TUBE THORACOSTOMY

Tube Thoracostomy
Used to evacuate abnormal accumulation collection in the pleural space

Conditions that may require CTT

Pleural effusion Empyema Chylothorax *trauma is a common indication due to accumulations of blood or air

Pathophysiology
Pleural space potential space that separates the visceral & parietal pleurae w/ a thin layer of lubricating fluid Parietal pleura interior of the chest cavity Visceral pleura lung
*both are smooth, serous membranes

Pathophysiology
slight negative pressure lung inflated inspiration negative intrathoracic pressure transmitted to lung parenchyma expansion of lung

Pathophysiology
Large accumulation of blood, fluid, or air in the pleural space interferes w/ normal inspiratory inflation compromise respiratory function Progressive accumulation (tension pneumothorax) pneumothorax) CV compromise + respiratory compromise

Pneumothorax
Negative pressure is lost lung collapses air enters from outside or from the lung

Spontaneous Pneumothorax
Primary rupture of subpleural bleb in px w/o underlying lung dse
men > women (6x) Tall, thin, 20-40 y/o, smoker 20-

Spontaneous Pneumothorax
Secondary more common & occur in pxs w/ underlying lung/parenchymal lung/parenchymal dse (COPD, asthma, PTB, pneumonia, bronchiectasis, atelectasis, bronchiectasis, atelectasis, FB)

Traumatic Open Pneumothorax

Or sucking chest wound Occurs when chest wall is penetrated
*wound is larger than the trachea, air preferentially enters the wound rather than the trachea w/ each inspiration *lung will not expand & no ventilation will occur

Traumatic Closed Pneumothorax

Following blunt chest trauma Usually due to rib fracture that injures the lung & allows air into the pleural space Alveolus/bleb ruptures due to the increase in intrathoracic pressure against a closed glottis (blunt chest trauma/CPR)

Tension Pneumothorax
Results from traumatic causes Fractures of the trachea or bronchi, a ruptured esophagus, the presence of occlusive dressing over an open pneumothorax, pneumothorax, or chest compression Risk is increased for pxs w/ chest trauma who are undergoing positivepositivepressure ventilation

Tension Pneumothorax
Occurs when a pulmonary or bronchial injury creates a ball-valve mechanism ballprogressive accumulation of air

Hemothorax
Caused by injuries to the heart, lungs, great vessels, intercostal vessels, mediastinal veins, chest wall vessels, or fractured rib

Chylothorax
From injury of the thoracic duct Initially collects extrapleurally, & may extrapleurally, not begin to fill the pleural cavity for 2210 days Diagnosis is made by a thoracentesis that demonstrates a milky white fluid w/ a high fat & lymphocyte content & 4-5 gm/dL of protein gm/dL

Empyema/Effusions Empyema/Effusions
Infection or gross pus in the pleural space S. aureus most common isolate

Indications
PNEUMOTHORAX CTT may be unnecessary in pxs w/ isolated small/moderate traumatic pneumothoraces in the absence of respiratory compromise or when positivepositive-pressure ventilation will not be required

Indications
PNEUMOTHORAX Healthy, reliable, & minimally symptomatic pxs w/ no underlying lung dse & small pneumothoraces (<10% -20%) observation

Indications
PNEUMOTHORAX w/o any intervention or continuing leak, a small pneumothorax will resolve over days-weeks days Supplemental O2 will speed this process by increasing the rate of pleural air absorption

Guidelines of the American College of Chest Physicians for the Management of Primary & Secondary spontaneos Pneumothorax

Primary Spontaneous Pneumothorax

Clinically stable patients w/ small pneumothoraces: pneumothoraces: Pxs managed by observation should remain @ ED for 3-6hrs under close 3observation for serial examinations & rpt CXR Ff-up w/in 12hrs to 2 days w/CXR Ff-

Primary Spontaneous Pneumothorax

Clinically stable patients w/ large pneumothoraces: pneumothoraces: Lung should be reexpanded & should be hospitalized Use small-bore catheter (<14F) or small(< placement of a 16-22F chest tube 16 Catheters or tubes may be attached either to a Heimlich valve or to a water seal device (left in place until lung expands & air leaks have resolved

Primary Spontaneous Pneumothorax

Clinically stable patients w/ large pneumothoraces: pneumothoraces: Pxs unwilling to be hospitalized: discharged fr ED w/ a small-bore smallcatheter to a Heimlich valve if the lung has reexpanded after the removal of pleural air Ff-up w/in 2 days Ff-

