Chest tube

Chest tube
The free end of the Chest Drainage Device is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest.
Other names	Intercostal drain
Specialty	pulmonology
ICD-9-CM	34.04
MeSH	D013907
[edit on Wikidata]

A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a

The concept of chest drainage was first advocated by Hippocrates when he described the treatment of empyema by means of incision, cautery and insertion of metal tubes.^[2] However, the technique was not widely used until the influenza epidemic of 1918 to evacuate post-pneumonic empyema, which was first documented by Dr. C. Pope, on a 22-month-old infant.^[3] The use of chest tubes in postoperative thoracic care was reported in 1922,^[4] and they were regularly used post-thoracotomy in World War II, though they were not routinely used for emergency tube thoracostomy following acute trauma until the Korean War.^[5]

Uses

Medical uses of chest tube are as follows:^[6]

• air
  or gas in the pleural space
• Pleural effusion: accumulation of fluid in the pleural space
  • Chylothorax: a collection of lymph in the pleural space
  • pyogenic infection
    of the pleural space
  • Hemothorax: accumulation of blood in the pleural space
  • Hydrothorax: accumulation of serous fluid in the pleural space
  • Urinothorax: accumulation of urine in the pleural space

Contraindications

Contraindications to chest tube placement include refractory coagulopathy and presence of a diaphragmatic hernia, as well as hepatic hydrothorax.^[7] Additional contraindications include scarring in the pleural space (adhesions).

Complications

Complications that are sometimes associated with chest tubes include the potential for clogging, air leaks, infection,

Complications that arise while the chest tube is being inserted or within the first day of the insertional procedure include a risk of injury to organs near the insertional site.[10]

Positional complications

Complications that arise after the tube has been inserted for one day or longer include the potential for tube blockages (obstruction), air leaks, kinking, or entrapment in the lung fissure once the lung has been expanded. Chest tube clogging can lead to retained blood around the heart and lungs that can contribute to complications and increase mortality.

Minor complications include a subcutaneous hematoma or seroma, anxiety, shortness of breath, and cough (after removing large volume of fluid). In most cases, the chest tube related pain goes away after the chest tube is removed, however, chronic pain related to chest tube induced scarring of the intercostal space is not uncommon.^{[citation needed]}

Subcutaneous emphysema indicates backpressure created by undrained air, often caused by a clogged chest tube or insufficient negative pressure.^{[citation needed]} If a person has subcutaneous emphysema, it is likely their chest tube is not draining and consideration should be given if it should be unclogged or another tube should be placed so that the air leaking from the lung can be adequately drained.

Infections

Problems keeping the site clean or with sterilizing instruments can lead to infections.^[10] When chest tubes are placed due to either blunt or penetrating trauma, antibiotics may decrease the risks of infectious complications.^[14]

Removal complications

There is also a risk of complications after the chest tube as been removed.^[10] Potential complications include problems with re-sealing the chest that can lead to trapped air or if a foreign object is retained in the chest after the procedure.^[10]

Device

Characteristics

Chest tubes are commonly made from clear plastics like

Chest tube have an end hole (proximal, toward the patient) and a series of side holes. The number of side holes is generally 6 on most chest tubes. The length of tube that has side holes is the effective drainage length (EDL). In chest tubes designed for pediatric heart surgery, the EDL is shorter, generally by only having 4 side holes.[17]

Channel style chest drains, also called Blake drains, are so-called silastic drains made of silicone and feature open flutes that reside inside the patient. Drainage is thought to be achieved by capillary action, allowing the fluids to travel through the open grooves into a closed cross section, which contains the fluid and allows it to be suctioned through the tube.^[18] Though these chest tubes are more expensive than conventional ones, they are theoretically less painful.^[19]

Chest drainage system

A

The free end of the tube is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest. Alternatively, the tube can be attached to a flutter valve. This allows patients with pneumothorax to remain more mobile.^[20]

More recently digital or

It can be inserted in an area described as the "safe zone", which is a region bordered by the lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi and a horizontal line superior to the nipple.[24] This should translate to the tube being inserted into the fifth intercostal space slightly anterior to the mid axillary line.^[25]

Chest tubes are usually inserted under

Chest tubes can also be placed using a trocar, which is a pointed metallic bar used to guide the tube through the chest wall. This method is less popular due to an increased risk of iatrogenic lung injury. Placement using the Seldinger technique, in which a blunt guidewire is passed through a needle (over which the chest tube is then inserted) has been described.

Protocols to maintain chest tube patency by preventing chest tube clogging are necessary.

Postoperative drainage

The placement technique for postoperative drainage (e.g. cardiac surgery) differs from the technique used for emergency situations. At the completion of open cardiac procedures, chest tubes are placed through separate stab incisions, typically near the inferior aspect of the sternotomy incision. In some instances multiple drains may be used to evacuate the mediastinal, pericardial, and pleural spaces. The drainage holes are placed inside the patient and the chest tube is passed out through the incision. Once the tube is in place, it is sutured to the skin to prevent movement. The chest tube is then connected to the drainage canister using additional tubing and connectors and connected to a suction source, typically regulated to -20 cm of water.^[18]

Dressings

After suturing,

Chest tubes should be kept free of dependent loops, kinks, and obstructions which may prevent drainage.[27] In general, chest tubes are not clamped except during insertion, removal, or when diagnosing air leaks.^{[citation needed]}

Chest tube clogging with blood clots of fibrinous material is common. When this occurs, it can result in retained blood around the heart or lungs that can lead to complications such as hematoma that needs to be drained, effusions, empyema, or, in the long term, fibrothorax. Thus its critical to maintain chest tube patency. Manual manipulation, often called milking, stripping, fan folding, or tapping, of chest tubes is commonly performed to clear chest tube obstructions. However these approaches are controversial. No conclusive evidence has demonstrated that any of these techniques are more effective than the others, and no method has shown to improve chest tube drainage.^[28] Furthermore, chest tube manipulation has proved to increase negative pressure, which may be detrimental, and painful to the patient.^[28] For these reasons, many hospitals do not allow these types of manual tube manipulations.^[29]

One option is active chest tube clearance without breaking the sterile field. According to a consensus of multiple experts in cardiac surgery, anesthesia and critical care in 2019 the ERAS Guidelines for Perioperative Care recommends active clearance of chest tubes to prevent retained blood and other complications.^[30] Makeshift efforts such as open chest tube clearing that involves breaking the sterile environment separating the chest tube from the drainage canister tubing to suction it out should not be performed.^[31]

The chest tube can only be removed when the subject clinical condition is stable, the lungs are fully aerated as seen on chest X-ray, chest tube drainage is less than 200 cc per day, and there is no air leak into the lungs pleura.^[32]

Site of placement

In December 2018 the European Respiratory Journal published correspondences that raise the possibility of improving mobility as well as patient outcomes by placing a chest tube more optimally.^[33][34]

References