tube thoracostomy

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بسم الله الرحمن الرحيم وَمَنْ أَحْيَاهَا فَكَأَنَّمَا أَحْيَا النَّاسَ جَمِيعاً المائدة ( 32 )

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TUBE THORACO- STOMY By Dr Mahmoud M. Alsalahy Assist. Prof of Chest Medicine Banha University, Egypt

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Chest tubes and bottles are some of the simplest devices used in the practice of medicine. Yet they are often misunderstood , sometimes misused and are a mystery to medical students, nurses and some practicing doctors . (THE BULLETIN OF THE HONG KONG MEDICAL ASSOClATlON VOL. 29, 1977)

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Tube thoracostomy is the insertion of a tube into the pleural cavity to drain air, blood, bile, pus, or other fluids Provides continuous, large volume drainage until dealing with the under-lying pathology Numerous indications in which patients are at great risk for major morbidity or mortality

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INDICATIONS Pneumothorax If > 20 % of the hemithorax In any ventilated patient Tension pneumothorax after initial needle relief Persistent or recurrent pneumothorax after simple aspiration Secondary spontaneous pneumothorax in patients over 50 years Rapidly accumulating pleural effusion

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INDICATIONS Empyema and complicated parapneumonic effusion Hemo or haemopneumothorax Postoperative ( in cardiac & mediastinal surgery) Chylothorax Chest trauma When pleurodesis is needed

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CONTRA INDICATIONS Absolute: The need for emergent thoracotomy Fused pleural space Relative : include the following : Coagulopathy Pulmonary bullae Pulmonary, pleural, or thoracic adhesions Loculated pleural effusion or empyema Skin infection over the chest tube insertion site

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CLINICAL NOTES Chest tubes in post thoracic surgery: 1. For lung resections: 2 tubes must be inserted one for air and one for fluid 2. For pneumonectomy: only one basal tube for fluid 3. For intra-thoracic extra pulmonary operations: only one basal tube if pleura is opened

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E QUIPMENTS Chest tube drainage device with under water seal Sterile gloves Preparatory solution Sterile drapes Surgical marker Lidocaine 1% with epinephrine Syringes, 10-20 mL (2 ) Needle, 25 gauge ( ga ) , 5/8 in Needle, 23 ga , 1.5 in; or 27 ga , 1.5 in; for instilling local anesthesia

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E QUIPMENTS Blade (No . 10 or 11) on a handle Large and medium Kelly clamps Scissors Silk or nylon suture, 0 or 1-0 Needle driver (holder) Vaseline gauze Sponge gauze squares, 4 ″ x 4 ″ (10 ) Sterile adhesive tape, 4 ″ wide Chest tube of appropriate size : = Man : 28-32F = Woman : 28F = Child : 12-28F = Infant : 12-16F = Neonate : 10-12F

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Chest tubes (Catheters) Different sizes From infants to adults Small for air, larger for fluid Different configurations Curved or straight Types of plastic PVC Silicone Coated/Non-Coated Heparin Decrease friction

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POSITIONING Best is semi recumbent at a 30- 45° The arm on the affected side should be abducted and externally rotated A soft restraint or silk tape can be used to secure the arm in this location Safe Triangle

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Best positioning: 30 ⁰ elevation, 45 ⁰ rotation

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TECHNIQUE Give O2 IV line Observe Identify the 5 th space and the mid axillary line (MAL) Clean the area (remove excess hair) Mark the site of insertion (4 th or 5 th space between MAL and AAL) Wear sterile gloves, gown, hair cover, and goggles or face shield Apply sterile drapes to the area.

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TECHNIQUE contd. Administer a systemic analgesic (unless contraindicated ). Use the 25-ga needle to inject 5 mL of the local anesthetic solution into the skin overlying the initial skin incision Infiltrate the skin area of incision by 5 ml of the anesthetic then direct down to periosteum and infiltrate with 10 ml Advance the needle and aspirate to confirm entry to pleura ANESTHESIA If no air or fluid aspirated?

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TECHNIQUE contd. INCISION Use the No. 11 or 10 blade Ideal is 2-4 cm long Overlying the rib that is below the desired ICS entry. The incision should be in the same direction as the rib itself.

