INTRODUCTION OF CHEST DRAINAGE TUBES
Pleural drainage tubes are inserted for evacuation of
air or fluid from the pleural space in diseases such as pneumothorax,
hemothorax, and empyema.
Placement of an intercostal tube or catheter for pneumothorax can be readily accomplished under local anesthesia, with or without an intercostal nerve block. Chest tube placement may be done at the bedside, but strict aseptic precautions should be observed. The second or third anterior intercostal space in the midclavicular line or the fourth or fifth intercostal space in the midaxillary line are the preferred sites for chest tube placement. To help select the optimal point of entry, chest radiographs should be reviewed unless the clinical situation is one of extreme urgency.
Anteriorly placed chest tubes in the second and third
intercostal space must be placed at least two finger-breadths lateral to the
sternal border to avoid injury to the internal mammary vessels. Lateral tube
placements must not be made too low in case there is penetration of the sloping
diaphragmatic attachment where it joins the chest wall. The act of tube
insertion should not be forceful but done with deliberate tactile
control to avoid injuring the diaphragm or an enlarged heart if placed on the
left side. Pleural access should always be on the superior surface of the rib
to avoid the neurovascular bundle.
During the process of local anesthesia, needle aspiration
and ready withdrawal of air or fluid should precede any tube insertion. Failure
to find a free pleural space necessitates choosing another site for tube
insertion. Because the parietal pleura can be quite sensitive, adequate local
anesthesia is essential. The use of ultrasonography to select an appropriate
insertion site has revolutionized pleural access. The site for tube insertion
should be one that is away from adherent lung. Tubes placed to drain fluid
should be directed posteriorly, but they should be directed anteriorly when
placed to drain air.
Multifenestrated tubes should be checked carefully to
be sure that all openings lie well within the pleural space. Thoracostomy tubes
should be sutured to the skin, but such suture fixation cannot be depended on to
hold the tube securely in place; for this purpose, careful binding with
adhesive tape is required. All connections of the tube to the drainage system
should be secured as well, and care should be taken to protect against traction
and tube angulation.
An underwater seal is attached to the tube and tube
patency is present if an oscillating column within the tube is observed. Having
the patient cough or sniff is the best way to demonstrate small oscillations of
tube fluid; barely detectable tube fluid oscillation signifies either full lung
expansion or tube blockage. Exacerbation of subcutaneous emphysema or an
increasing pneumothorax with a tube in place usually signifies tube blockage or
improper placement. Depending on the clinical situation, suction may also be applied to
the tube.
After an intercostal tube has been inserted, its
position and effectiveness must be checked by radiography as soon as possible.
Smaller tubes (8-14 Fr) can be used to drain
pneumothoraces and simple pleural effusions. Larger tubes (>14 Fr) are
typically required to drain empyema or hemothoraxes.
