Chest Tube Placement by Dr. Christopher Weldon.
Hello.
My name is Christopher Weldon.
I'm a surgeon and intensivist at Children's Hospital Boston in Boston, Massachusetts in
the United States.
Today, I will be giving a demonstration on the placement of a thoracostomy tube, or better
known as a chest tube.
During this demonstration, I will show you the steps that you take to prepare the patient
for a thoracostomy tube or a chest tube, the steps involved with physically placing the
chest tube, and then hooking it up to the pleurovac device or the suction device to
remove both air and fluid from the chest once the tube is placed.
And finally, we'll go over the possible complications with not only placement of the tube, but also,
a malfunctioning or non-functioning tube.
The steps that we will use will simply be those that we perform on a daily basis in
this hospital, which may be slightly different than your home institution.
Furthermore, the use of sedatives or other agents to assist you in the placement of the
tube is beyond the scope of this video.
But we must remember first and foremost that patient safety and the relief of pain and
discomfort are of paramount importance.
Indications.
This procedure may be performed when there is compression of the lung and mediastinal
structures secondary to the accumulation of air, fluid, or blood in the plural space.
Contraindications.
There are no true contraindications to this procedure, but you may need to choose an alternative
site in patients with a skin infection over the chest tube insertion site.
You will need to exercise caution in patients with coagulopathy or a platelet count less
than 50,000 per microliter, pulmonary bullae, pleural adhesions, or diaphragmatic adhesions.
Equipment.
You will need the following equipment to perform the procedure: surgical chest tube, antimicrobial
scrub, scalpel, forceps, Kelly clamp, sutures, needle driver, suction source, chest tube
collection device, male-to-male connector, shoulder roll, monitoring equipment.
Procedure: Preparation.
After appropriately prepping myself by scrubbing my hands with a antimicrobial agent and then
using universal precautions to make sure that I protect myself from the patient and the
patient from me, I then take the time to confirm both the laterality and the procedure that
will be performed with the remainder of the surgical team.
A surgical time-out must be performed prior to any invasive procedure and should include
confirmation of patient, procedure site, and potential complications.
After confirmation of that, I will then take any number of antimicrobial agents of which
to prep the chest, which includes, in this case, a combination of isopropyl alcohol and
chlorhexidine.
We will then prep out our chest, using wide arcs starting at the middle, extending outwards,
and prep much more of the chest wall into the field than actually is needed just in
case there's any problems during the procedure itself.
Care is taken to make sure that the patient is appropriately anesthetized again, that
appropriate sedatives are on board, the patient has been appropriately prepped for the procedure,
and that the prepping solution is in place.
After the prepping solution has been utilized, it's taken off the field, after which point
the entire field is then draped using sterile towels.
Procedure: Placement.
Once the patient has been appropriately prepped with the proper antimicrobial agents and draped
in a sterile fashion, the most important thing to remember is that our landmarks must still
be into view.
In placing a chest tube for air, fluid, or both, the most important landmark in the patient
is the nipple.
The nipple signifies roughly the fourth inner thoracic space at which point the chest tube
is then placed in the anterior axillary line, just lateral to the nipple but at the same
level to ensure that the chest tube is not placed too low on the patient, thereby violating
the diaphragm and placing the chest tube inadvertently into the peritoneal cavity.
Again, we appropriately identify the nipple, come across to the anterior axillary line
laterally on the affected side, after which point then we'll place a chest tube through
that rib space and into the pleural space.
With the patient appropriately prepped and draped prior to doing the procedure, we confirm
one last time the reason why the procedure is being done and confirm the side that the
procedure needs to be done on, in this case his left chest.
We then confirm our anatomical landmarks, which is the nipple and the anterior axillary
line, which should represent either the fourth or the fifth interspace where the chest tube
will be placed.
We palpate the ribs in that area.
We will then make the incision, tunnel in above that incision, just above the rib.
We will then bluntly dissect into the pleural space, holding the position with the clamp,
after which point the tube will then be placed through the clamp into the pleural space.
Ideally, once the patient has been appropriately, again, prepped, draped, and anesthetized,
confirm placement.
We then document the placement of the nipple at the junction of the anterior axillary line
on the affected side.
We then make an incision below the affected rib space.
The incision needs to be large enough not only to accept the chest tube but also to
accept the clamp for the dissection into the chest cavity itself.
The incision is made with any sharp knife that is then placed off the field so as not
to inadvertently injure the operator or the assistants.
You then take the blunt instrument.
You then find your affected rib space.
You then gently dissect in directly over the rib cephalad to where you are, thereby confirming
the location.
You then dissect into the pleural space.
Once you have adequate entrance into the pleural space, the clamp is left in as a bookmark,
if you would, to guide the passage of the chest tube, which is in place through the
clamp itself and then into the patient.
Sometimes the chest tube will be assisted by placing the clamp around the tube to help
guide it through the ribs and into the pleural space.
Once the chest tube has been adequately placed, it then needs to be secured in a proper position
with the placement of a suture in and around the chest tube itself.
The chest tube may be secured in many different ways.
We attempt to perform a single Roman stitch whereby we tie it down to the skin first,
locking it in place on the skin, and then having the suture go in around the tube itself
to then secure it to the skin stitch.
Sometimes more than one suture is needed to perform this technique.
An occlusive dressing is then placed over the site of chest tube insertion.
Once the tube has been placed in the proper location and secured in place, we then take
a male-to-male connector so that we can connect the chest tube output to our collection device
to collect both air and blood.
Once the tubes have been placed via the connector, the tube is ensured to be in adequate position
with no evidence of leakage of air or fluid around the tube and secured in place.
We use an Atrium Single system collection device whereby our negative pressure is conducted
through this compartment.
We generally raise to a level of 20 centimeters of water.
This is our water seal chamber, which we then raise to 2 centimeters of water pressure,
after which point this serves as our collection apparatus to collect fluid.
Fluid will then collect sequentially starting in the rightmost chamber, going towards the
middle, and then finally to the leftmost, after which point any evidence of leakage
of air from the pleural surface or from within the pleural space is dribbled out through
a water seal chamber, after which point our negative pressure is delivered through here.
Your actual collection device may vary dramatically depending on your precise location and your
equipment at hand.
Removal of Chest Tube.
The chest tube can be removed when there is no further leakage of fluid or air into the
pleural space.
When there is no ongoing leakage of fluid or air in the pleural space while on suction,
the chest tube is placed to atmospheric pressure or waterseal and a chest radiogram is obtained.
If there is no reaccumulation of air or fluid in the pleural space on chest x-ray or in
the collection device, the chest tube can be removed.
Complications.
The complications that you may observe include injury to lungs, heart, liver, other organs
and soft tissues, bleeding, pneumothorax, infection.
Assessment and Monitoring.
First of all, it is important to monitor the patient's vital signs including oxygen saturation.
You will also want to monitor how much, if any, air, fluid, or blood was removed during
the procedure.
Lastly, you will want to assess the patient's comfort before, during, and after the procedure.
Documentation.
Following chest tube placement, you should document the following information in the
patient's medical record: indication for procedure, date and time, size and site of chest tube
placement, amount and type of drainage removed, confirmation of placement on chest x-ray,
adverse outcomes.
Thank you very much.
This concludes the demonstration of placement of a chest tube or tube thoracostomy.
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