Chapter 21. Chest Tube Insertion

• • Prolonged drainage of air or fluid (eg, empyema, hemothorax) from the pleural space.

  • Definitive treatment of a tension pneumothorax (after needle decompression).

Relative

• • Bleeding diathesis.

  • Mechanical ventilation.

  • Presence of adhesions: may require pleurodesis.

• • Sterile gloves, mask, and gown.

  • Iodinated skin preparation with sterile sponges.

  • Sterile towels.

  • Local anesthetic (1% lidocaine without epinephrine).

  • 5-mL syringe with 25-gauge needle.

  • 18-gauge 2-inch needle.

  • #10 scalpel with handle.

  • Chest tube and Kelly clamp for large bore insertion.

  • Pleurevac or other drainage system, including all connectors necessary to connect to chest tube and to suction.

  • Suction.

  • Needle holder.

  • Suture scissors.

  • 2-0 silk suture.

  • 4 × 4 gauze.

  • Transparent occlusive dressing.

• • Bleeding.

  • Infection.

  • Pain.

  • Pneumothorax.

  • Puncture of organ (ie, lung, liver, spleen).

• • Patient should have intravenous access.

  • Oxygen should be available.

  • Monitor oxygen saturation with pulse oximetry.

  • Younger patients may need sedation or anesthesia for procedure, especially with large bore chest tube insertion.

  • Explain procedure in a developmentally appropriate manner before and during procedure.

• • Patient lying on bed with head of table elevated 30 degrees with arm above head.

• • Neurovascular bundle is under the rib (Figure 21–1).

Prepare Sterile Field

• • Cleanse area in sterile fashion.

  • Drape surrounding area with sterile towels.

Numb the Area

• • Use 25-gauge needle and 5-mL syringe to infiltrate skin and make wheal under skin.

  • Change needle to 18 gauge with 2-inch needle.

  • Infiltrate through wheal, over top of rib, to anesthetize the periosteum, and into pleural space.

  • • Be sure to aspirate first, and know when you are in the pleural space.

    • The pleura needs to be anesthetized, but, to avoid a puncture of the lung, do not advance the needle further.

Insertion of Chest Tube by Seldinger Technique

• • Remove syringe from needle (Figure 21–2A).

• • Pass guidewire through needle into pleural space (Figure 21–2B).

• • Remove needle (while always maintaining a hold on the guidewire).

  • Make small incision at site of insertion (large enough to pass chest tube) (Figure 21–2C).

  • Starting with smallest dilator, insert dilator over guidewire using a twisting motion (while always maintaining a hold on the guidewire) (Figure 21–2D).

  • Repeat with larger dilators over guidewire until track is large enough to easily ...