothorax may at times be just closely followed with serial imaging if the patient is not in distress, has a relatively small space (<5 cm down from the chest apex), is reliable, and has been stable for at least several hours. Should it increase in size or should the patient develop respiratory distress, a chest tube should be placed. Usually a chest tube placed for air should be in the anterolateral fourth or fifth intercostal space and directed anteriorly.
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Hydrothorax: The character of the intrapleural fluid determines the management course. Intrapleural fluid may be serous, serosanguineous, purulent, or bloody.
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Pleural effusion: Serous or serosanguineous fluid may be either exudative or transudative. Transudative effusions result from increased hydrostatic pressure within the capillaries or decreased oncotic pressure related to an underlying process such as congestive heart failure or cirrhosis. Exudative effusions result from increased permeability of the capillary membrane from a process such as an infection or malignancy. Ordinarily, exudative effusions require chest tube drainage, whereas transudative effusions can be managed by treating the underlying causative medical condition.
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Exudative
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Malignant: effusions that have been confirmed to be related to a malignancy by positive cytology may be drained by a chest tube but are likely to recur unless treated by pleurodesis.
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Infectious: effusions confirmed to be infectious by the presence of organisms on Gram’s stain, positive culture, or pH less than 7.0, should be drained by chest tube placement.
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Transudative: Pleural effusions that do not satisfy Light’s criteria for exudative effusions are deemed to be related to an underlying medical condition predisposing to volume overload, such as congestive heart failure, cirrhosis, or renal failure.
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Hemothorax: Bloody pleural fluid is considered to be a hemothorax if the hematocrit is greater than 50% of that of the peripheral blood.
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Traumatic: Post-traumatic hemothorax should be drained with a large-bore chest tube. Undrained blood in the chest will develop into a fibrothorax and result in underexpansion of the lung. A well-placed chest tube will drain early hemithorax, but an undrained clot may require the addition of intrapleural fibrinolytics or decortication for resolution.
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Empyema: Pleural fluid may be classified as exudative or infectious based on the above-mentioned criteria, but an empyema is a true abscess of the chest. It is purulent intrapleural fluid that is loculated, and it does not change position with repositioning of the patient. Patients may have spiking fevers and sepsis if it is undrained. Proper chest tube positioning for empyema drainage may be curative if all of the pus is drained.
PROCEDURE
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What size?
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The choice of size depends on the indication for the drainage. For a hemothorax or empyema, a large-bore tube (i.e., at least 28 Fr) is needed. For a pneumothorax, a smaller (i.e., 24–28 Fr.) tube is adequate.
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Where does it go?
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The indication for the chest tube determines the location for the insertion. Most often, a tube is placed one to two intercostal spaces below the nipple in the anterior axillary line. For fluid drainage, the tube should be directed posteriorly. For air, it will be most effective if it is directed anteroapically.
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What do I need?
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A nurse to administer narcotics (although most of the time, you can perform the procedure with local anesthetic only), thoracostomy tray, chest tube, 4 × 4s, betadine, 0 silk, cloth tape, sterile towels, sterile gown/gloves/mask, chest drainage system, suction, 20 mL of 1% lidocaine (this is the most important part of pain control). A functioning intravenous needle should be in place as patients can develop hypotension from a vagal response during tube placement or lung re-expansion.
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Where do I start?
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Position patient so that correct side is close to edge of bed, with the arm above the head. Place something under the patient to elevate the side for the tube at a 45-degree angle. Prep a wide area with betadine or chlorhexidine.
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First, anesthetize a small area with local anesthetic. Prior to making an incision, aspirate with a 22-gauge needle in the interspace where you intend to enter the pleura. This maneuver confirms that a tube in that location will provide the desired drainage of air or fluid.
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The periosteum, interspace, and pleura are liberally anesthetized with local anesthetic, and then a small (˜1.5 cm in length) incision is made in the anterior axillary line over about the sixth rib.
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Before tunneling, place your sutures so you can secure the tube once it is in the chest. We generally place one 2-0 silk stitch at the edge of the incision to hold the tube in place and a second stitch directly in the middle of the incision to be tied after the tube is removed. This latter stitch can have its end knotted together and then be wrapped around the tube while the tube is in place. Placing the sutures at this point in the procedure (before the tube is placed) gives additional time for the local anesthetic to take effect and makes tying the tube in after placement more convenient.
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Next, using a sharp Kelly clamp, bluntly dissect over the rib in the intercostal space to be accessed. You should hug the top of the rib. The neurovascular bundle runs on the inferior posterior surface of ribs, so it is critical to stay on the top of the rib. An intercostal artery injury during chest tube placement will lead to a significant hemothorax and likely require surgery for evacuation.
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Handheld ultrasound guidance
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At times either the fluid or the air in the chest can be minimal and loculated, so the chest tube must be directed exactly into the desired space. In these circumstances, the surgeon can use a handheld ultrasound to locate the space and help guide a drainage tube into it. Smaller percutaneous tubes (pigtail catheters) or guidewire directed larger tubes are best used ( Fig. 46-1 ).
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Penetrating the pleura should not require force if spreading of the intercostal muscles is adequate. Selecting one spot and spreading the intercostal tissue slowly, repeatedly, and completely will allow entry into the pleura without pain or undue force. When the pleura is opened, there should be either a rush of air or fluid.
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Open the jaws of the Kelly clamp widely in the pleura to make the chest tube hole big enough for the tube. If needed, a finger may be passed into the thorax to confirm an intrapleural location and to feel for adhesions that can be gently lysed, as needed.
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The tube can be guided into the pleural cavity with a Kelly clamp or by using a trocar chest tube. Make sure the last hole of the tube is all the way into the chest cavity. If there is resistance to insertion of the chest tube, do not force it—you may be in the fissure. Pull back and redirect the tube. It is a good idea to have a Kelly clamp occluding the other end of the tube as it is being placed to keep the fluid from excessive soiling. This should not be done if the tube is being placed for pneumothorax. You will notice condensation in the tube as the pneumothorax escapes through the tube.
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Secure the tube with the 2.0 silk suture. Make sure the incision is occluded to minimize drainage around the tube or air into the chest. Wrap the second stitch around the tube for use after the tube is removed.
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After it is secured, hook the tube to the collection system but do not place to suction initially. Tape the tubing connection with thin strips of cloth tape in an H shape so that you can still visualize the connection. Tape the entrance site with cloth tape to create a seal. Create a mesentery of tape for the floundering remainder of the tube.
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Note: If the tube is placed for a large pleural effusion, place a partial occluding clamp on the tube to drain the chest slowly. Do not put to suction immediately. Rapid draining is painful and can cause hemodynamic or respiratory complications or re-expansion pulmonary edema.
Figure 46-1
A to D, Technique of tube thoracostomy placement.
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SELDINGER TECHNIQUE
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Fully equipped commercial chest tube kits are available.
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Following a 2-cm incision, an introducer needle is introduced into the pleural space with aspiration of air or fluid as described earlier.
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A guidewire is inserted through the needle introducer and directed to a desired position (e.g., apical for pneumothorax).
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Dilators of increasing size passed over the guidewire to form a tract for the chest tube.
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After the chest tube and its accompanying dilator are passed into the pleural space, the guidewire and dilator are removed.
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Cautions regarding the Seldinger technique:
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Does not permit appreciation of adhesions
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Presence of adhesions may facilitate lung parenchymal puncture
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Should be attempted only with obvious separation of lung and parietal pleura on imaging studies.
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