Tube Thoracostomy (Chest Tube)

Tube Thoracostomy (Chest Tube)

David Ray Velez, MD

Table of Contents

Tube Size
Placement Technique
Drainage System
Removal

Tube Size

Pneumothorax (PTX): 8-16 French

Pleural Effusion/Hemothorax (HTX): 24-28 French

  • *Older Teaching to Use the Largest Size Possible (36-40 French) for Hemothorax Has Fallen Out of Favor – In General Clotted Blood Will Not Drain No Matter How Big the Tube Is
  • Use Smaller Sizes in Peds

Excessively Large Sizes Cause Significant Discomfort and Can Inhibit Deep Breathing without Additional Benefit

Chest Tube Sizes Compared to Average Intercostal Space (Mid-Axillary 5th Space) 1

Placement Technique

Prepare

  • Position Supine with the Ipsilateral Arm Extended or Over the Head
  • Prep and Drape Skin
  • Inject Local Anesthetic – Inject the Incision Site and the Tract All the Way Down to the Pleura

Incision

  • Target 4th/5th Intercostal Space at Anterior Axillary or Mid-Axillary Line
  • Make a 2-3 cm Transverse Incision Over the Inferior Rib
  • Using Curved Clamp Bluntly Dissect and Tunnel Immediately Above the Rib
    • Never Go Below the Rib (Risk Damage to the Neurovascular Bundle)
  • Penetrate the Pleura with the Curved Clamp and Spread the Penetration Site

Insertion

  • Insert a Finger to Confirm Position and Bluntly Dissect Any Surrounding Adhesions
  • Place a Clamp In-Line with the Tip of the Chest Tube
  • Insert the Chest Tube Using the Clamp and Direct it into Position
    • Pneumothorax (PTX): Aim Anterior/Superior
    • Hemothorax (HTX): Aim Posterior

Suture Anchor the Tube to the Skin

Always Obtain a Post-Placement Plan Radiograph to Confirm Placement and Lung Expansion

Alternative Techniques

  • Seldinger Technique
  • Ultrasound (US)-Guided
  • Intervention Radiology (IR)-Guided

Thoracic Irrigation (Thoracic Lavage)

  • Definition: Irrigation of the Thorax Through the Chest Tube Upon Insertion
  • Used for Hemothorax Only (Not Pneumothorax)
  • Reduces the Risk of Retained Hemothorax and Secondary Interventions
  • Irrigation Volumes ≥ 1,000 mL Normal Saline are Preferred – Shown Shorter Hospital Length of Stay

Chest Tube Placement 2

Triangle of Safety 3

Drainage System

Classic “Three Bottle” System

  • Bottle #1 (Collecting Bottle): Collects Fluid from the Patient
  • Bottle #2 (Water Seal): Allows Air to Escape but Prevents External Air Entry Back into the Chest
    • “Bubbling” Indicates an Air Leak
  • Bottle #3 (Suction Control): Adjustable Manometer Set to Specific Depths to Set a Controlled Suction Pressure
    • Most Often Set to 20 cm H2O

“Four Bottle” System

  • Adds an Additional Venting Bottle Connected to the Collecting Bottle
  • Fourth Bottle is Vented to the Air and Not Connected to Suction
  • Acts as an Additional Water Seal to Prevent Pneumothorax in the Event of Unexpected Suction Failure

Classic “Three Bottle” System 4

Modern Collecting Systems (Atrium, Pleur-Evac)

  • Entire System is Combined in a Single Piece of Equipment
  • Collecting Chamber Acts as Bottle #1
  • Water Seal Acts as Bottle #2
  • Suction Control Can be “Wet Suction” or “Dry Suction”
    • Wet Suction: Acts as a Traditional Bottle #3 Using Fluid
    • Dry Suction: Controls Suction Using a Pressure Control Valve

Modern Collecting System 5

Removal

Removal

  • Use an Occlusive Dressing to Prevent Inspiration of Air Back into the Pleural Cavity
    • Ex: Xeroform or Vaseline-Soaked Gauze
  • Cut Any Suture Anchoring to the Skin
  • Remove Chest Tube on Expiration, After A Complete Full Inspiration
    • Increases Intrathoracic Pressure to Decrease the Risk of Recurrent Pneumothorax Upon Pull
    • *Exact Timing is Debated and Some Prefer Pulling with an Inspiratory Hold

Repeat Chest Radiograph

  • Consider Repeating Chest Radiograph After Chest Tube Removal (“Post-Pull CXR”)
    • Often Done at 4 Hours or 24 Hours
  • *No Evidence that Post-Pull CXR is Necessary – Some Prefer Repeat Imaging Based Solely on Symptoms

References

  1. Gammie JS, Banks MC, Fuhrman CR, Pham SM, Griffith BP, Keenan RJ, Luketich JD. The pigtail catheter for pleural drainage: a less invasive alternative to tube thoracostomy. JSLS. 1999 Jan-Mar;3(1):57-61. (License: CC BY-NC-ND-3.0)
  2. Mohammed HM. Chest tube care in critically ill patient: A comprehensive review. Egyptian Journal of Chest Diseases and Tuberculosis. 2015. 64(4):849-855. (License: CC BY-NC-ND-4.0)
  3. Hill J. Taming the SRU. (License: CC BY-NC-SA-3.0)
  4. Shi H, Mei L, Che G. [The current concepts of closed chest drainage in lobectomy of lung cancer]. Zhongguo Fei Ai Za Zhi. 2010 Nov;13(11):999-1003. (License: CC BY-4.0)
  5. British Columbia Institute of Technology (BCIT). Wikimedia Commons. (License: CC BY-SA-4.0)