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Return to: Twitter Facebook Linkedin Reddit Get Citation Citation AMA Citation Sassalos P, Brunsvold ME. Sassalos P, Brunsvold M.E. Sassalos, Peter, and Melissa E. Brunsvold.Chapter 44. Tube Thoracostomy. In: Minter RM, Doherty GM. Minter R.M., Doherty G.M. Eds. Rebecca M. Minter, and Gerard M. Doherty.eds. Current Procedures: Surgery New York, NY: McGraw-Hill; 2010. http://accesssurgery.mhmedical.com/content.aspx?bookid=429§ionid=40112058. Accessed June 22, 2017. MLA Citation Sassalos P, Brunsvold ME. Sassalos P, Brunsvold M.E. Sassalos, Peter, and Melissa E. Brunsvold.. "Chapter 44. Tube Thoracostomy." Current Procedures: Surgery Minter RM, Doherty GM. Minter R.M., Doherty G.M. Eds. Rebecca M. Minter, and Gerard M. Doherty. New York, NY: McGraw-Hill, 2010, http://accesssurgery.mhmedical.com/content.aspx?bookid=429§ionid=40112058. Download citation file: RIS (Zotero) EndNote BibTex Medlars ProCite RefWorks Reference Manager © Copyright Tools Search Book Top Return Clip Chapter 44. Tube Thoracostomy Peter Sassalos, MD; Melissa E. Brunsvold, MD + Indications Print Section ++ Pneumothorax.Hemothorax.Chylothorax.Empyema.Pleural effusion (persistent).Thoracic trauma or surgery. + Contraindications Print Section ++ Absolute ++ None. ++ Relative ++ Coagulopathy.Overlying skin infection.Overlying chest wall malignancy.Intrapleural adhesions.Loculated pleural collection. + Informed Consent Print Section ++ Potential Risks ++ Bleeding.Infection. Skin and subcutaneous infection.Empyema.Risk of anesthetic if used.Death.Possible injury and need for repair of surrounding structures. Intercostal neurovascular injury.Great vessel injury.Pulmonary parenchymal injury.Diaphragmatic injury.Cardiac injury.Splenic injury on left side.Hepatic injury on right side.Persistent air leak.Need for emergent thoracotomy or future additional procedures. + Equipment Print Section ++ Sterile gown and gloves, cap, mask, eye protection.Povidone-iodine or chlorhexidine preparation, sterile towels.Local anesthesia.Chest tube (varied sizes, depending on indication and size of patient).Chest tube management system.Scalpel, Kelly clamp, needle driver, scissors, nonabsorbable suture, Xeroform or petroleum gauze, sterile gauze, foam tape. + Patient Preparation Print Section ++ The patient does not need to have an empty stomach although this is preferable if conscious sedation is used in the nonemergent setting.Preoperative antibiotics are not required. + Patient Positioning Print Section ++ The patient should be supine with the ipsilateral arm positioned over the head to facilitate adequate exposure of the anterolateral thoracic wall. + Procedure Print Section ++ Local anesthesia with or without conscious sedation may be used. When local anesthesia is used, infiltration of the skin, subcutaneous tissue, muscle, and parietal pleura provides the best anesthesia.Figure 44–1: A transverse skin incision parallel to the intercostal space is planned, usually at approximately the fourth or fifth intercostal space at the midaxillary or anterior axillary line. The goal of this placement is to avoid the diaphragm, intra-abdominal organs, and breast tissue (in women), and to allow for placement anterior enough that the patient does not lie on the tube after placement.Figure 44–2A—C: The skin incision is made using a scalpel at one intercostal level below the planned entry site of the chest tube into the pleural space. The subcutaneous tissue and intercostal muscles are dissected bluntly in a transverse direction using a hemostat or Kelly clamp until the parietal pleura is reached.Figure 44–3: During dissection of the subcutaneous tissue and muscles, the Kelly clamp should be directed cranially toward the rib above and the tips should be pointed toward the superior aspect of this rib to avoid the course of the intercostal neurovascular bundle inferior to each rib.Figure 44–4: Using a Kelly clamp, the pleural space is entered parallel to the ribs in a controlled fashion with the tips of the instrument closed. Once the pleural space is penetrated, the clamp should be opened to allow egress of air or fluid.A finger should be placed in the pleural space and swept to check for adhesions prior to tube placement.Figure 44–5: Once the pleural space is entered and freed of any adhesions, the chest tube is clamped at its fenestrated end with a Kelly clamp and, using finger guidance, the tube is advanced into the pleural space in the posterosuperior direction of the apex to the desired tip location. The tube is advanced to various lengths depending on the patient; however, all fenestrations should be intrapleural to create a closed system.Figure 44–6: Once the chest tube is in place, it is connected and secured to a chest tube management system and placed on suction, typically at 20 cm H20 negative pressure. The chest tube is secured in place by a nonabsorbable U-stitch through the skin with ends wrapped and tied around the tube.Xeroform or petroleum gauze is placed around the tube opening and gauze and foam tape are applied. ++Figure 44–1Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++Figure 44–2A–CGraphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++Figure 44–3Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++Figure 44–4Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++Figure 44–5Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++Figure 44–6Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + Postoperative Care Print Section ++ A chest radiograph should be obtained at the conclusion of the procedure to assess placement.The patient's hemodynamic status should be monitored for signs of cardiopulmonary distress.The chest tube output should be recorded; if there is considerable blood loss a thoracotomy should be considered.Each time the patient is evaluated, assessment of the nature of the output and presence of an air leak should be noted.Typically, when the patient has clinically improved, the output is decreased (values vary based on surgeon preference), and an air leak has resolved the chest tube is transitioned from suction to water seal in anticipation of removal.To remove a chest tube, great care must be taken to prevent introduction of air into the pleural space. An assistant should hold pressure with petroleum gauze and dry gauze over the tract as the tube is rapidly removed at the end of an inspiration.The previously placed U-stitch may be tied to close the skin opening (see Figure 44–6); however, this is optional.A chest radiograph should be obtained to assess for interval development of a pneumothorax. + Potential Complications Print Section ++ Bleeding: intercostal neurovascular or great vessel injury. May present with hemorrhage.Treatment includes resuscitation, hemostatic control through possible thoracotomy, and consultation with a cardiovascular surgeon.Solid organ injury: pulmonary parenchymal injury, diaphragmatic injury, cardiac injury, splenic injury on the left side, or hepatic injury on the right side. May present with bleeding or dysfunction of the involved organ.Treatment is directed at the affected organ system.Persistent air leak. May manifest if a bronchopleural fistula is present or pulmonary parenchymal injury has occurred.Treatment would require surgical management by a thoracic surgeon. + Pearls and Tips Print Section ++ Infiltration of the parietal pleura prior to the procedure provides the best anesthesia.Although the fourth or fifth intercostal space is typically used for tube thoracostomy, any variety of intercostal locations can be used if pathologic findings preclude standard placement.To avoid loss of the pleural opening, spread the Kelly clamp widely after entering the pleural space and do not remove the clamp before a finger is placed into the pleural space.Sweep a finger in the pleural space before placing the chest tube to avoid parenchymal injury.Use nonabsorbable suture to secure the chest tube; the area is often moist from chest tube output and bleeding and an absorbable suture might dissolve. + References Print Section ++Rozycki GS, McNeil J, Thal ER. Diagnostic Procedures Used to Establish Priorities. In: Thal ER, Weigelt JA, Carrico J, eds. Operative Trauma Management: An Atlas. New York, NY: McGraw-Hill; 2002:20–34.