Chapter 26

1. Indications

1. 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 tube placement. (See Chapter 63.)

1. Pneumothorax compromising ventilation and causing increased work of breathing, hypoxia, and increased PaCO2.

1. Drainage of significant pleural fluid (pleural effusion, empyema, chylothorax, hemothorax).

1. Postsurgical drainage after repair of a tracheoesophageal fistula or esophageal atresia.

2. 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, and a 25-gauge needle); chest tube 10F for infants <2000 g, 12F for infants >2000 g. Sterile gloves, a mask, eye protection, hat, and gown, and a suction-drainage system (eg, the Pleur-Evac system) are also needed.

3. Procedure

1. The site of chest tube insertion is determined by examining the anteroposterior and cross-table lateral or lateral decubitus chest films. 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. Transillumination of the chest may help detect pneumothorax. With the lights in the room 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 and "lights up" compared with the unaffected side. Transillumination may not reveal a small pneumothorax. Unless the infant's status is rapidly deteriorating, a chest radiograph should be obtained to confirm pneumothorax before the chest tube is inserted. See Figure 10–19 for a radiograph showing a left tension pneumothorax.

1. Position the patient so the site of insertion is accessible. The most common position is supine, with the arm at a 90-degree angle on the affected side.

1. Select the appropriate site (Figure 26–1). For anterior placement, the site should be the second or third intercostal space at the midclavicular line. For posterior placement, use the fourth, fifth, or sixth intercostal space at the anterior axillary line. The nipple is a landmark for the fourth intercostal space.

1. Put on a sterile gown, mask, hat, and gloves. Cleanse the area of insertion with povidone-iodine solution, and drape.

1. Infiltrate the area superficially with 0.5–1% lidocaine (see dose in Chapter 69) and then down to the rib. Infiltrate into the intercostal muscles and along the parietal pleura. Make a small incision (approximately the width of the tube, usually ≤0.75 cm) in the skin over the rib just below the intercostal space where the tube is to be inserted (Figure 26–2A).

1. Insert a closed curved hemostat into the incision, and spread the tissues down to the rib. Using the tip of the hemostat, puncture the pleura just above the rib and spread gently. The intercostal vein, artery, and nerve lie below the ribs (see Figure 26–2A). This creates a subcutaneous tunnel that ...

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