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  1. 1. Chest Tubes: Indications, Placement, Management, and Complications Timothy B. Gilbert, MD,* Brian J. McGrath, MD,t and Mark Soberman, MD:j: Gilbert TE, McGrath B], Soberman M. Chest tubes: indications, placement, management, and complications.} Intensive Care Med 1993;8:73-86. Use oftube thoracostomy in intensive care units for evac- uation ofair or fluid from the pleural space has become commonplace. In addition to recognition ofpathological states necessitating chest tube insertion, intensivists are frequently involved in placement, maintenance, trouble- shooting, and discontinuation ofchest tubes. Numerous advances have permitted safe use of tube thoracostomy for treatment of spontaneous or iatrogenic pneumo- thoracies and hydrothoracies foUowing cardiothoracic surgery or trauma, or for drainage of pus, bile, or chy- lous effusions. We review current indications for chest tube placement, insertion techniques, and available equipment, including drainage systems. Guidelines for maintenance and discontinuation are also discussed. As with any surgical procedure, compUcations may arise. Appropriate training and competence in usage may re- duce the incidence of compUcations. From the 'Cniversity of Maryland Medical Center, Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Baltimore, MD; the tDuke University Medical Center, Depart- ment of Anesthesiology, Durham, NC;and *the Cleveland Clinic Foundation, Department of Surgery, Cleveland, OH. Received Mar 17, 1992, and in revised form Sept 2. Accepted for publication Sept 4, 1992. Address correspondence to Dr Gilbert, Department of Anesthe- siology, University of Maryland at Baltimore, South Hospital, 11th Floor, Wing C, 22 South Greene sr. Baltimore, MD 21201-1595. Historical Development Drainage of the pleural space by thoracostomy originated with Hippocrates around the fourth cen- tury B.c. Using rudimentary skills of incision and cautery, he inserted a metal tube for the treatment of empyema, noting ". . . if pure and white pus flow from the wound, the patients recover; but if mixed with blood, slimy and fetid, they die" [1J. Despite its prognostic utility, his metal tube tech- nique failed to enjoy widespread use until well into the nineteenth century. Anel (around 1700) adapted a large syringe at- tached to many funnel-shaped cannulae for tempo- rary aspiration of pneumothoracies in casualties of war, whereas his contemporary Boerhaave applied suction through a blunt-tipped flexible tube perfo- rated laterally [2J. However, aspiration of pleural air or fluid become commonplace only after the sim- ple hypodermic syringe was developed [3]. Playfair (1872) recognized the importance of maintaining a fluid seal to prevent entrainment of air [4]. Shortly thereafter, Hewitt (1876) described a completely closed apparatus, the basic design of which allowed both drainage and irrigation of the pleural space [5]. A relative hiatus occurred until the influenza pandemic of 1917 necessitated reintroduction of tube thoracostomy for drainage of postpneumonic empyemas, following the report of Major Graham and the Empyema Commission [6]. Use in surgical patients following thoracotomy was advocated by Lilenthal (1922) [7], but its application during trauma resuscitations did not become accepted practice until World War II [8J and the Korean con- flict [9]. Indications and Contraindications for Placement Currently accepted indications for chest tube place- ment are listed in Table 1. Most applicable to the field of critical care medicine are iatrogenic pneumothoracies, traumatic hemothoracies, and placement following cardiothoracic surgery. The need for placement (and its urgency) often depend Copyright © 1993 Blackwell Scientific Publications, Inc. 73
  2. 2. 74 Journal of Intensive Care Medicine Vol 8 No 2 March-April 1993 Table 1. Indications for Chest Tube Placement Pneumothorax Spontaneous Iatrogenic Tension Ilemothorax Traumatic Spontaneous Postoperative Pleural effusion Parapneumonic or empyema Malignant Sympathetic effusion Esophageal perforation Chylothorax Postsurgical Thoracotomv Cardiac . Bronchopleural fistula Hypotension in patients with chest trauma Lung abscess Thoracostomy rewarming lavage Contrast thoracograrns Sclerotherapy on the specific clinical situation, patient symptoms, and degree of underlying lung pathology. Spontaneous or iatrogenic pneumothoracies of less than 25% volume (<4 cm apical collapse or < 1 em lateral collapse [10-12]) in asymptomatic or minimally symptomatic patients without severe pul- monary disease may be observed for increasing size. Bedrest and restricted exertion are suggested [13], especially if the separation of visceral and pari- etal pleurae is so small that the underlying lung may be damaged by chest tube insertion [14]. Con- versely, patients with severe distress, expanding pneumothoracies (confirmed on serial radio- graphs), or severe lung disease who may not toler- ate minimal loss of lung function should be consid- ered for urgent chest tube placement. Some authors advocate needle or intravenous (IV) cathe- ter aspiration as an alternative [15-17]. Any pneumothorax under tension as evidenced by cardiovascular depression or mediastinal shift on chest radiograph should have immediate de- compression by needle first, unless definitive tube thoracostomy is readily available. Roughly 80% of patients with spontaneous pneumothoracies treated with tube thoracostomy will have straight- forward recovery. Further management by open pleural abrasion [18], pleurodesis [19], or pleurec- tomy with wedge resection of the ruptured bleb is indicated for pneumothoracies with large per- sistent air leaks, pneumothoracies complicating bullous disease, or recurrent pneumothoracies [10-12]. Spontaneous pneumothorax occurring in