27: Chest Tube Placement

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.

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.

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 up; if fluid is suspected, the infant should be placed with the suspect side down. See Figure 11–20 for a radiograph showing a left tension pneumothorax.

   1. False-positive transillumination. Subcutaneous air, severe pulmonary interstitial emphysema, lobar emphysema, pneumomediastinum, large air bubble in the stomach, and too dim of a light source.

   2. False-negative transillumination. Weak light source, bright room lights, small pneumothorax, thick chest wall with edema, thick skin folds on a large baby, and dark pigmented skin.

3. 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. Some say position the infant with a rolled up towel to 60-75 degrees off bed to evacuate air, and 15-30 degrees for fluid, chyle, blood, or pus.

4. Select the appropriate site

   1. Emergency needle aspiration (tension pneumothorax). Needle aspiration is done at the second intercostal space at the midclavicular line on the suspected side of the pneumothorax. The needle is inserted above the third rib. See Chapter 70 and Figure 70–1. The fourth intercostal space at the anterior axillary line can also be used (needle would be inserted above the fifth rib).

   2. For air or fluid. Placement is the same except the tube is directed differently. The chest tube should be at the fourth or fifth intercostal space between the anterior axillary line and midaxillary line (modified Buelau position). This site is safe for both thoracic sides, for both preterm and term infants, as only lung parenchyma and no organ structures are found. See Figure 27–1.

      1. Air. Skin incision is at fifth or sixth rib. If skin incision is at the fifth rib, the pleura is punctured above the fifth rib in the fourth intercostal space. If the skin incision is at the sixth rib, the pleura is punctured above the sixth rib in the fifth intercostal space. Insert the tube anteriorly and toward the apex.

      2. Fluid. Skin incision at the fifth or sixth intercostal space. If skin incision is at the fifth rib, the pleura is punctured above the fifth rib in the fourth intercostal space. If the skin incision is at the sixth rib, the pleura is punctured above the sixth rib in the fifth intercostal space. Insert the tube posteriorly and inferiorly.

   3. The nipple is a landmark for the fourth intercostal space. Do not place the tube in the nipple area of a female, as this can cause future asymmetrical breast tissue development.

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

6. Prophylactic antibiotics. Cochrane review states there is no evidence to recommend or refute the use of prophylactic antibiotics in infants when a chest tube is placed.

7. Pain management. There are no prospective studies on pain management for chest tube insertion.

   1. The American Academy of Pediatrics (AAP) recommends slow infiltration of the area with a local anesthetic before incision (unless life-threatening instability) and the use of systemic analgesia with a rapidly acting opiate (fentanyl). If there is not enough time to infiltrate before the chest tube is inserted, infiltration should be done after the chest tube is in (may decrease later pain responses).

   2. Local anesthetic. Slowly infiltrate the area superficially with 0.5–1% lidocaine and then down to the rib. Infiltrate into the intercostal muscles and along the parietal pleura.

   3. Systemic analgesia with a rapidly acting opiate (fentanyl).

   4. General nonpharmacologic measures should also be used.

8. Standard (traditional) chest tube insertion

   1. Make a small incision (approximately the width of the tube, usually ≤0.5–75 cm) in the skin over the rib just below the intercostal space where the tube is to be inserted (see Figure 27–1).

   2. 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 (avoids the subcostal blood vessels, minimizes vascular injury) and spread gently. The intercostal vein, artery, and nerve lie below the ribs (Figure 27–2A). This creates a subcutaneous tunnel that aids in closing the tract when the tube is removed. This tunnel can be carried superiorly over the next rib, anteriorly (for air) or posteriorly (for effusion) parallel to the ribs, or obliquely.

   3. When the pleura has been penetrated, a rush of air is often heard or fluid appears. Insert the chest tube through the opened hemostat (Figure 27–2B). Be certain that the side holes of the tube are within the pleural cavity. The presence of moisture in the tube usually confirms proper placement in the intrapleural cavity in a pneumothorax. Use of a trocar guide is usually unnecessary and may increase the risk of complications such as lung perforation. The chest tube should be inserted 2–3 cm for a small, preterm infant and 3–4 cm for a term infant. (These are guidelines only; the length of tube to be inserted varies based on the size of the infant.) An alternative approach to tube insertion is to measure the length from the insertion site to the apex of the lung (approximately the midclavicle) and tie a silk suture around the tube the same distance from the tip. Position the tube until the silk suture is just outside the skin.

   4. Hold the tube steady first and then allow an assistant to connect the tube to a water seal vacuum drainage system (eg, Pleur-Evac system). Five to ten centimeters of suction is usually used. Start at the lower level of suction and increase as needed if the pneumothorax or effusion does not resolve. Some recommend starting at 10 cm increasing 20 cm, if necessary. Excessive suction can draw tissue into the side holes of the tube. Systems such as the Pleur-Evac provide both continuous suction and water seal. A water seal prevents air from being drawn back into the pleural space.

   5. Secure the chest tube with 3–0 silk sutures and silk tape (Figure 27–2C). Close the skin opening with sutures, if necessary. Use a purse-string suture around the tube or a single interrupted suture on either side of the tube.

   6. Obtain an immediate chest radiograph (AP and lateral) to verify placement and check for residual fluid or pneumothorax. Look for tachypnea, dyspnea, increasing oxygen requirement, hypotension, or worsening arterial blood gas. Positioning of the tube must always be verified by a chest radiograph. Place a sterile clear occlusive dressing at the site. Figure 27–3 shows a standard chest tube in position.

