Chest tube drainage - Dr.Tinku Joseph

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PowerPoint presentation on Intercostal drainage (ICD) or Chest tube drainage. In this this presentation I have included different methods by which a chest tube can be inserted to drain fluid, pus, air from the Pleural cavity. please do mail me your feedback on this presentation at

Transcript of Chest tube drainage - Dr.Tinku Joseph

  • WHAT ARE THE ISSUES ? When to put a drain Site of insertion Choosing the drain Drainage system Clamping the chest drain Time & method of removal Trouble shooting
  • INDICATIONS Pneumothorax primary spontaneous ptx Secondary spontaneous ptx Tension ptx(after initial needle aspiration) Malignant pleural effusion Empyema and complicated parapneumonic pleural effusion Traumatic haemo pneumothorax Postoperative,eg: after oesophageal, cardiac, pulmonary,mediastinal or pleural surgery. Treatment with sclerosing agents or pleurodesis Post pneumonectomy bronchopleural fistula
  • CONTRAINDICATION Lung adherent to the chest wall Uncorrected coagulopathy
  • SITE OF INSERTION ? Exact site depends on the location of abnormality. 5th ICS in mid axillary line is the site used most often. Earlier it was believed that air can be drained only through anteriorly placed tube in 2nd ICS in mid- clavicular line.A tube placed too medially can injure internal mammary artery causing serious haemorrhage. Experience has shown that a tube of proper size,inserted through 5th ICS in mid axillary line can drain effectively.
  • TRIANGLE OF SAFETY Area bordered by the anterior border of latissmus dorsi,the lateral border of the pectoralis major, a line superior to the horizontal level of nipple,with its apex towards axilla This is the usual site which corresponds to the 5th or 6th ICS in mid-axillary line
  • POSITION OF THE PATIENT A chest tube can be inserted in supine,sitting or lateral position. Most preffered is supine position,in which patient lies flat on the bed,slightly rotated to the opposite side,with ipsilateral arm behind her/his head. Patients who are breathless may be asked to sit upright in the bed,leaning over a cardiac trolley with a pillow to place their arms
  • If chest tube is inserted to drain blood,pus or another fluid, the patient should be seated when the tube is inserted to ensure that the diaphragm is in the most dependent position and the fluid is collected in the lower part of the chest When chest tube is placed for pneumothorax,the patient should be in recumbent position if anterior chest tube is placed, and should be in decubitus position if an axillary tube is placed In case of loculated pathology it is good practice to do an USG or CT guided ICD.
  • MATERIALS REQUIRED Sterile gloves and gown Skin antiseptic solution, e.g. iodine or chlorhexidine in alcohol Sterile drapes Gauze swabs A selection of syringes and needles (2125gauge) Local anaesthetic, e.g. lignocaine (lidocaine) 1% or 2% Scalpel and blade Suture (e.g. 1 silk) Instrument for blunt dissection (e.g. curvedclamp)
  • Guidewire with dilators (if small tube being used) Chest tube Connecting tubing Closed drainage system (including sterile water if underwater seal being used) Dressing
  • GUIDEWIRE TUBE THORACOSTOMY Easiest way to insert a chest tube. Usually done under the guidance of either USG or CT. This procedure uses the Seldinger technique with guide wires & dilators. Skin,periosteum and parietal pleura are anesthetized and incision is made in skin 18 gauge needle attached to a syringe is introduced into the pleural space. Fluid or air is aspirated to confirm the diagnosis. Syringe is removed and J wire is threaded through the needle in desired direction into the pleural space Needle is then removed and smallest dilator is been inserted with a rotating movement, it is advanced into pleural space.
  • The first dilator is removed leaving the wire in place. Then the next size dilator is advanced over the guidewire into the pleural space and removed. Finally chest tube containing the inserter is been threaded over the guide wire. Once tube is in place inserter & guide wire are withdrawn. Tube is then clamped until it is attached to chest drainage system. Tube is been anchored in place by means of purse string suture. Incision is sutured without tension to avoid necrosis of skin Sterile dressing applied.
  • TROCAR TUBE THORACOSTOMY Initially requires a 2-4cm incision parallel to superior border of the rib through the skin and subcutaneous tissues after LA. Trocar is inserted between the ribs into the pleural cavity,with flat edge cephalad to prevent damage to intercostal vessels The hand not applying force should be placed next to the chest wall to control depth of penetration Once trocar is in pleural space,stylet is removed and chest tube with its distal end clamped is inserted into the pleural space. Tocar is then removed.
  • Alternate trocar method uses a chest tube with a trocar positioned inside the tube DISADVANTAGES More chances for puncturing lung & other vital organs.
  • OPERATING TUBE THORACOSTOMY Most commonly practiced Patient should be given anxiolytic 10-15mins before the procedure and liberal doses of LA be used. 3-4cm incision is made in the skin parallel to the chosen intercostal space. The incision should be made down to the fascia overlying the intercostal muscle. Once fascia has been incised the muscle fibers are spread with a blunt tipped hemostat Incision is then made in the intercostal fascia just above the superior border of the inferior rib over which tube will pass Parietal pleura is then penetrated using blunt tipped hemostat
  • Hole in the parietal pleura is then enlarged with operators index finger Operator should then palpate adjacent pleural space to detect any adhesions. Chest tube with its distal end clamped is then introduced with help of a hemostat into the pleural space Tube is sutured in place(mattress sutures) as per BTS guidelines Site is cleaned and sterile dressing applied
  • ADVANTAGES Safer then other methods Adhesions between lung & chest wall can be removed. DISADVANTAGES Insertion of tube ectopically
  • SINGLE PORT THORACOSCOPY Hopkins rod lens telescope is loaded into the most proximal port of chest tube. Under direct visualization the chest tube is placed into the costodiaphragmatic gutter and scope is been removed & tube fixed.
  • PLEURAL DRAINAGE SYSTEMS ONE WAY(HEIMLICH)VALVE this drainage system is by far the simplest Chest tube is attached to a one way flutter valve assembly, which is constructed so that the flexible tubing is occluded whenever the pressure inside the tubing is less than atmospheric pressure & is patent whenever the pressure inside the tubing is above the atm pressure When pleural pressure and pressure in the tube are negative flutter valve is closed and no air enters pleural space. When pleural pressure becomes positive the tube is patent and air or fluid can egress from pleural space.
  • ADVANTAGE It is a simple & renders freedom of the patient from a bulky drainage apparatus Patients can be sent home with the flutter valve in place
  • ONE BOTTLE COLLECTION SYSTEM Consists of one bottle that serves as both a collection container and a water seal. Chest tube is connected to a rigid straw inserted through a stopper into a sterile bottle Enough sterile solution is instilled into the bottle so that tip of the rigid straw is approximately 2cms below the surface of saline solution. Bottles stopper must have a vent to prevent pressure from building up when air or fluid coming from pleural space enters the bottle.
  • When pleural pressure is positive,the pressure in the rigid straw becomes positive,and if the pressure inside the rigid straw is greater than the depth to which straw is inserted into the saline solution,air(or liquid)will enter the bottle and will be vented to the atmosphere(or collect in the bottle). If the pleural pressure is negative,fluid will be drawn from the bottle into the rigid straw and no extra air will enter the system. Thus water in the bottle seals the pleural space from air or fluid from outside the body
  • ADVANTAGES: Easy to carry & works well for uncomplicated pneumothorax DISADVANTAGES: If large amounts of fluid is draining from patients pleural space level of fluid will rise in one bott