Chest Tube
Indications
Large hemothorax or pneumothorax
Needle decompress first if tension pneumothorax
Preparation
Materials
Local anesthesia
Sterile clothing (including face-shield, gown, gloves, hair net)
Chest tube
Size for adults range 28-32 Fr (no clear evidence for larger tubes)
Size for children usually 3 x uncuffed ETT (4+age/4)
Infant 8-12 Fr
Chidlren 16-24 Fr
Load chest tube on back of curved hemostat (Kelly)
Clamp opposite end tube (to prevent mess)
Scalpel
22G long needle
Suture material (1-0, 2-0 non-absorbable silk)
Pleurivac or Seal drain system
Set up to create water seal (as per manufacturer), attach to suction
Vaseline gauze dressing with tape
Position
Supine or 30 degrees head up
Arm secured away (abducted, and elbow flexed)
Clean and drape wide area from clavicle to subcostal, sternum to posterior axillary line
Procedure
Identify area above 5th intercostal space and anterior to mid axillary line
Usually above and lateral to nipple, pectoral crease, xyphoid process, tip of scapula
Anesthetize from below angled superiorly to reach parietal pleura of 4th-5th ICS just above rib (to avoid neurovascular bundle inferior to ribs)
Incision >2-3cm parallel to rib with scalpel
Hemostat to dissect until reaching pleura
"Pop" the pleura, and stretch out pleural incision
Use finger to feel lung, check for lung adhesions
Advance tube through pleura, and direct posteroinferiorly for fluid and anterosuperiorly for air
Unclamp and push in until last hole inside pleural space
Check placement
See "fog" in tube if unclamp end while patient breathes
Rotate tube (check for kinks)
Attach collection system (underwater seal drain)
May need to cut the end of chest tube to easily attach
Consider starting at -20cm H20 of suction
Suture and tie many knots
Imaging
Chest X-ray for placement and follow-up
Pull-back tube if crosses mediastinum
Removal
Prepare dressing materials
Cut suture
Valsalva (hold breath and bear down), or inspiratory pause (if ventilated)
Pull tube quickly and seal dressing
Leave dressing x 48h