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TECHNIQUE contd. BLUNT DISSECTION Use a hemostat or a medium Kelly clamp Bluntly dissect a tract in the subcutaneous tissue by intermittently advancing the closed instrument and opening it Dissect down to intercostal muscles

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TECHNIQUE contd. Further blunt dissection down to the intercostal muscle

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TECHNIQUE contd. Further blunt dissection down to the pleura

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TECHNIQUE contd. Palpate the tract with a finger as shown, and make sure that the tract ends at the upper border of the rib under the skin incision Adding more local anesthetic to the intercostal muscles and pleura at this time is recommended . CONFIRM A PROPPER TRACK

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A closed and locked Kelly clamp is used to enter into the pleural cavity by controlled pressure and twist . Make sure to guide the clamp over the upper margin of the rib . Once inside the pleural cavity, open the clamp to enlarge the entry and withdraw it open TECHNIQUE contd. ENTERING THE PLEURAL SPACE

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Use a sterile, gloved finger to appreciate the size of the tract and to feel for lung tissue and possible adhesions TECHNIQUE contd. CONFIRM TRACK AGAIN

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Rotate the finger 360º to appreciate the presence of dense adhesions that cannot be broken and require placement of the chest tube at another site TECHNIQUE contd. CHECK FOR ADHESIONS

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TECHNIQUE contd. The proximal end of the chest tube is held with a Kelly clamp that guides the chest tube through the tract . The distal end of the chest tube should always be clamped until it is connected to the drainage device. TUBE INSERTION

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Tube insertion guided by a curved Kelly clamp

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Desired intra pleural length equals the distance between incision and lung apex Direct the tube upwards and posteriorly in pneumothorax and above the diaphragm in effusion Before securing the tube with stitches, look for a respiration-related swing in the fluid level of the water seal TECHNIQUE contd. PROPPER TUBE POSITION

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TECHNIQUE contd. SECURING THE TUBE Two separate through-and-through, simple, interrupted stitches on each side of the chest tube are recommended Each stitch should be tightly tied to the skin, then wrapped tightly around the chest tube several times to cause slight indentation, and then tied again

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SECURING THE TUBE TECHNIQUE contd. Sealing suture: A central vertical mattress stitch with ends left long and knotted together can be placed to allow for sealing of the tract once the chest tube is removed . Place petrolatum ( eg , Vaseline) gauze over the skin incision as shown

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Prepare a Y-shaped fenestrated drain gauze from regular gauze (4 x 4 in). Apply support gauze dressing around the chest tube and secure it to the chest wall with 4-in adhesive tape

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CLINICAL PEARLS Don’t get out the SAFE TRIANGLE Wait sufficiently for anesthesia to give effect Avoid too small and too large incisions Keep track above the upper border of the rib In case of tension empyema or effusion remove 50-200 mls by a syringe to avoid spraying out pleural contents on opening the pleura Check for optimal position of the tube inside the chest by X-ray

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Left side chest tube in a good position Right side chest tube in a wrong position

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COMPLICATIONS Complications are reduced when done by experienced operators Good experience is gained after doing at least 10 SUPERVISED procedures (ATS) Experience maintained by doing 5 procedures / year (ATS) Complications may be dangerous and fatal so good tube care and follow up is essential

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COMPLICATIONS contd 1. Improper placement Horizontal (over the diaphragm) (Acceptable for hemothorax) Subcutaneous - Must be repositioned Placed too far into the chest (against the apical pleura) - Should be retracted In inter lobar fissure: Correct Placed into the abdominal space - Should be removed

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2. Bleeding Local - Usually responds to direct pressure Hemothorax ( lung vs IC artery injury ) - Might require thoracotomy if it does not resolve spontaneously COMPLICATIONS contd

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3. Organ penetration and injury: Lung - Occurs as a result of pleural adhesions or use of a thoracostomy tube trocar Liver or spleen with hemoperit-oneum - Requires emergent laparotomy Stomach, colon, or diaphragm - Occurs as a result of unrecognized diaphragmatic hernia COMPLICATIONS contd

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4. Dislodgement: Due to accidental pull – re-introduce a sterile tube 5. Pleural infection and empyema: If sterilization is poor 6. Mal or non function: r eplace COMPLICATIONS contd

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SEALING THE TUBE The tube must be sealed after insertion Sealing is by underwater system or Heimilch valve Underwater seal is the most commonly used It is either single bottle, two bottles or three bottles system The seal is a straw that pass through the bottle cap and settle 2-3 cm below water

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SEALING THE TUBE When intrapleural pressure rises above 3 cm water contents of pleura are expelled but hydrostatic pressure of water prevent water from gaining into the pleura Excess fluid accumulated in the bottle must be removed regularly otherwise back pressure occurs The bottle must be kept below the bed level (100cm below insertion)

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CONCEPT Most basic concept Just like a straw in a drink, air can be pushed through the straw, but air can’t be drawn back up the straw Tube from the patient Straw concept Tube open to atmosphere vents air

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UNDER WATER SEAL 1 2

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3 Trap Seal Manometer

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Disposable 3 bottle one unit system ( Pleuro-Evac )

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Heimlich Flutter Valve One way flutter valve Used for ambulant patients with pneumothorax Must be placed in a correct position otherwise will be fatal When functioning makes a duck like quacks Inspiration Expiration

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MANAGING CHET TUBES

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Patients with chest tubes should be managed on specialist wards by staff who are trained in chest drain management (BTS)

