Chapter 27

### I. INDICATIONS

1. Evacuation of pneumothorax compromising ventilation and causing increased work of breathing, hypoxia, and increased Paco2.

2. Relieve tension pneumothorax causing respiratory compromise and decreased venous return to the heart, resulting in decreased cardiac output and hypotension. This is an emergency that should be handled by immediate needle aspiration before chest tube placement. (See Chapter 70.)

3. Drainage of significant pleural fluid (pleural effusion, empyema, chylothorax, hemothorax, extravasation from a central venous line). Studies have shown that placement of a drainage catheter rather than aspiration alone is more effective and just as safe.

4. Postsurgical drainage after repair of a tracheoesophageal fistula, bronchopleural fistula, esophageal atresia, or other thoracic procedure.

### II. EQUIPMENT

Prepackaged chest tube tray (sterile towels, 4 × 4 gauze pads, 3–0 silk suture, curved hemostats, a no. 11 or 15 scalpel, scissors, a needle holder, antiseptic solution, antibiotic ointment, 1% lidocaine, 3-mL syringe, 25-gauge needle); sterile gloves, mask, eye protection, hat, gown, suction-drainage system (eg, the Pleur-Evac system). A high-intensity fiber optic light for transillumination is helpful (see Chapter 40). Chest tube types and sizes are as follows:

1. Standard (traditional) chest tube insertion. Requires a skin incision with blunt chest wall dissection and sutures. Use polyvinyl chloride (PVC) chest tubes 8, 10, or 12F. Recommended size for weight: 8 or 10F <2000 g, 12F >2000 g.

2. Percutaneous chest tube with pigtail catheter. Does not require a skin incision. The pigtail catheter is inserted through a needle. This is an easier and less invasive technique requiring less anesthesia. Disadvantages are that the catheter may kink and become obstructed since they are softer. It may not drain a pneumothorax with an ongoing air leak. Pigtail catheter sizes range from 5F to 12F with 8 and 10F most commonly used.

### III. PROCEDURE

1. The site of skin insertion for the elective chest tube insertion is the same for both air and fluid, but the direction of the tube is determined by examining the anteroposterior and cross-table lateral or lateral decubitus chest films for air or fluid. Air collects in the uppermost areas of the chest, and fluid in the most dependent areas. For air collections, place the tube anteriorly. For fluid collections, place the tube posteriorly and laterally.

2. Transillumination of the chest may help detect pneumothorax but not a small pneumothorax (see Chapter 40). With the room lights turned down, a strong light source is placed on the anterior chest wall above the nipple and in the axilla. The affected side usually appears hyperlucent (“lights up”) and radiates across the chest as compared with the unaffected side. Unless the infant's status is rapidly deteriorating, a chest radiograph should be obtained to confirm pneumothorax before the chest tube is inserted. A lateral decubitus or cross-table lateral x-ray film should be done. If air is suspected, the infant should be lying on his or her side with the suspect side ...

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