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Surgical insertion of a chest tube

Insertion of a chest tube is a common procedure. Indications count pneumo- and hemothorax among others; and in acute situations, a chest tube can be lifesaving. This video illustrates the surgical insertion of a chest tube in a patient suffering from hydro-pneumothorax. The video shows the identification of the anatomical structures that create the safe triangle, and a safe insertion of a chest tube into the pleural cavity.
Chest tube insertion is a basic surgical procedure, often conducted by residential surgeons. It is important to know the guidelines for inserting a chest tube, in order to reduce the risk of damaging organs or neurovascular structures.

Procedure: This video illustrates the surgical insertion of a chest tube in a patient suffering from hydro-pneumothorax. Introduction: Insertion of a chest tube is a common surgical procedure within clinical practice. Indications: Indications for a chest tube insertion include air (pneumothorax) or fluid (hydro-, chylo-, pyo- or hemothorax) in the pleural cavity. Contraindications: Relative contraindications count pulmonary adhesions, pulmonary disease, and trauma, along with coagulopathy and diaphragm hernia. These conditions have different etiology, and in acute situations insertion of a chest tube can be lifesaving. Results: This video tutorial shows the identification of the anatomical structures that create the safe triangle, and a safe insertion of a chest tube into the pleural cavity. Conclusion: Chest tube insertion is a basic surgical procedure, often conducted by residential surgeons. It is important to know the guidelines for inserting a chest tube, in order to reduce the risk of damaging organs or neurovascular structures.
Chest tube insertion is a common procedure and a basic core skill in an acute hospital setting. Indications for chest tube insertion count pneumothorax, pleural effusion, empyema, haemothorax, chyle leak to the pleural cavity and postsurgical(1). Relative contraindications include pulmonary adhesions, pulmonary disease, and trauma, along with coagulopathy and diaphragm hernia. Complications to chest tube insertion such as misplacement, damage to the intercostal neurovascular bundle, and organ injury have been described(2). Organ injuries count damage to the lung, diaphragm, liver, colon, esophagus, truncus sympathicus, heart, and great vessels(3). In this case, a 69-year-old male was admitted to the hospital with a large pleural effusion on the right side. After drainage of the pleural cavity, the lung did not expand. Several chest tubes failed to treat the hydro-pneumothorax in a regional hospital setting before the patient was transferred to our department of cardiothoracic surgery. The patient received a surgically inserted chest tube, and in this procedure, a safe and standardized placement is crucial to minimize the risk of complications to an otherwise common and simple procedure.
Pre-operative workup: The patient’s chest X-ray showed a clear apical and lateral loosening of the right lung along with a small amount of pleural effusion and a well-defined air-fluid surface. Anatomy and landmarks: The patient is placed on his back, with his right arm elevated above the head. The needle is inserted in “the safe triangle” between the anterior and mid-axillary lines, and above the level of the nipple. Be sure to let the needle follow the cranial margin of the costa to minimize the risk of lesioning the intercostal neurovascular bundle. The needle is inserted slowly through the intercostal muscle layers and into the pleura under constant aspiration. Pause when air hits the syringe. Retract the needle and apply local anesthetics around the pleura, muscle, subcutaneous and cutaneous tissue. Detailed steps of the procedure (included in the video):  Antiseptic preparation: The surgical field is prepared and covered according to standard antiseptic procedures. Access to the pleural cavity: A 2-3 cm wide skin incision is cut over the needle entry point. Then the surgeon carefully, bluntly dissects through the subcutaneous tissue and intercostal muscles using a forceps, following the cranial margin of the costa. Once the pleura is reached, the forceps are closed and the pleura carefully punctured. The forceps are opened near the edge of the pleura to stretch the entrance hole. The sound of air escaping the chest cavity will confirm the puncture. A finger is inserted and moved around in contact with the inside of the thoracic wall to search for and disengage any smaller adhesions that might be to ensure correct placement. Chest tube insertion: The chest tube is grabbed with a forceps and gently slid it into the chest cavity. The tube is placed correctly when it slides smoothly into the cavity. The tube should be directed upwards in case of pneumothorax and downwards in case of pleural effusion. The tube should be inserted so that all the drainage holes are within the chest cavity. A simple skin suture is placed for fastening of the chest tube. A horizontal mattress suture is placed for closing the wound when the chest tube is later removed. The needle is cut off and the suture secured. Additional skin stitches can be applied if necessary. Connect the chest tube to the system: The chest tube is connected to a closed system and is it controlled that oscillation occurs. The procedure is finished with the application of a protective airtight occlusive dressing.
On the postsurgical X-ray, the chest tube is sufficiently placed at the base of the right pleural cavity, draining the hydro-pneumothorax and in the progress of expanding the right lung.
