Chest Tube

Chest Tube & Under Water Seal Apparatus

 it’s a type of Thoracotomy which should be done at the OR

 Insertion:
 Site= 5th ICS mid-axillary line (or anterior-axillary line)

 Timing = when breathing in (As the lung expands & diaphragm goes up & chest wall comes near the lung , so that will push air/bl…etc through the chest tube).

 The tube has a radio-opaque line to make sure the opening is inside the pleura when seen by the CXR

 Steps of insertion:

 Inserted under completely ASEPTIC technique
 Position the pt
 LA if pt is conscious
 Incise the skin b/w 4th & 5th ICS b/w mid- & anterior-axillary line
 (incision is made in the skin and subcutaneous tissues sufficient to admit a finger easily).
 Perform blunt Kelly-clamp dissection over the rib into the pleural space to avoid injury of the neurovascular bundle
 Perform finger exploration to confirm intrapleural placement
 Place the tube posteriorly & superiorly

- A large bore tube is used for the drainage of blood and fluid, where as a smaller bore tube may be used for the removal of air.
- The seal must be under chest level, & the chest tube in apex of pleural cavity.
- The intercostals drainage tube is inserted with the stylette withdrawn (so as not to damage the underlying lung tissue)
- pressure of suction is -18 cm than water, so the lung will be more expanded
- The liquid trap is interposed between the tubing existing from the pleural cavity and atmosphere, so :
o if the pressure in the pleural cavity >atmospheric pressure, air or fluid will be drained out through the water immersed tube.
o When the pleural pressure becomes negative, atmospheric pressure air is prevented from being sucked into the pleural space by the water seal.
 Duration:

 Leave 3-5 day w/ CXR follow up , then clamp checking for air leak
 If the lung expands on the same day, don’t remove, to allow lung injured area to heal ( instead of removing & inserting several times)

 Techniques for Drainage;

 Open technique: insert chest tube w/o trochar
 Closed technique: with trochar, may injure muscles, vessels

 Indications for insertion:

 Evacuate:
 Air = Pneumothorax (simple, tension)
 Blood = Hemothorax
 Pus = Empyema
 Chyle (lipids) = chylothorax
 Pleural effusion = hydrothorax

 Install medications:
 Chemotherapy
 Abc as in empyema
 post operative



 When should it be clamped??

 disconnection of the tube from the collection device
 changing a full or malfunctioning fluid device
 during removal of chest tube
 if sudden hypotension follows rapid evacuation of a large Hemothorax
 pt w/ Hemothorax with chest tube & you want to send him to CXR ~ clamp the tube to avoid bl from going into the chest again b/c it’s a stagnate blood which stimulates bacterial growth









 Complications:

 Failure of the procedure , e.g. misplacement of the tube in the chest wall
 Injury to:
• Neurovascular bundle  Hemorrhage, Pain
• Organ e.g. lung, heart, spleen, liver, esoph ( d/t incorrect position)
 Infection to wound site or pleura (Empyema)
 Introduction of Pneumothorax (while removing or if there was a hole in the tube)


 Care of Chest Tube:

1- CXR:
- to check it is correctly inserted
- to observe lung expansion

2- Check if it is functioning well:
- movement of meniscus
- bubbles in the water

3- Clamp the tube after 3-5 days, to know if the leak has sealed :
- if there is still a leak the tube will blow
- if bubbles stop (no more air in the pleural cavity) Òremove tube (6-24hr)


 Chest Tube Removal:

 Procedure:
- Sedation
- Remove all dressings, cut the anchoring suture
- Cleanse the skin w/ bactericidal solution
- W/ sterile gloves on, pinch the skin around the tube
- Have the pt perform Valsalva maneuver, & rapidly remove the tuve while pinching the skin around it to prevent air introduction
- Apply Abc ointment & cover w/ occlusive dressing
- Dressing should remain for 24-48 hr