Tubes, drains and catheters

Tubes, drains and

catheters

How, when, which, what

what

Anatomy
Indications
Insertion
Tubes
Drainage
Examples

Alain Tremblay MDCM, FRCPC, FCCP

Dr. Ward Flemons

Dr. Ward Flemons

Anatomy of the pleural space

Anatomy of the pleural space

visceral
pleura

ribs
pleural
cavity

parietal
pleura
lung

intercostal
vessels

pleural
cavity
lung

hilum

intercostal
space

costo
diaphragmatic
sulcus
costo
diaphragmatic
sulcus

diaphragm
FRONT
VIEW

diaphragm
LATERAL
VIEW

collapsed lung

Indications

Drainage of air

Pneumothorax

Drainage of fluid

Primary or secondary
Spontaneous or traumatic /iatrogenic

Malignant pleural effusion

Parapneumonic effusions / Empyema
Hemothorax
Others

left pneumothorax

Insertion technique:
Factors to consider

Insertion technique

Varies with

Percutaneous

Type of tube chosen

Indication
Experience
Urgency

Insertion technique:
Factors to consider

right empyema

Post operative

Blind
Blind

Quick
Cheap
OK for most indications
No need for radiologist or
special training

Watch out if loculated

pleural space

No inspection of pleural
space
Care / image guidance
required if loculated
pleural space

More complex
More pain?
Incision

Allows digital
examination of pleural
space
Allows placement of large
bore tubes

Anatomy of the pleural space

rib

lung

intercostal
nerves and vessels
intercostal muscles

Accurate / optimal
placement
Useful in loculated or
complex spaces
Move patient
Equipment, training,
expense

Surgical

Image guided (U/S, CT)

Simple
Less painful
Less traumatic
Quick

intercostal space

fluid (or air)

free in the
pleural cavity

intercostal
space

diaphragm
diaphragm

Loculated vs free pleural effusion (air or liquid)

Loculated vs free pleural effusion (air or liquid)

rib

pleural
adhesions

pleural
adhesions

pleural adhesion

lung
loculated
effusion

loculated
effusion

rib

fluid (or air)

free in the
pleural cavity

pleural
adhesions

lung

Chest Tube inserted

Loculated empyema

with an inner rigid guide

Advantages
Simple and quick
Cheap
Allows drainage of large quantities
of fluid or air
Single use

Drawbacks
The rigid tube+guide may be
traumatic to the lung
Pleural lavage or tube desosbstruction
needs disconnection of the circuit
Dangerous in case of loculated
effusion (pleural adhesions)
slide 29

Tubes

Classic PVC chest tubes

Sizes 14 36 french
Stiff
Inserted surgically
Good for

Thick

fluid (blood, pus)

Large air leaks

Bad for
Pain, wound

infections

Tubes

Pneumothorax kit

Small bore tubes

Pigtails (8(8-14 Fr)

Strait pneumothorax
pneumothorax tubes (8 Fr.)

Percutaneous
With or w/o image guidance
More comfortable, less traumatic
Plugs easily, need for flushing
Good for lighter
lighter fluids, most airleaks

Small pigtail catheter inserted over a guide wire Seldinger technique (Fuhrman pleural drainage set)

dilator

pigtail
catheter

Chest Tube inserted

over a guide wire (Seldinger technique)

intoducer
needle

multipurpose
tube adapter

introducing wire
guide
(in sterile sleeve)

Chest Tube inserted

Tubes

over a guide wire (Seldinger technique)

Tunneled pleural catheters (Pleurx

(Pleurx))
Malignant effusions
Long term use
Intermittent home drainage
Low complication rates
Soft / Comfortable

TPC Insertion
15.5 F silicone
tube with
fenestrations and a
one way drainage
valve

Polyester cuff that holds the

tunneled portion just beneath
the skin and acts as a barrier to
infection
TPC System
The system consists of a catheter allowing
intermittent home drainage of pleural fluid into
plastic vacuum bottles.

One way valve

accessed
using drainage
kit into 600ml
drainage bottle
Photo compliments of Dave Lowery

Photo compliments of Dave Lowery

Photo compliments of Dave Lowery

Photo compliments of Dave Lowery

Photo compliments of Dave Lowery

Photo compliments of Dave Lowery

Pneumothorax
drainage options

Drainage systems

What, and how much are you draining?

Air?
Simple aspiration
Massive airleak

Liquid?

Both?

Bags, Bottles
3

bottle / Pleurevac systems

Heimlich Valve

can use perforated rubber glove finger fastened

to a tube

Chest Tube adapter

3 bottle systems

connecting
ports
(luer lock)

chest tube

three way
stop cock
suction tube

slide 48

Chest Tube adapter

Chest Tube adapter

chest tube

Advantages

allows continuous access to the pleural drainage circuit

without any tube disconnection for:

instillation of
talc slurry

pleural lavage
desobstruction of the chest tube
intraintra-pleural instillation of:

fibrinolytic agents
talc slurry

Getting pleural fluid samples

closed system (
( risk of infection)
can be connected to most types of chest tubes

slide 49

Pneumothorax
Treatment options

Observation
Simple aspiration
Chest tube - Tube thoracostomy

Surgical tubes only if large airleak suspected or

documented

MPE Treatment:
Pleurodesis
No advantage of large bore tube

Group\
Group\Success
Small (n=58)
Large (n=44)

6 weeks 4 months
55%
55%

1212-14 Fr pigtails ok

Flush tubes regularly

May need multiple tubes
Consider thrombolytics,
thrombolytics,
surgical options

MPE Proposed Algorithm

Chest 2001;120:19-25

Image guided tubes best

Larger bore

Small strait tubes usually adequate

Rare need for image guidance
Attached to Heimlich valve or underwater seal

Empyema
Treatment options

47%
49%

Known Malignancy
Symptomatic Effusion

Therapeutic Thoracentesis
and
Referral for
Pleurx Placement

No Known Malignancy
Symptomatic Effusion
Diagnostic/Therapeutic
Thoracentesis
Ancillary Investigations

Malignant Effusion
Referral for
Pleurx Placement

Non
Malignant

82 y.o.
y.o. engineer with previous
asbestos exposure MPE
How would you manage this symptomatic patient?
A)

B)

C)

D)

Pleurx Patients
82 y.o. engineer with previous asbestos exposure

Repeated
thoracentesis
Thoracoscopic
talc poudrage
Chemical
pleurodesis via
chest tube
Opiates

Mesothelioma

April 2002
-Closed pleural Bx
-Pleurx placement

Mesothelioma

July 2002
-Spontaneous pleurodesis
-Pleurx removed

June 2003
-Patient passes away
-No recurrence of effusion
-Hospital days: 0

Trauma / Surgical option

Trauma / resuscitation / hemothorax

Post thoracic surgery

Large PVC tubes best approach

Thank You!