Guidelines suggest a small-bore chest tube (<20F) for the treatment of pneumothorax(1, 4). However, this patient presented with pneumothorax for 12 days. Several chest tubes had been inserted and the patient already had a small catheter upon arrival. In such cases, a large-bore chest tube can be chosen to facilitate the expansion of the lung(5, 6). In this patient, the chest tube placement procedure is performed blindly, as this is standard in many institutions. This results in the drainage tube in this video is placed basally in the pleural cavity. This is well known when placing the chest tube blindly, and a study shows that the location of the chest tube, whether it was placed basally or apically, did not influence the chest tube duration(7). Guidelines also state that any chest tube position can be effective and if the chest tube is well functioning it should not be repositioned based on position alone(1). However, if malfunction of the chest tube due to positioning is suspected reinsertion or repositioning may be necessary. Usually, the tube will remove the air from the chest cavity very short after insertion. In this video, a full treatment effect was not achieved at the time of the post-placement X-ray. This is often the case in patients with a prolonged medical history of pleural effusion, and some degree of a trapped lung is expected(8). Postoperative care After insertion, the chest tube must be observed for oscillation, air, and secretion to confirm function. In case of pleural effusion or empyema, the tubes should also be flushed regularly to avoid clogging. It is important to prevent insufficient breathing due to pain to ensure deep inspiration and the best possible conditions for lung expansion. It is also important to mobilize the patient and to supply the treatment with lung physiotherapy such as positive expiratory pressure (PEP-treatment) to best possibly mobilize the lung and optimize the lung expansion. In a well-mobilized patient, the chest tube can be removed when the air production has been 0-20 ml/min for 6 hours or 0-40ml/min for 12 hours. After removal, a chest X-ray must be performed to assure complete lung expansion. The skin sutures can be removed 10 days after the chest tube removal. It is important in the postoperative period to mobilize the patient and perform pulmonary physiotherapy. Critical steps of the procedure Proper local anesthetic is mandatory in chest tube insertion. The procedure can be a very painful and unpleasant experience for the patient if proper local anesthetics are not applied. Take a few minutes break after injecting local anesthetics before the incision and dissection is made. If the procedure is painful to the patient the operator should consider if a little more time is needed before dissection, or if the local anesthetics is applied in the right place. Additional local anesthetics may be needed. If the dissection through the thoracic wall is performed dorsally to the area where the local anesthetics is applied, the local anesthetics may not work since the intercostal nerves approach from the spine. Therefore the operator must inject the local anesthetics directly under and laterally to the insertion site in the intercostal space. Moreover, the operator should be very careful to dissect through the thoracic wall in the same intercostal space that has local anesthetics applied. The risk of dissecting through an intercostal space without local anesthetics is elevated in very obese patients due to the longer distance from the skin to the thoracic wall. Common pitfalls Among young doctors, a study showed that 45% would have placed the chest tube outside the safe anatomical triangle(9). Hence, greater postgraduate education regarding chest tube insertion is essential to ensure correct treatment and avoid misplacement. Another common pitfall is misplacement due to adherent lung tissue. It is crucial that the operator carefully studies the X-rays or CT scans available and studies the history of the patient (especially prior surgery) before chest tube insertion. Many misplaced chest tubes can be avoided if the operator is well prepared before the procedure. Look for adherences and decide preoperatively where to place the chest tube. If the digital exploration does not reveal an open space pleural cavity the procedure must be aborted. Adherent lung tissue is the most common reason for lack of open space pleural cavity and misplacement of the chest tube to the lung tissue is often seen in these cases. Trocars should be avoided since the risk of damage to underlying tissue is elevated with the trocar technique. Limitations of the technique This is a blind technique. Hence, the operator has limited ability to check intraoperatively if the chest tube is placed in the part of the pleural cavity that needs drainage. As a rule of thumb, the operator should aim to direct the chest tube upwards anteriorly in case of pneumothorax and downwards backward in case of liquids. However, optimal chest tube placement is seen in only 53% of the cases, due to the lack of control of the direction of the chest tube inside the pleural cavity during the insertion(10) Potential further applications of the technique Placing a chest tube can be a difficult task, and optimal positioning of the chest tube is important. Hence, auxiliary devices such as the KatGuide have been developed to help the surgeon and accurate the position of the chest tube to the intended part of the pleural cavity. Auxiliary tools improve the probability of optimal chest tube positioning and reduce the risk of misplacement.
The author Niels Katballe is a consultant thoracic surgeon, and inventor of “The KatGuide” device, for safe and accurate chest tube insertion. The KatGuide technique is not used or mentioned in this tutorial video. (Katballe N, Moeller LB, Olesen WH, Litzer MM, Andersen G, Nekrasas V, et al. A Novel Device for Accurate Chest Tube Insertion: A Randomized Controlled Trial. The Annals of thoracic surgery. 2016;101(2):527-32.)
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1. Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax. 2003;58 Suppl 2(Suppl 2):ii53-9. 2. Kwiatt M, Tarbox A, Seamon MJ, Swaroop M, Cipolla J, Allen C, et al. Thoracostomy tubes: A comprehensive review of complications and related topics. Int J Crit Illn Inj Sci. 2014;4(2):143-55. 3. Kesieme EB, Dongo A, Ezemba N, Irekpita E, Jebbin N, Kesieme C. Tube thoracostomy: complications and its management. Pulm Med. 2012;2012:256878. 4. Zardo P, Busk H, Kutschka I. Chest tube management: state of the art. Curr Opin Anaesthesiol. 2015;28(1):45-9. 5. Porcel JM. Chest Tube Drainage of the Pleural Space: A Concise Review for Pulmonologists. Tuberc Respir Dis (Seoul). 2018;81(2):106-15. 6. Baumann MH. What size chest tube? What drainage system is ideal? And other chest tube management questions. Curr Opin Pulm Med. 2003;9(4):276-81. 7. Riber SS, Riber LPS, Olesen WH, Licht PB. The influence of chest tube size and position in primary spontaneous pneumothorax. J Thorac Dis. 2017;9(2):327-32. 8. Huggins JT, Maldonado F, Chopra A, Rahman N, Light R. Unexpandable lung from pleural disease. Respirology. 2018;23(2):160-7. 9. Griffiths JR, Roberts N. Do junior doctors know where to insert chest drains safely? Postgrad Med J. 2005;81(957):456-8. 10. Katballe N, Moeller LB, Olesen WH, Litzer MM, Andersen G, Nekrasas V, et al. A Novel Device for Accurate Chest Tube Insertion: A Randomized Controlled Trial. The Annals of thoracic surgery. 2016;101(2):527-32.

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