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Proper connection to the seal Connections must be sealed with adhesive tape No prophylactic antibiotics needed No dependent loops to be present 1or 2 loops near the patient facilitate movements and minimize pain While in bed fix the tube to the bed with a pin Dressing must be changed if soaked Two loops near the patient Dependent loop Wrong connection

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The following can significantly restrict tube function and could be dangerous: A full bottle with glass straw tip deep under the fluid surface . Too narrow or too soft tubing may spontaneou - sly kink or collapse or the patient may lie on it An obstructed or small size air vent permits pressure to build up in the chest bottle . Any fluid in a dependent loop of tubing will obstruct flow and create back pressure, especially to an air leak

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Patient must be taught: To keep the bottle down To have good inspirations to inflate the lungs To observe any change in the bottle and to call for help when: Develops respiratory distress Excess bubbling occurs Excess blood seen Oscillation stops The tube move from place 100 cm

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Morning Evening 24 hour total Date Air Fluid Others Air Fluid Others CHEST TUBE FOLLOW UP CHART

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Use of suction to chest bottles is somewhat controversial When properly applied, chest tube suction is very useful There are different ways: thoracic pumps or wall suction SUCTION WALL PUMP

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Conditions where Suction is Useful: Pneumothorax: Persistent leak after 18-24 hrs A defect in seal system that cannot be corrected 2. Effusion: When thick and not easily drained 3. Hemothorax: Unless active bleeding is present 4. After open heart surgery SUCTION contd.

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CLAMPING Clamping the tube is indicated in: During insertion and if signs of REPE develops During transportation During seal changing As a test for leaking connections After introducing pleural sclerosant After pneumonectomy: controlled For milking and striping Before removal

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TUBE REMOVAL A chest tube can be safely removed when: Patient clinically well X-ray shows fully expanded lung In pneumothorax: no leak for 24 hrs In effusion: less than 50-80 ml ( some: 200-300 ml ) fluid gain/24 hrs The fixing stitches are cut, patient takes deep inspiration, tube withdrawn, the track sealed rapidly with a gauze, the sealing stitch is tightened

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TROUBLE- SHOOTING ( WHAT TO DO? )

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4 possibilities: Wrong placement: correct Large leak: put on suction Pleural cortex (rim): decortication E ndobronchial obstruction: bronchoscopy I f the lung fails to re-expand after ICT placement ?

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Occurs with high volume air leak Commonly occurs at start of suctioning Overcome by silicon antifoam spray or adding ethanol to the bottle If foaming (excess froth in the bottle ) occurs ?

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The tube will stop oscillation Check for kinking, if not( a possible clot ) Milking: distal clamping and proximal milking Striping: proximal clamping and distal striping Clean with a sterile Fogarty catheter Change the tube if all fail If the tube is blocked and stop function ?

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Means a poor functioning tube SE may indicate tension pnx . SE is disfiguring and annoying to the pt. If pt. is stable: reassure and search for a block and correct If tube is working = a large leak; put on suction If pt. is distressed: release tension If surgical emphysema (SE) develops ?

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3 possibilities: Disconnected from the seal Dislodgement of ICT from chest A leak within the lung itself This means excessive air leak If the seal bottle on suction suddenly bubbles furiously ?

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1 st check the patient: ● Stable and no manifestations of respiratory distress: Check for tubing disconnection and reconnect Aseptically re-insert a dislodged tube Ask the pt to cough to expel any air entered the pleura

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1 st check the patient: ● Unstable with manifestations of respiratory distress: Give 100% O2 and monitor by oxymetry Support circulation if needed and monitor BP Examine chest for signs of tension pntx . Obtain X-ray chest to confirm Check tubing and do as before

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● If the ICT tube is dislodged : Continue pt. support and monitoring Swap the area of insertion and the exposed portion of the tube with Betadine Stop suction, cut the stay suture, re introduce tube till all holes are inside Make new stay sutures to fix the tube New X-ray chest to check position Give prophylactic antibiotics

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These patients need VATS or open thoracotomy IF lung air leak persist after one week on suction ?

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3 possibilities: Severe active bleeding: support circulation, call for thoracotomy Mild active bleeding: wait and see under close observation A collected blood passed a block: close observation If a sudden gush of blood appear in the drain bottle ?

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ICT IN VENTILATED PATIENTS ICT can cause: Decrease Vt Decrease oxygenation and CO2 removal Inappropriate cycling of the ventilator 4. Persistence of air leak (BPF) So, this situation is somewhat difficult SPECIAL SITUATION

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Ventilator management: Minimize airway pressure: Decrease Vt Decrease respiratory rate Decrease inspiratory time Use least PEEP possible

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Ventilator management: DIFFERENTIAL VENTILATION Ventilate only the healthy side Ventilate both sides differently using Carlen ᾿ s tube Tube pressurization in expiration and occlusion during inspiration Make leak site more dependent High frequency ventilation

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Thank You