pa- tients with certain underlying systemic diseases (e.g., Marfan syndrome, cystic fibrosis, malignan- cies) should also be considered for open thoraco- tomy to prevent recurrence [20]. Recurrent catame- nial pneumothorax should be considered an indication for diaphragmatic exploration [21]. Spontaneous pneumothorax occurring in patients with acquired immunodeficiency syndrome (AIDS) typically poor surgical candidates, may best be treated by tube thoracostomy and closed pleurode- sis [22]. Thoracoscopic pleurodesis and wedge re- section have been performed; however, long-term results are as yet unknown. Traumatic pneumothoracies generally follow similar guidelines as spontaneous pneumothora- cies, although the need for repeat tube placement for recurrence is increased [23]. The appearance of a pneumothorax of any size during the use of posi- tive pressure ventilation warrants tube thoracos- tomy placement, because rapid expansion is possi- ble [10,20,24,25]. Bilateral tube thoracostomies have been used prophylactically in patients with severe acute respiratory insufficiency requiring positive pressure ventilation in excess of +40 cm H20, but its efficacy has not yet been confirmed [26]. Large, acute fluid accumulations (e.g., traumatic hemothorax), which can occupy the entire hemithorax, require immediate tube drainage, a common therapeutic intervention during trauma resuscitations [27-29]. Criteria for further manage- ment by open thoracotomy is discussed elsewhere [10,30-32]. Penetrating trauma, especially if com- bat-related, will be more likely to require open drainage and repair [33]. Spontaneous hemothorax is infrequent; it is more common in patients with coagulopathies, and should be treated if large, ex- panding, or symptomatic. Chylous effusions may eminate from injury to the thoracic duct [34]. Other cavity fluids, such as bile [35] and urine [36], from pleuroperitoneal communications have also been drained using tube thoracostomies. Pleural effusions, which usually evolve over days or weeks, may undergo tube thoracostomy for both diagnosis and symptomatic relief. Transudative ef- fusions, especially when small and mobile, may be observed for expansion. True empyemas and com- plicated parapneumonic effusions (satisfyingLight's criteria [37]) have historically been drained by tube thoracostomy, usually following diagnostic thora- centesis [38,39]. Some authors have suggested thoracoscopy [40], minithoracotomy [40,41], repeti- tive thoracentesis [42], or IV catheter drainage [43- 45] as alternatives. However, a recent retrospective study compared treatment of complicated para-
  3. 3. pneumonic effusions with antibiotics with or with- out drainage. Morbidity, mortality, and clearance time were similar; resolution occurred in 81% (11 of 16 patients) treated with antibiotics alone [46]. Empyemas secondary to trauma, which may fail to improve following initial tube thoracostomy, may more likely need open decortication for resolution [23,47,48]. Postoperative empyema" may act simi- larly [49]. In patients with recurrent malignant effu- sions, antineoplastic agents can be administered di- .~ reedy through thoracostomy tubes [50,51]; incidence of drug exposure throughout the pleural space is high and reduces systemic exposure to antitumor agents [52]. Closed pleurodesis with irritants such as talc, te- tracycline, or silver nitrate for recurrent pneurno- thoracies or hydrothoracies can be performed at bedside [10,19,50,53,54], preferably with concur- rent administration of local anesthetics to reduce discomfort [55]. Only rarely has tube thoracostomy been used in place of formal open drainage for lung abscesses [38,56,57] and giant emphysematous bullae [58-60] in patients believed to be high surgical risks. Equip- ment and personnel for emergency placement of a chest tube should be readily available whenever any patient with giant bullae receives positive pres- sure ventilation [61]. Posttuberculous broncho- pleural fistulae can also be treated initially with closed tube thoracostomy, although most ulti- mately require open thoractorny window or decor- tication (62). Thoracostomy tubes have been used as access devices for continuous warm saline pleural lavage in severely hypothermic patients in both emer- gency resuscitation [63,64] and operative manage- ment [65), as well as for injection of contrast agents for detection of diaphragmatic rupture in blunt trauma patients [66]. Evulsion biopsy of the pleura can be performed concomitant with insertion of thoracostomy tubes if the blunt dissection tech- nique is employed [67,68). Although no absolute contralndtcations to chest tube placement exist (other than patient refusal [69)), physicians must use judgment in determining the relative risks in patients with coagulopathies or immunosuppression. Some authors suggest even more aggressive management in immunosup- pressed patients, including open thoracotomy for most empyemas [49,70]. Methods of Insertion Equipment. Components necessary for closed thoracostomy tube placement include appropriate- Gilbert et al: Chest Tubes 75 I I Fig 1. Typical presterilized equipment tray contains supplies necessary for immediate tube thoracostomy placement. Straight and angled chest tubes are also shown, which are selected according to patient re- quirements. sized chest tubes, a drainage device with or without a suction source, connecting hoses with connec- tors, and a tray of insertion instruments (Fig 1). Presterilized supplies (without chest tube or drain- age system) available in out' institution are listed in Table 2. Modern chest tubes are constructed of translu- cent, minimally thrombogenic, pliable polyvinyl plastics and are nonpyogenic and disposable. They must conform to applicable federal guidelines (American National Standards Institute), and they are implantation-tested and sterilized. Older rub- ber tubes, which irritate the pleura and produce adhesions, have occasionally been used to treat re- current spontaneous pneuothoracies [71]. Available in a variety of internal diameters OD), typical adult Table 2. Suggested Sterile Thoracostomy Insertion Supplies Clamp: large Kelly, 2 Cups for scrub and anesthetic, 2 Drape with center hole, 1 Hemostats: straight and curved, 2 each Local anesthetic Needle holder, 1 Needles: no. 18, no. 22, and no. 25, 1 each Scalpel blades: no. 11 and no. IS, 1 each Scalpel handle, 1 Scissors: Mezenbaum, 1 Sponges: 4" x 4", 10 Suture, nonabsorbable: 1-0 or 0-0; cutting needle, 1 Syringes: 5 and 10 mL, 1 each Towels, 4 Tray and coverings
