Last Updated on October 22, 2022
“Knowing how to insert branula is not enough. A doctor should also master chest tube insertion, as good as branula insertion”
Introduction
2 methods
• Open method
• Closed method (do not use this method)
Important parts of a chest tube
• Radio-opaque tip and a marker strip along the edge
• Fenestrated end (with holes for drainage of air / fluid)
Chest drainage system
Types
• Single-bottle system (underwater seal)
• Two-compartment system (underwater seal)
• Three-compartment system (underwater seal)
• Wet-suction
• Dry suction
Underwater seal system – 1-bottle system
• Tip of the rigid straw is immersed at least 2 cm below surface of water
• Disadvantages
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Further reading:
Chest drainage systems in use, by NIH
Underwater seal drainage system, by LITFL
Inspiration, by LibreTexts
Chest tube Insertion
Indications
(i) Pneumothorax / tension pneumothorax
(ii) Pleural effusion
• Empyema
• Haemothorax
• Chylothorax
(iii) Post-op
• Post thoracotomy
• Post VATS
Complications
During insertion
• Injury to internal organs / structures e.g. heart, liver, spleen, diaphragm
• Bleeding
Post-insertion
• Infection
• Subcutaneous emphysema
• Improper placement / Chest tube dislodgement
• Re-expansion pulmonary oedema
Equipment
• Gown, sterile gloves, mask
• Sterile drapes
• Dressing set / ‘Pneumothorax set’
• Gauze
• Antiseptic solution e.g. chlorhexidine
• Curved blunt artery forceps
• Needle holder
• Scissors
• Scalpel blade size 10
• Syringe: 10 mL x2
• Needle: 1 green, 1 blue needle
• Adhesive dressing tape (e.g. Hypafix®)
• Lignocaine 1%
• Suture — Silk O
• Chest tube of appropriate size
Pre-Insertion
• Ensure correct indications
• Ensure correct patient
• Ensure correct site
• Consent
Inserting a chest tube
• Mark the safety triangle
• Positioning
• Clean area of insertion with antiseptic solution
• Drape the area of insertion
• Syringe out 1% lignocaine then infiltrate to the area of interest (using blue needle)
• Use scalpel bladeto make a 2 – 4 cm skin incision near upper border of the rib below (at 5th intercostal space), and just anterior to mid-axillary line
• Once subcutaneous layer is cut, split muscle layers using curved blunt artery forceps till the level of pleura
• Use curved blunt artery forceps to pass through the parietal pleura
• Insert your index finger to widen the tract, then feel for the lung and check for adhesion
• Remove trocar from the chest tube
• Place blunt artery forceps at the fenestrated end of chest tube
• Use blunt artery forceps to guide chest tube into pleural cavity, to the correct direction
• Release the blunt artery forceps, then advance the chest tube into pleural space
• Ensure all fenestrated areas are inside the pleural cavity
• Connect chest tube to underwater seal system
• Check whether the chest drain is functioning
• Secure chest tube with Silk 0 suture
• Also, suture the skin incision site
• Apply sterile occlusive dressing to the chest tube as shown below:
Video
Chest tube removal / Re-anchoring
Steps
• Teach patient Valsalva manoeuvre (i.e. breath holding on maximal inspiration
• Positioning of patient
• Prepare the equipment
• Clean the area of chest tube insertion site with chlorhexidine
• Drape the area of chest tube insertion site
• Clamp the chest tube e.g. using sponge forceps
• Make a pursed-string suture prior to removal of chest tube
• Instruct your assistant to pull out the chest tube when patient has inspired and is holding his breath
• Close the pursed-string suture simultaneously when your assistant is removing the chest tube, rapidly
Post chest tube removal
• Vital signs
• Examine the lungs: air entry bilaterally
• Repeat chest X ray
Chest tube removal / Re-anchoring set
• Dressing set
• Needle holder
• Stitch scissors
• Silk 0 suture (prepare 2)
• Gauze (prepare 2)
• Chlorhexidine
• 10 cc syringe
• Green needle; Blue needle
• Lignocaine for injection
• Tegaderm + dry gauze
Is the Chest Tube Functioning?
Yes, if:
• Periodic presence of air bubble in the underwater seal
• Fluctuation of fluid level in water-seal chamber / inside the chest tube
Other Knowledge Required
• Anatomy of safety triangle
• Suture technique e.g. Surgical Knot Tying: One-handed, pursed-string suture
Miscellaneous
• Do not insert chest tube into an open wound due to trauma. Instead, chest tube should be inserted at the ipsilateral side, as long as it’s inserted at safety triangle
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