c l i n i c a l f o l i o s : d i s c u s s i o n

Chest Tube Placement



Related narrative: Chest Tube Placement (Tube Thoracostomy)

Chest tube decompression of the pleural space is most commonly used after thoracotomy, for spontaneous pneumothorax, and for hemo/pneumothorax resulting from blunt or penetrating trauma. The latter indication is often an emergency life-saving intervention. Penetrating chest wounds due to gunshot generally cause more damage than stab wounds, and while it is helpful to know the trajectory of the bullet, it is not an absolute predictor of damage, since bullets and fragments ricochet. In the face of an anterior gunshot wound without an exit wound as in this case, the extent of the damage is not initially clear.

Since this patient's vital signs were relatively stable, it was possible to get a quick upright chest X-ray to assess for other damage aside from the likely right chest injury. Up to 500 cc of blood may be present in the pleural cavity before it is evident on chest X-ray, and double that amount may be missed if the patient is supine. There were no signs of life-threatening conditions such as tension pneumothorax or cardiac tamponade, and no indication of massive blood loss. The chest X-ray showed only a right hemothorax. If the patient had signs of respiratory distress, the chest tube would have been placed presumptively first on the right without an X-ray.

Proper technique of chest tube placement is illustrated by this case. The site is prepped, and if time permits and the patient is conscious, local anesthesia is infiltrated subcutaneously and intercostally. The common site for chest tube placement is in the anterior axillary line in the 5th or 6th intercostal space, which corresponds to the level of the nipples in the male. The domes of the diaphragms can rise to this level, and lower placement of the tube endangers the diaphragm and the abdominal organs immediately beneath (see abdominal anatomy).

The endothoracic fascia and pleura form a surprisingly tough membranous barrier lining the chest cavity, and are best penetrated first with the tip of a long curved blunt clamp. The left hand should be held around the clamp and stabilized against the chest wall to limit deep penetration when the clamp is pushed through. The tip of the clamp should hug the top of the lower rib of the interspace to avoid injuring the intercostal neurovascular bundle which runs in a groove inside the lower border of each rib. When punching through the pleura, a quick sharp push is more effective than a slow steady push, and prevents the pleura being separated from the chest wall.

A large bore (greater than 34FR) chest tube is indicated for trauma because blood will clot off and block smaller tubes. A spontaneous pneumothorax due to rupture of a bleb may be managed by a smaller tube. The proximal end of the tube should be clamped prior to releasing the clamp at the tip, to prevent an uncontrolled outflow of contained blood. The tube is connected to underwater seal. Suction is applied if there is evidence of a large air leak. The tube is sutured securely to the skin, and PA and lateral chest X-rays are done to confirm position.

The last hole is intentionally placed on the radio-opaque line, so that it can be identified, and the position adjusted if it is in the subcutaneous tissue and not in the chest. Such malposition can result in air leak and ineffective function of the tube. If there is a massive hemothorax (greater than 1500 cc initial output, or greater than 200-300 cc/hr after the initial drainage) the patient is taken emergently to the operating room. If a massive hemothorax is suspected, and there is time, preparation before chest tube placement for collection of the blood for autotransfusion is a helpful adjunct. It is important to effectively drain blood from the pleural cavity, both because of acute respiratory compromise, and because residual blood can lead to fibrothorax and respiratory restriction. For this reason the tube is checked frequently for function (fluctuation in water level, bubbling) and milked to remove clot from the lumen.

This page was last modified on 2-Feb-2002.