  4. 4. 76 Journal of Intensive Care Medicine Vol 8 No 2 March-April 1993 sizes range from 5 to 12 mm (no. 16-38 French), whereas 2- to 8-mm devices (no. 6-24 French) are used primarily in pediatric patients. Straight tubes for anterior, lateral or posterior placement are available with or without internal trocars. Angu- lated tubes are used predominantly for dependent supradiaphragmatic positions without trocars. All are typically imprinted with distance markers for determining insertion. depth, and a radiopaque stripe for radiological confirmation of proper placement. The proximal end is slightly flared for connection to the suction apparatus, and the distal end is slightly tapered and fenestrated with multi- ple drainage holes to prevent clogging. Modified catheters, such as the tunnel tip thoracic catheter with a severely tapered tip [72], and catheters in- tended for suprapubic [73], bladder [9],or pericar- dial drainage [74,75] may be useful for specific or difficult placements. Combined catheter/flutter valve systems for emergency use by prehospital personnel have been developed [76,77], because formal tube thoracostomy placement in the field is rarely justified [78]. Resistance to air flow within a chest tube system increases with decreasing diameter, increasing length (including connecting hoses), and aspiration of fluid-saturated air [79]. Pressure and flow rela- tionships are generally not linear because of the circuit's complex geometry, including bore irregu- larities such as kinking, clotting, and distal hole oc- clusion [80]. The ideal circuit would allow little re- sistance to either air or fluid passage, neither leak nor occlude easily, and provide a constant source of negative pressure to the pleural space. Timing and Location of Placement. The rela- tive urgency for placement of a chest tube often depends on the clinical scenario during which air or fluid accumulates in the pleural space. Location of the insertion site depends historically on the contents being drained from the pleural cavity, most often directed by routine chest radiography. Obtaining an upright, anteroposterior (AP) chest film after a period of erect posture may gravitate mobile effusions to dependent areas or air to the apicies, which may be difficult to visualize on rou- tine supine films. Illustrations of tube placement can be found in the literature [15,81-83]. Free pleural air has commonly been aspirated from the wide, second intercostal space in the mid- clavicular line, because air gravitates superiorly in semiereet patients. More medial placement is pro- hibited by the traversing internal mammary artery. The fourth or fifth intercostal spaces in the midaxil- lary line are often used to avoid obvious scarring. In addition, the tube may also be easier to place, better tolerated, and less restrictive for respiratory care [40]. Use of the second intercostal space may be preferred in infants, because an anterior loca- tion within the pleural cavity is more readily achieved with improved air evacuation [84]. This location may be reserved as an auxiliary site in adults to augment evacuation of residual air [81]. Lateral tubes placed for air retrieval are angled an- teriorly and apically.A posterior approach has been described for refractory apical air collections when anterior and lateral adhesions prevent insertion [85]. Hydrothoracies, whether blood, pus, or lymph, are usually approached laterally through the fourth or fifth intercostal space in the midaxillary line with a larger bore tube (7-12 mm), depending on the viscosity of fluid encountered and likelihood of clotting. Placement of the chest tube posterobasally in the dependent paravertebral gutters (in supine patients) may facilitate drainage in certain situa- tions. Insertion Techniques. Three techniques for in- sertion are available and are in general a matter of personal preference, although ease of use and com- plications may differ. The two direct techniques, which require surgical incision, are (1) blunt dis- section and (2) trocar puncture. Anewer technique requires a minimal incision by placing the chest tube indirectly with guidewires or introducers into the pleural cavity. This percutaneous method has found utility among physicians inexperienced in di- rect methods [86,87]. Regardless of technique, the site selected must be decontaminated with povidone iodine, chlor- hexidine, or other surgical scrub, and draped ap- propriately to maintain view of anatomical land- marks. Innervated by ventral intercostal nerves, the chest wall requires generous local anesthetic infil- tration into the subcutaneous, periosteal, and pari- etal pleural tissue layers to prevent untoward dis- comfort. Anylocal anesthetic can be used; however, bupivacine or etidocaine may provide prolonged analgesia. Intravenous sedation with short acting agents such as fentanyl citrate or midazolam hydro- chloride should be considered in appropriate situa- tions with proper monitoring. Supplemental oxy- gen may be required in many situations. For direct insertion techniques (Fig 2), the over- lying skin is pulled superiorly to create a diagonal insertion tract, which later will readily seal after tube removal. A 2 em intercostal incision just supe- rior and parallel to the caudad rib is made through skin and subcutaneous tissues. A larger incision may predispose the site to an air leak, whereas a smaller incision may impede tube placement. Digi-
