1. Tube Thoracostomy Yasser Farag El-ghoneimy M.D. Assistant Prof. of Cardiothoracic Surgery KFHU – Khobar – Saudi Arabia 2005

2. Outline Historical review Indications Contraindications Technique of insertion Size of the tube Site Underwater seal system Complications Removal of chest tube Changing a chest tube After care of the chest tube Quiz

3. Items for evaluation of trainee learning this procedure Anatomy of the chest, lungs, pleura Indications, and contraindications of this procedure Use of sterile technique and Universal Precautions Technical ability Appropriate documentation Understanding of potential complications and their correction

4. Introduction Tube thoracostomy is one of the simplest most effective and most important of all thoracic operations. It is a life saving procedure. It has saved countless lives. There is No single factor affecting the outcome of thoracic surgery as do the chest tube. Although it is important to know how to do a chest tube, but the most important is to know how to take care of the patient after tube insertion.

5. Historical note The surgical principle of drainage fluids dates back to Hippocrates (460-377 BC) – Aurelius Celsus (30-45 AD) - a Roman physician and medical writer. Credit for the chest tube is usually given to Crosswell Hewett, who in 1876, developed a system of continuous drainage of the cavity using a rubber catheter that drained into a jar filled with antiseptic. Popularized by Kenyon in 1911

6. What is the pleural space

7. Indications 3 Basic purposes: 1. Drainage of blood or exudate from the pleural space. 2. Removal of air from the pleural space. 3. Maintain complete lung expansion during postoperative period or in ventilated patients.

8. Indications 1. Pneumothorax: Primary spontaneous pneumothrax Secondary pneumothorax Traumatic pneumothorax Catamenial pneumothorax 2. Hemothorax: Traumatic, spontaneous 3. Empeyma: acute, chronic. 4. Chylothorax

9. Indications 5. Recurrent pleural effusion (for pleurodesis) 6. Postoperative (thoracotomy, thoracoscopy) 7. Prophylactic : -Pts with rib fracture on ventilator -Pts with rib fracture undergoing surgery

10. Pneumothorax

11. After tube insertion

12. Chest trauma

13. After tubes insertion

14. Pneumothorax

15. After tube insertion

16. Hemothorax

17. Hemothorax (CXR)

18. Hemothorax (CT)

19. Chest tube drainage

20. What will chest tube do? Relieves pain due to pressure exerted by excess fluid Drains infectious material Prevents collapse of the lung due to increased pressure Allows lungs to re-inflate

21. Contraindications Infection over insertion site Uncontrolled bleeding diathesis

22. Technique Patient’s position Anesthesia Sterilization Site of the chest tube Size of the chest tube Instruments Sutures

23. Preprocedure patient education Obtain informed consent Inform the patient of the possibility of major complications and their treatment Explain the major steps of the procedure, and necessity for repeated chest radiographs

24. Patient’s position Setting position Semi-setting position Supine position

25. Patient’s position

26. Site mid-axillary line, between 4th and 5th ribs

27. Site

28. Materials Chest tube with or without trocar Chest tube suction unit (PleurevacR), tubing, wall suction hookup Chest tube tray to include scalpel blade and handle, large Kelly clamps, needle driver, scissors Packet of 0 or 1.0 silk suture on a curved needle Tape, gauze 2% lidocaine with epinephrine, 20 cc syringe, 23-gauge needle for infiltration Sterile prep solution; mask, gown and gloves

29. Anesthesia Conscious sedation during this procedure is an option for those patients who are clinically stable. Widely anesthetize area of insertion with the 2% lidocaine. Infiltrate skin, muscle tissues, and right down to pleura

30. Incising the chest wall

31. Opening the incision with a kelly clamp

32. Digital exploration

33. Using a Kelly clamp to guide insertion of the chest tube

34. Choice of the chest tube The tube should be plastic Rigid enough so the lumen is not compromised by pressure or kinking Should be marked with radioopaque marker that shows the position of last perforation

35. Size of Chest Tube

36. Drain insertion

37. Drain secured in place

38. Chest Tube Drainage Systemone-bottle water-seal system contain 100 ml of sterile water, an airtight cap two vent tubes. The air vent is the shorter tube. The air vent must always remain patent in order for pressure not to build up within the bottle. The longer vent tube, which will be connected to the patient’s chest tube, will extend to 2 cm under the water in the bottle.

39. Chest Tube Drainage SystemThe one-bottle water-seal system The water-seal (tube immersed in water) acts as a one way valve, so that air can escape from the pleural space, yet not return. More air bubbles will be noted when the patient coughs, sneezes or exhales. If there is no bubbling, there is either a blockage in the chest tubing, or expansion of the patient's lung has occurred and there is no longer air in the pleural space. A constant bubbling in the water seal bottle may indicate air leak; new or excessive bubbling must be reported immediately.