Secondary Spontaneous Pneumothorax

Clinically stable patients w/ small pneumothoraces: pneumothoraces: Hospitalized May be observed or treated w/ CTT (depending on extent of symptoms & course of pneumothorax) pneumothorax)

Secondary Spontaneous Pneumothorax

Clinically stable patients w/ large pneumothoraces: pneumothoraces: CTT should be placed for lung reexpansion w/ hospitalization

Indications
HEMOTHORAX CTT is also used to monitor the amount & rapidity of bld output

Indications
Indications for surgery after CTT: 1. Massive hemothorax (>1000-1500 mL initaial (>1000drainage 2. Continued bleeding (>300-500 mL in 1st hr or (>300>200 mL/hr for 1st 3 or more hrs) mL/hr 3. Increasing size of hemothorax on CXR 4. Persistent hemothorax after 2 functioning tubes placed 5. Clotted hemothorax 6. Large air leak preventing effective ventilation 7. Persistent air leak after placement of 2nd tube or inability to expand lung fully

Indications
EMPYEMA Some can be treated w/ serial thoracenteses but most pxs will require continuous drainage with a CTT Thoracentesis is done for assessment of fluid for signs of infection Thick pus, (+) gram stain, glucose of <60 mg/dL, pH <7.2, or LDH: effusion mg/dL, requires CTT drainage

Indications
EMPYEMA Tube is left in place until volume of the pleural drainage becomes clear yellow & is <150 mL in 24 hrs

Contraindications
Unstable px: no absolute contraindications px: Stable px: relative contraindication px: - anatomic problems (multiple pleural adhesions, emphysematous blebs, or scarring Coagulopathic pxs should be evaluated for clotting factors

TUBE LOCATION

Procedure
TUBE LOCATION Pneumothorax: 2nd ICS MCL (usually Pneumothorax: used for needle decompression) - most common location: mid-anterior midaxillary line Recommendation: 4th-8th ICS (most often used is 4th or 5th ICS) Entrance site: lateral to the edge of the pectoralis major & breast tissue

PATIENT PREPARATION

Procedure
PATIENT PREPARATION O2 supplementation w/ pulse oximetry monitoring Anterior axillary line: head elevated @ 3030-60 Arm of the affected side is placed on the pxs head Area is sterilized w/ povidone-iodine & povidonedraped w/ sterile towels

Procedure
ANESTHESIA 5 mg/kg is locally injected w/ 1% lidocaine Inject the anesthetic in the SQ area in the incision site then into the muscle, periosteum, periosteum, & parietal pleura

INSERTION

Procedure
INSERTION Make the initial skin incision at the ICS lower than the thoracic wall entry site To provide a better seal against air leaks w/ a #10 blade, make a 3-4cm 3transverse incision thru the skin & the SQ tissues directly over the rib located 1 ICS beneath the rib will pass over

INSERTION

Procedure
INSERTION Using blunt dissection w/ a large Kelly clamp, a track is created over the rib above by pushing forward w/ the closed points & spreading & pulling back w/ the points spread Push thru the muscle & the parietal pleura until pleural cavity is entered Palpable pop Rush of air or fluid

Procedure
INSERTION Tips of clamp still w/in the pleural cavity, are spread widely to make an adequate pleural entry Once pleura is penetrated, finger is inserted into the tract Fingers may be swept inside the cavity

INSERTION

INSERTION

Procedure
INSERTION Finger is left in the pleural space as a guide & the tube is passed over, under, or beside the finger into the pleural space directed superiorly & posteriorly Ensure that all holes in the tube is w/in the pleural space

Procedure
INSERTION Tube can be rotated 360 to reduce kinking Tube can be directed inferiorly if only fluid is to be drained Tube is attached to the water seal or suction setup by means of a sterile serrated connector before clamp is released Ask px to cough & thereafter observing bubbles to check patency

Confirmation of Tube Placement

Definitive assessment: CXR *if still w/ pneumothorax: consider pneumothorax: that tube is not in the pleural cavity, most proximal hole is outside, or a large air leak from the TBT may be delaying expansion

Drainage & Suction System

Drainage & Suction System

Underwater seal method Intrapleural fluid or air exits under a small amount of water & collects into a single collecting reseroir intrathoracic pressure > water pressure allow intrathoracic air or fluid to be expelled in the into the bottle