  5. 5. Gilbert et al: Chest Tubes 77 Fig 2. Technique for blunt dissection method of tube thoracostomy placement. (A) Following intercostal incision. a clamp bluntly dissects the anatomical layers toward the pleural space; (8) the index finger palpates the incision and confirms proper entrance into the ' pleural space ; and (C) the chest tube is guided by attachment to a clamp into the pleural space, After clamp removal, the tube is advanced into proper posi- tion, tal palpation through the incision confirms proper direction between the ribs and toward the pleural cavity, Blunt dissection affords greater control in place- ment of a pleural tube and is currently the more common method used with direct techniques, A large. curved [24.88]. or straight [89] clamp placed in the prepared incision is used to bluntly spread the pericostal layers. followed by repeated digital confirmation of proper direction. Finger palpation will also detect pleural puncture and assist removal of any pleural-based adhesions. A clamp affixed to the proximal end of the chest tube facilitates inser- tion through the chest wall and into the pleural space by supporting and directing the flexible tube. The trocar puncture technique uses a chest tube fitted with an internal sharp and rigid metal obtura- tor, which readily penetrates the suprapleural tis- sues. Using direct pressure in a twisting motion, this trocar-tube is judiciously inserted until a char- acteristic "pop" denotes pleural entrance. Afterthe pleura is entered, the tube is fed over the trocar into the pleural space. Unfortunately, such sharp trocars are associated with greater incidence of lung or other thoracic injuries [90-92]. Euphemisti- cally dubbed an "intercostal dagger" [93], some au- thors avoid the trocar technique to prevent injury to underlying lung, intercostal vessels, and other visceral organs [24,94,951· Safety may be improved when small-caliber chest tubes are employed (e.g., 3 mm tube with 18 gm trocar [96D. Percutaneous methods, using a large-bore, nee- dle-placed guidewire with an introducer sheath, Confirmation of Proper Placement. Routine chest radiography should follow any attempted chest tube placement. Ideally, AP and lateral views should be obtained, because certain ectopic loca- tions may not be discerned on AP view alone (e.g., within interlobar fissures [96,102,103D. In a retrospective study of 26 patients with thora- costomy-drained empyemas, only 4.8% (l of 21) of malpositioned tubes were identifiable on AP view alone, whereas an additional lateral view recog- nized 89% (8 of 9). Computer-assisted tomography (CAT) scan identified all 21 incidences of rnalposi- tion [104]. Displacement of a tube 's radiopaque marker on serial radiographs may denote lobar col- lapse [105). Ultrasonography, real-time fluoroscopy, and CAT scans have also been used for chest tube localization or placement. Image-guided catheter placement for empyemas or loculated effusions may improve the overall cure rate (106). Fluid locu- combine the aspects of a small incision with the safety of controlled serial dilation [97,98]. Devel- oped for the treatment of pneurnothoracies using small-bore tubes, minimal complications with im- proved patient comfort have been reported [86,87]. Malignant effusions and infected bullae have been treated similarly, although fibrin clot obstruction and inadvertent dislodging of the catheter during transport have occurred, suggesting a disadvantage .--'. of the small-bore system [87]. Currently, large adult tubes (i.e., up to 11 mm) can be placed with percu- taneous techniques using serial dilators instead of introducer sheaths [93]. After insertion by one of the above methods and removal of placement devices (trocar or clamp), the tube is further advanced in the direction dis- cussed to a depth beneath the skin at least 2 to 3 em greater than the most distal drainage hole. Release of trapped air or fluid suggests entrance into the pleural space. A slight twisting motion, using a fin- ger beside or through the insertion site, may aid in proper tube direction and placement. Two simple or horizontal mattress sutures of generous depth placed on either side of the insertion site should be placed to properly anchor the tube. Several ad- juncts for securing tubes' have been described [99,100]. Sterile dressings, 'preferably with antibi- otic Ointment, cover the site. Petroleum-coated gauze as an occlusive seal is no longer recom- mended because integument breakdown can occur and predispose to wound infections [88]. All con- nections should be supplemented with sturdy tape or plastic banding to prevent disconnection. Safety pins or rubber bands are suggested to attach the connecting hoses to the patient's clothing or bed, to prevent dislodgment [101]. c B A