40. The two-bottle water-seal system Utilizes the first bottle to collect drainage and air. The second bottle is the water seal. The first bottle, will have two short vents--one connected to the patient’s chest tube to allow drainage/air into the bottle; the other vent will have tubing to connect it with the first vent of the second bottle. The second bottle, the first vent will be long enough to be 2 cm under 100cc of sterile water. The second vent will be open to air to allow air pressure to escape.

41. The two-bottle water-seal systemAdvantages Ability to more closely monitor the amount and type of chest drainage. The nurse does not have to vigil over the 2 cm level of the water seal, though it will deserve monitoring at least every shift. It is easier to observe the amount of bubbling in the clear water of the second bottle, than it would be in the serosanguineous drainage of a one-bottle pleural drainage system.

42. The three-bottle pleural drainage system the first bottle to collect drainage, the second to be the water seal the third is the suction control.

43. The three-bottle pleural drainage system It provides a fairly stable water-seal level Allows for accurate documentation of the drainage and also controlled suction. On the downside, it is bulky and does not allow for easy transport or ambulation of this patient.

44. Pleur-evac Drainage system It is a three-chambered system that utilizes the same basic principles as the classic three-bottle system. It is lightweight, a single unit, portable and doesn’t shatter if broken. Holds up to 2500cc of drainage

45. Suction 5 to 10 cm H2O in children 25 to 30 cm H2O in adults

46. Removal of the chest tube Clinical criteria Radiological criteria Drainage system

47. Changing a chest tube Indications Blocked tube Empyema tube If the position is satisfactory-> tube in the same track If the position is unsatisfactory-> a new space and track.

48. Acute complications (technique) Haemothorax, usually from laceration of intercostal vessel (may require thoracotomy) Lung laceration (pleural adhesions not broken down) Diaphragm / Abdominal cavity penetration (placed too low) Stomach / colon injury (diaphragmatic hernia not recognised) Tube placed subcutaneously (not in thoracic cavity) Tube placed too far (pain) Tube falls out (not secured)

50. Late complications Blocked tube (clot, lung) Retained haemothorax Empyema Pneumothorax after removal (poor technique)

51. Patient Care Principles “Genius is nothing more than careful attention to details” Oliver Wendell Holmes

52. Patient Care Principles The nurse has the responsibility to maintain an intact and patent pleural drainage system. The connective tubing is long and rubbery; lay it on the bed, along the side, and loosely coil it near the drainage system Be sure the patient is not lying on it. Allow no kinks or dependent loops to occur in the tubing. Tape the connections to prevent air leaks.

53. Patient Care Principles Observe the amount and color of the drainage; when changes occur, report them to the physician. Mark the level of drainage at the end of the shift; and document. Ensure the suction is implemented as ordered.

54. Patient Care Principles Assess the patient's respiratory status at least every two hours. Listen to the breath sounds; observe the rate and rhythm of the respiration. Document respiratory status at the beginning of your shift, then again if there are any changes. Encourage the patient to deep breath and to cough.

55. Patient Care Principles Sit the patient up and give a pillow to hold against the abdomen as a splint, to reduce the pain during the cough and deep breathing. Observe and document the color, quantity and consistency of the sputum

56. Patient Care Principles The dressing over the chest tube insertion site may be changed daily, as ordered, or as necessary to be kept clean, dry and occlusive. Palpate the area around the tube insertion site to assess for subcutaneous emphysema; document its presence and extent; report if this is a new occurrence for the patient.

57. Patient Care Principles Excessive drainage, or greater than 100 cc per hour, noted in the collection bottle must be reported to the physician. Also report if the drainage becomes a frank red color, after having been more serous.

58. Patient Care Principles(Changing the drainage system) Turn off any suction connected to your patient's current system and double clamp the chest tube close to the chest wall. This will prevent air from entering the pleural cavity through an open chest tube. Have everything ready when you clamp the tube to limit the amount of clamping time. Quickly disconnect the old and reconnect the new equipment. Always observe your patient for a tension pneumothorax when the tube is clamped. A more critical patient will quickly sense the clamped tube. Securely tape the new connections.

59. Patient Care Principles If the chest tube becomes dislodged or pulls out unexpectedly, quickly cover the open insertion site with occlusive Vaseline gauze during the peak of patient inspiration. Call for Set up the equipment for reinsertion if indicated.

60. Patient Care Principles If the drainage system is accidentally broken or severely cracked, which allows atmospheric pressure into the system, insert the uncontaminated end of the connective tubing into a bottle of sterile water or saline to a depth of 2 cm until a new unit can be set up.

61. Documentation in the Medical Record Consent if obtained Indications and contraindications for the procedure on this patient Procedure used (trocar vs. non-trocar) Any complications, or “none” Who was notified of any complication (family, attending physician)