9. Modified Seldinger technique using a pigtail (Fuhrman) catheter. Advantages include speed, safety (fewer complications), improved discomfort, and easily learned. This is the preferred chest tube placement in tiny preemies. The catheter is a coiled, single-lumen polyurethane catheter (5–12F) with 8 or 10F being commonly used.

   1. Follow the site and anesthetic selections as noted above.

   2. Insert an 18-gauge needle with the syringe attached (or an 18-gauge IV catheter) into the skin over the top of the rib at the designated site into the pleural space. Pull back on the syringe while inserting the needle. Do not advance more than 2 cm in depth. Verify placement by aspirating for fluid or air. When air or fluid is obtained, stop insertion.

   3. Secure the needle and remove the syringe, keep lumen occluded. If an 18-gauge IV catheter is used, the IV catheter will act as the introducing needle.

   4. Straighten the J tip of the guide wire and insert into the hub of the needle or the IV catheter. Advance the guide wire into the needle about 2 to 3 cm past the tip of the needle or until the coloured line on the wire is at the level of the hub.

   5. Withdraw the needle or IV catheter while holding the guide wire.

   6. Thread the dilator down over the guide wire. Twist the dilator to dilate the skin, muscles, and pleura. The site has to be well dilated so the catheter will fit. Once dilated, remove the dilator while securing the guide wire.

   7. Straighten the pigtail catheter and insert over the guide wire. Advance until all holes are inside the skin and pleural cavity and then 1 to 2 cm further.

   8. Slowly remove the guide wire while holding the tube in place. The pigtail catheter will curl up inside the pleural cavity. Immediately connect the tube to the underwater sealed drainage (see Section III.H.4).

   9. For a pigtail catheter, one does not have to usually suture, since the skin often closes around the catheter. Place a sterile clear occlusive dressing at the site.

   10. Obtain an immediate chest radiograph (AP and lateral). To verify placement and check for residual fluid or pneumothorax (see Section III.H.6). Figure 27–3 shows a pigtail catheter in position.

1. Pain management. Removing a chest tube is known to be painful. AAP recommends general nonpharmacologic measures and a short-acting rapid-onset systemic analgesic. Methohexital has been used with good pain control and without major respiratory compromise. Some recommend EMLA (eutectic mixture of lidocaine and prilocaine) at the site of insertion and a slow IV opiate bolus.

2. For pneumothorax. If there is no more bubbling in the underwater seal or presence of air for 24 to 48 hours, discontinue the suction and leave the underwater seal for 4 to 12 hours (some units will leave it for 24 hours). Transilluminate, or preferably check an x-ray. If there is no air on x-ray or transillumination, it is okay to remove the chest tube. Never clamp a chest tube (tension pneumothorax risk).

3. Clean the skin area around the chest tube with an antiseptic solution. Remove any tape or sutures but leave the wound suture. Cover entry site with gauze and your fingertips to prevent air from entering chest as the tube is withdrawn, then cover with petroleum gauze. Keep pressure on it. Cover with gauze and remove sutures when healed.

4. Clinical signs and symptoms of respiratory distress will identify almost all patients with significant pneumothoraces following chest tube removal. Monitor for tachypnea, dyspnea, increasing oxygen requirement, hypotension, or worsening arterial blood gas. Transillumination and chest x-ray may be necessary.

1. Infection. Strict sterile technique minimizes infections. Cellulitis is common. Intrapleural inoculation of Candida has been reported after chest tube placement. Many institutions recommend prophylactic antibiotics (eg, Nafcillin) when a chest tube is placed (controversial). Empyema requires antibiotics and drainage.

2. Bleeding. May occur if one of the major vessels (intercostal, axillary, pulmonary, or internal mammary) or the myocardium is perforated, or if the lung is damaged during the procedure. It can cause a hematoma or hemothorax. This complication can be avoided if landmarks are properly identified. Bleeding is less likely if a trocar is not used. Bleeding may stop during suctioning; however, if significant bleeding continues, immediate surgical consultation is necessary. Tears of subclavian vessels and thymic trauma can occur with hemorrhage. Bleeding can be more significant with a coagulopathy.

3. Nerve damage. Passing the tube over the top of the rib helps avoid injury to the intercostal nerve running under the rib. Horner syndrome, diaphragmatic paralysis, or eventration from phrenic nerve injury has been reported. The medial end of the chest tube should be no less than 1 cm from the spine on frontal chest radiograph (phrenic nerve paralysis is related to the abnormal location of the medial end of the chest tube). The main nerve tract lies outside the pericardium in the middle mediastinum. The tip should not be against the mediastinum.

4. Trauma. The premature lung is at greater risk of trauma because the chest wall is thin and the lung tissue is fragile. Lung trauma (perforation or laceration) can be minimized by never forcing the tube into position. Trauma can also occur to the breast tissue. Iatrogenic tracheobronchial perforation (tube through esophagus, carina, right main bronchus) and tracheoesophageal fistula have been reported. Liver trauma with hemoperitoneum can occur. Damage to the heart, great vessels, diaphragm, thymus, and liver and spleen can all occur but are rare.

5. Subcutaneous emphysema. Secondary to a leak through the pleural opening.

6. Chylothorax. Results if the catheter causes trauma to the thoracic duct. It is best to avoid penetration into the posterior superior mediastinum.

7. Cardiac tamponade. See Chapter 38.

8. Fluid and electrolyte imbalance/hypoproteinemia.

9. Rare complications. Myocardial perforation, severing the phrenic nerve, subclavian vessel tear with blood loss, thymic trauma with blood loss, trauma to the liver with hemoperitoneum, traumatic arteriovenous fistula, aortic obstruction, compression of the aorta, and displacement of the trachea can all occur.