  6. 6. 78 Journal of Intensive Care Medicine Vol 8 No 2 March-April 1993 From Pleural-.- Cavity One-Bottle System From Pleural----. Cavity Two-Bottle System From Pleural-.- Cavity Three-Bottle System CollecUon Bailie -.. To Suction ~ To Suction ~AlmOSPheriC Vent ....... ToSuction Suction Control Fig 3. One-, two-, and three-bottle systems for drainage of the pleural space are shown. Typical water seal levels of 2 cm H20 and suction control levels of 20 cm H20 are demonstrated. lations can be located and marked in the radiology department, with subsequent tube placement by qualified radiology or other personnel. Tube tracks, skin holes, air-fluid levels, and pleural thick- ening may remain visible radiologically for several weeks following removal due to a local serositis from the prosthetic tube [107,108]. These radio- graphic densities may mimic more serious con- ditions, such as bullous disease, atelectasis, or recurrent pneumothorax [109]. The radiopaque bullet-shaped tip of a chest tube has also been con- fused with an actual bullet in a gunshot wound victim [110]. Drainage Systems Prior to insertion of a chest tube, an appropriate drainage device should be prepared for immediate attachment. Although currently available devices vary Widelyin appearance, size, and complexity, all devices consist of a combination of one or more of the following: (1) water seal, (2) drainage trap, (3) pressure control chamber, and (4) connecting hoses. At a minimum, a drainage device requires a water seal that prevents air entrainment into the pleural cavity while air or fluid are being drained externally. In the case of simple pneumothorax, this may consist of a l-bottle water seal [111]vented to atmospheric or lower pressure (Fig 3, top). Un- fortunately, this simple device is not adequate for fluid collections, because the intrapleural pressure required to overcome the water seal increases as fluid accumulates within the bottle, necessitating frequent emptying. Addition of a trap to collect the pleural effluent creates a 2-bottle system, with the trap upstream from the water seal (Fig 3, middle), thus obviating repeated water seal adjustments. Most modern drainage devices consist of an addi- tional third bottle (Fig 3, bottom) that acts as a control chamber to maintain constant negative pressure; the height of water within the bottle regu- lates the suction applied to the pleural space. These devices are typically capable of delivering up to - 30 ern H20 suction pressure. Greater negative pressures in excess of -60 cm H20 may be achieved by filling this chamber with fluids of higher density, such as mercury [112]. More elabo- rate devices (4 or more bottles) exist for balanced drainage and irrigation of the pleural space [113]. Commercially available devices compartmental- ize the antiquated 3-bottle system into 1 disposable, lightweight plastic, transportable apparatus, which allows regulation of both water seal threshold and
  7. 7. Fig 4. Commercially available drainage systems com- partmentalize water seal, suction control, and drainage trap into a single, disposable, light-weight transportable system. vacuum pressure control (Fig 4). Some systems (e.g., Pleurevac) retain the classic water column for suction regulation, whereas others (e.g., Davol) employ a valve to regulate the amount of suction applied to the pleural space. Quantitation and sam- pling of effluent should be readily obtainable from a translucent chamber with a capacity of at least 1 L (preferably 2L). Most devices must be maintained on a level surface, and adequate safety suppons or brackets should be attached to prevent tipping, loss of water seal, or cross-mixing of chambers. Each device differs in size, cost, drainage capacity, flow characteristics, and maximum pressure achieved- the last is limited primarily by the flow rate of the suction source and the internal resistance of the drainage unit [114]. Because reabsorption of air in the pleural space proceeds at only roughly 1% of lung volume per day [115], suction is generally applied through the drainage system. In fact, negative suction pressure should generally exceed any potential positive ex- piratory pressure to prevent reaccumulation of air in the pleural space. In most fluid collections, suc- tion is normally required for its mobilization and for maintenance of tube patency. A notable excep- tion is malignant pleural effusion, which may be 2 eM i T 20 CM r Gilbert et al: Chest Tubes 79 best managed by initial drainage by water seal alone. Suction may induce partial pleurodesis, thus decreasing the efficacy of subsequent chemical pleurodesis. Application of suction may increase the incidence of bronchopleural fistula formation or reexpansion pulmonary edema [10,12]. The amount of suction applied to the pleural space should be determined by medium to be drained, size of the patient (i.e., adult vs pediatric), and amount of air leak present, given the constraints of any individual drainage apparatus [116]. More than one chest tube may be siphoned into a drainage unit through "y" connectors, although flow per tube decreases, Flutter valves-as exemplified by the Heimlich [117], Vycon or Thomas [12] devices-are substi- tutes for formal water seal, and consist of a small one-way rubber valve attached directly to the distal end of the chest tube. These devices are primarily used for pneumothorax evacuation (especially in the ambulatory population [11,12]) and to facilitate patient transport. In selected patients with persis- tent air leak with either a stable pneumothorax or no pneumothorax, placement of a flutter valve may avoid thoracotomy or discharge from the hospital in cenain high-risk pauend (e.g., those with AIDS or elderly debilitated patients). Effluent from these devices can readily be collected via colostomy [118,119] and urinary drainage bags [120]. Connecting tubing should be at lea'it 1.3 em in diameter to accommodate high gas flows (up to 60 Llmin [116]) and no more than 200 em in length. Resistance to flow is increased unacceptably in ex- cessively long or narrow hoses [79]. Preferably, tub- ing should be translucent enough to visualize clots and sufficiently stretchable to allow "milking." Tub- ing connectors, the narrowest component in the drainage system, should be similarly clear, un- breakable, and typically 6 to 12 mm in diameter. They are the source of greatest resistance to air or fluid flow and a common site of obstruction. Maintenance The functional status of each chest tube and drain- age device needs to be assessed frequently to rec- ognize and prevent complications. All components from the insertion site to the drainage device (in- cluding each individual chamber) should be in- spected for leaks and improper function. Coordi- nated motion of the water seal level and patient respiration implies appropriate continuity with the pleural space. However, when a persistently nega- tive column in the water seal chamber is main- tained with a well-expanded lung, effective pleuro-
