CHEST TUBE INSERTION

Purposes

1. Drainage of hemothorax, or large pleural effusion of any cause

2. Drainage of large pneumothorax (greater than 25%)
3. Prophylactic placement of chest tubes in a patient with suspected chest
trauma before transport to specialized trauma center
4. Flail chest segment requiring ventilator support, severe pulmonary contusion
with effusion

Contraindications

1. Infection over insertion site

2. Uncontrolled bleeding diathesis

Materials

1. Chest tube with or without trocar

2. Chest tube suction unit (PleurevacR or SaharaR), tubing, wall suction hookup
3. Chest tube tray to include scalpel blade and handle, large Kelly clamps,
needle driver, scissors
4. Packet of 0 or 1.0 silk suture on a curved needle
5. Tape, gauze
6. 2% lidocaine with epinephrine, 20 cc syringe, 23-gauge needle for infiltration
7. Sterile prep solution; mask, gown and gloves

Size of Chest Tube

Adult or Teen Male 28-32 Fr
Adult or Teen Female 28 Fr
Child 18 Fr
Newborn 12-14 Fr

Pre-procedure patient education

1. Obtain informed consent

2. Inform the patient of the possibility of major complications and their
treatment
3. Explain the major steps of the procedure, and necessity for repeated chest
radiographs

Procedure

1. Put on the gloves and mask.

2. Determine the placement site. For a patient with hemothorax, the site is
about nipple level (the 5th intercostal space) on his affected side. For a
patient with
pneumothorax, the site is usually the second intercostal space, midclavicular
line.
3. Prepare and drape the patient.
 4. Locally, anesthetize the skin and rib periosteum, if the patient's condition and
time permit.
5. Incise the skin, creating a tunnel. Using a scalpel and blade, make a two to
three centimeter transverse incision through the subcutaneous tissues, just
over the top of the rib. Create a tunnel by spreading the clamp
6. Using the clamp, make a hole into the pleural space. Grip the clamp along its
shaft to prevent plunging too deeply into the chest. Make the hole at the top
edge of the patient's rib. Spread the clamp to enlarge the hole and remove
the clamp.
7. Explore the pleural space. With the sterile gloved index finger of your
dominant hand, explore the intrathoracic area to confirm that it is free of
adhesions or clots. Be careful to guard against extrapleural tube placement.
8. Insert the chest tube in this manner:
(a) Grasp the chest tube with the clamp. Beveling the end of the chest
tube with scissors to facilitate the passage of the tube through the
chest wall. Remove any sharp edges.
(b) Guide the chest tube into the pleural space.
(c) Advance the tube to the apex, leaving no holes external to the pleural
space.
NOTE:
Air whistling in and out of the tube indicates proper intrapleural placement of
the tube but creates open pneumothorax. Therefore, the chest tube is
improperly placed.
9. Look for fogging of the chest tube when the patient breathes out, an
indication of a properly placed tube.
10.Quickly attach the chest tube to an underwater seal apparatus.
NOTE:
If a drainage system is not available, improvise with a Heimlich valve.
11.When the tube is properly placed, secure it with a suture attached to the skin.
Leave one suture long and tie that suture securely around the chest tube.
12.Apply the dressing. Follow this procedure:
(a) Apply tincture of benzoin to the skin.
(b) Place petroleum gauze around the tube exit site to make an airtight
seal.
(c) Cover the gauze with a dry, sterile dressing.
(d) (d) Secure the test tube with adhesive tape.
13.When it is possible, obtain a chest x-ray to be sure the chest tube has been
placed properly