  8. 8. 80 Journal of Intensive Care Medicine Vol 8 No 2 March-April 1993 desis is generally present. Periodic "milking" or "stripping" of connecting hoses is almost univer- sally advocated to maintain patency, despite a lack of objective data to support the practice [121]. In fact, pressures exceeding -400 em H20 have been recorded at the junction of the chest tube and con- necting hose during stripping [122]. If air alone is being evacuated, stripping is unnecessary [123]. If continuous bubbling through the water seal chamber' develops, intermittent clamping of the connecting hoses commencing at the drainage de- vice and continuing toward the patient will reveal most sources of leakage. Connectors are notorious sites of air entrainment. Aircan also leak adjacent to the chest tube through an improperly sized inser- tion channel, which is best repaired by additional suturing. Persistent air leaks can suggest broncho- pleural fistula. A large bronchopleural fistula may prevent appropriate alveolar ventilation and carries a high mortality [124J. High-frequency jet ventila- tion techniques [125], independent lung ventilation [126], intermittent inspiratory chest tube occlusion (IICTO) [105,127,128], and chest tube pressuriza- tion (CTP) [25] have been developed as effective interventions for controlling severe broncho- pleural fistulas. Rough quantitation of air leak (Umin) can be estimated on most commercial drainage systems by observing bubble flow through gradient tubes in the water seal chamber. Occlusion of the tube should be suspected if no respiratory variation of the water seal chamber is noted. Saline irrigation should be attempted initially [40]. Sterile passage of a suction or Fogarty embolectomy catheter can also extract occlusive clot [129]. Eibrinolytic agents are infrequently used to remove refractory occlusions [130,131]. Blockage of the tube from within the hemithorax may occur from closely opposed pleura and lung tissue or from placement within interlobar fissures (the major fissure is the more likely site [101,103]). Polyvinyl tubes tend to be- come more pliable at body temperature, resulting in kinking subcutaneously or intrapleurally. Ultimately, replacement of a nonfunctional chest tube through a second site may be necessary if per- sistent occlusion is not correctable. Prolonged clamping of chest tubes during active pleural drain- age, as during transportation or patient care, should be avoided because rapid reaccumulation of air can result in tension pneumothorax [9,10] or increase risk of disconnection [132]. Likewise,clamping dur- ing performance of cardiopulmonary resuscitation (CPR) to prevent loss of intrathoracic pressure is not recommended, because pneumothorax may impede venous return and impair oxygenation [133]. Variations in intrapleural pressure do not seem to have a significant influence on CPR [134]. When suction is discontinued for placement on wa- ter seal, the suction tubing should be removed from the drainage device. Although most modern systems have a valve to relieve excessive positive pressure, suction tubing connected to the system (without applied suction) does not allow for egress of air via the usual route. Pain management for thoracostomy patients, es- pecially if accompanied by an incision for car- diothoracic surgery, may be problematic. In addi- tion to routine systemic or regional analgesia, local anesthetic infiltration at the insertion Site, transcuta- neous nerve stimulator (TENS) units, and intercos- tal nerve blocks (including cryoablation) may be useful adjuncts. Pleural anesthetics can be given di- rectly through chest tubes [135], through a catheter secured within chest tubes [136], or directly through the chest wall with a percutaneously placed [137,138] or a surgically placed [139,140] epidural-type catheter. A posteriorly placed cathe- ter with the patient supine yields greater absorp- tion near proximal portions of the intercostal nerves [135,141]. Evaluation of pain relief with these techniques vary among studies [135,139,141- 143]. Adverse effects have been noted with intra- pleural anesthetics, including inadequate relief [140,143] and absorption of toxic doses of local an- esthetic with systemic effects [143,144]. Discontinuation and Removal Tube thoracostomy can be discontinued whenever the presenting indication is resolved or the appa- ratus becomes nonfunctional. For pneumothorax, this generally implies near-complete resolution of pleural air (less than 10% residual pneumothorax) without detectable air leak in the water seal cham- ber. For fluid, drainage rates of less than 50 mL every 8 hours (150 rollday) are desired. Chest tubes are commonly not removed until after posi- tive pressure ventilation is discontinued, although this practice is not universal [20]. Prior to removal, some authors suggest a short period (12-24 hr) of water seal without suction, followed by briefclamp- ing of the connecting hose to ascertain if reaccumu- lation of air or fluid has occurred [10]. Signs of expansion or tension must be monitored if clamp- ing is performed [11,101]. Removal of the tube im- mediately after cessation of an air leak and lung reexpansion may result in recollapse in up to 25% of patients [145]. For this reason, continuing pleural drainage for an additional 24 to 48 hours following the last evidence of any air leak may promote pleu- ral symphysis.
  9. 9. Prior to removal, the chest tube entry site should be cleansed, sutures freed, and sterile dressing pre- pared. At end exhalation, the patient should per- form a Valsalva maneuver and be warned of poten- tial burning or pulling sensations [146]. The tube is rapidly removed and the skin sealed with an occlu- sive dressing [147,148] or by tightening indwelling sutures [75,99,149], which allows healing to occur by primary intension with less scarring. Pausing, during tube removal or allowing the patient to breath during removal may allow air to reenter the pleural space and cause a recurrence of a pneumothorax. Despite preparation, some patient may inhale in response to pain, increasing the chance of air reentry [40]. A follow-up chest radio- graph should be performed at (typically within 24 hr) following chest tube removal to detect residual or recurrent pneumothorax. Complications Complications from chest tube placement occur with relative frequency, owing to the proximity of both major vascular and visceral structures near the insertion site and within the reach of a migrating chest tube. Complications can be divided into placement-, maintenance-, and discontinuation-re- lated categories (Table 3). Table 3. Complications Associated with Use of Chest Tubes Placement Lung laceration Intercostal artery hemorrhage Diaphragm penetration Phrenic nerve palsy Heart laceration or compression Great vessel puncture, occulusion, or erosion Thoracic duct puncture Injury of major extrathoracic viscera Stomach, liver, spleen Horner's syndrome Extrathoracic soft-tissue placement Maintenance Unilateral reexpansion pulmonary edema Empyema Lung entrapment with focal infarction Subcutaneous emphysema Arteriovenous fistula formation of chest wall Pleural reactions Necrotizing fasciitis Pneumothorax with inadvertent disconnection Discontinuation Recurrence of pneumothorax Pleurocutaneous fistula Retained catheters or fragments Gilbert et al: Chest Tubes 81 Although most information regarding complica- tions has been anecdotal, one retrospective series of 1,249 patients with acute thoracic trauma neces- sitating tube thoracostomy reported an overall 2.4% incidence of empyema; the majority occurred following trocar placement [94]. The subgroup of 447 patients with placement by blunt dissection had a 1% technical complication rate, with diaphrag- matic perforation, lung and stomach lacerations [94]. These are operator-related errors and likely avoidable with proper training and technique. Lunglaceration is more likelyto occur in patients with poor lung compliance or pleural adhesions (e.g., following pleurodesis, sclerotherapy, old in- flammation) [91,92,94]. Perforation in infants may be heralded by persistent or repeated pneumo- thoracies despite the presence of a chest tube, or by atelectasis or infiltrate near the end of the chest tube [150]. Infants with severe respiratory distress syndrome (IRDS) appear to be at particularly high risk for this complication [151]; other risk factors include left-sided placement, use of multiple tubes, and gestational age less than 28 weeks [152]. Other mediastinal structures, such as the aorta [153,154], may be obstructed. ' Cardiogenic shock, following risk atrial lacera- tion [90] or right ventricular compression [155], has been reported. Chylothorax, resulting from tho- racic duct injury, can follow left-sided tube place- ment [156]. Intercostal artery hemorrhage resulting from injury to the neurovascular bundle located at the inferior surface of the superior rib is best pre- vented by placement through the caudad-most por- tion of the intercostal space [92]. Because the artery becomes increasingly vermiculate with age, elderly patients may be at greater risk for intercostal artery puncture [157]. Diaphragmatic penetration may be an isolated occurrence [94] or may result in laceration to the esophagus, stomach, liver, or spleen [81,158]. The diaphragm rises to the level of the fourth intercos- tal space during full expiration [94]. Therefore, per- foration is best avoided by inserting the chest tube no lower than the fourth intercostal space (later- ally), preferably during inspiration following blunt dissection and digital exploration [24]. Higher placement may result in bleeding from the pectora- lis muscle or breast injury [94]. Ipsilateral hemi- diaphragmatic palsy from isolated injury to the in- trathoracic phrenic nerve has been reported [159-161], as has contralateral hemidiaphragmatic elevation secondary to atelectasis, with transsaggital migration of a medially deployed tube [162]. If the tip of a chest drain is allowed to migrate to the apex of the pleural cavity, injury to the ascend- ing sympathetic chain at the lung cupola can result
  10. 10. 82 Journal of Intensive Care Medicine Vol 8 No 2 March-April 1993 in ipsilateral Horner's syndrome [163-166]. This in- jury is believed to result from repeated trauma and hematoma formation consequent to respiratory motion. Serial chest radiographs may forewarn its occurrence [167]. Subcutaneous emphysema, eminating from the thoracostomy site to involve portions of the chest wall and neck, is usually only a cosmetic problem [88]. Air migration may result from the inciting injury or from inability to vent pleural air. Treatment is rarely indicated unless re- sidual pneumothorax remains or cardiopulmonary instability exist". Venting with skin incisions, needle aspiration, or cervical mediastinotomy are rarely required for tension pneumomediastinum [20]. Improper extrathoracic soft-tissue placement, al- though usually not injurious, prevents proper evac- uation of the pleural cavity. To avoid pleural con- tamination, no chest tube should be advanced further through the insertion site once placement has been completed. Rapid reexpansion of atelec- tatic lung may result in unilateral pulmonary edema [168], which may be fatal [169]. Young patients and those with large pneumothoracies appear at great- est risk [170]. It has also been suggested that pneumothoracies present for more than 24 hours may predispose to reexpansion pulmonary edema. Initial drainage by water seal has been suggested in this situation. Edema has been attributed to either extreme vacuum pressure exerted on the pleural space in the face of an obstructed bronchus [171] or simply rapid reexpansion of lung leading to sub- acutely collapsed [169]. In the case of pleural effu- sions, removing fluid at a rate no greater than 1 LI hour has been advised to decrease the likelihood of pulmonary edema [73]. If excessive pleural suction is used, lung infarction and subsequent aspiration into the thoracostomy tube may also occur [172]. Suction from a chest tube may potentiate pleural effusion in patients with impaired venous drainage [173] or induce myocardial ischemia [174]. Intrapleural infection following tube thoracos- tomy, either from insertion [23] or the presenting injury, ranges from 1 to 16% [29,175,176]. Most se- ries report rates under 3% [177]. Development of empyema is more frequent in trauma patients with incomplete drainage, penetrating injury, or pro- longed use [178]. Necrotizing fasciitis, attributed to soiling from anaerobic bacteria during empyema drainage, can be a lethal complication [179]. Rou- tine use of prophylactic antibiotic coverage (typi- cally first- or second-generation cephalosporins) for prevention of infection in all patients receiving tube thoracostomy has been empiric, costly, and potentially dangerous [14,180,181]. Prophylaxis for patients with thoracostomy for spontaneous pneumothorax is probably unnecessary, although little data are available [180]. Three offour prospec- tive, randomized studies (clindamycin in penetrat- ing thoracic trauma [177] and cefamandole [180] or cefazolin [182] in both penetrating and nonpene- trating thoracic trauma) found a four- to nine-fold decrease in the incidence of empyema, pneumonia, or lung abscess in antibiotic-treated patients versus control subjects. A fourth study using cephapirin was equivocal [181]. Intrapleural administration of antibiotic through a chest tube for postthoracos- tomy empyema has been described [183]. Miscellaneous complications include arteriove- nous fistula formation within the chest wall or great vessels [184,185], unexpected pleural reactions to a chest tube [109], and pneumothorax following in- advertant disconnection of the suction apparatus. Disconnections can occur at insertion Site, drainage device, or, more commonly, connectors or tubing. Even simple Heimlich valves, if improperly re- versed, can result in potentially dangerous compli- cations, such as tension pneumothorax [186]. Com- plications may appear after chest tube removal, including recurrence of pneumothorax [148] and formation of pleurocutaneous fistula tracts. Re- tained thoracostomy tubes within the pleural cavity have been percutaneously retrieved under fluoros- copy with a rigid nephroscope [187]. Competency in Placement and Usage Physiciansresponsible for placement, maintenance, and removal of tube thoracostomies should be properly educated and demonstrate evidence of competency as part of a quality review or creden- tialing process. Tube thoracostomy has been desig- nated a mandatory skill for all physicians involved in general surgery and emergency medicine [188- 190] and is a desirable skill for physicians in pulmo- nary, pediatric, and critical care [191-193]. Few general internists are taught or can perform this skill [194,195]. Such training should begin prior to internship (i.e., during medical school) if possible [196]. The American College of Surgeons Advanced Trauma Life Support curriculum includes tube tho- racostomy as a required station [197]. Use of re- cently deceased patient" or cadavers has been advo- cated despite ethical concerns [198]. Nonanimal training models for house staff have also been de- scribed [199]. Although no specific guidelines exist, 10 to 12 observed procedures are suggested for minimal competence in routine placement of tube thoracostomies. Minimal training requirement for various subspecialties may be necessary to assure adequate experience in this invasive procedure [193].
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