The essential steps to inserting a pleural drainage tube are summarized in Table 9-2. The technique can also be viewed online.8 Good insertion technique and appropriate post-insertion care are associated with less morbidity and shorter hospital stays.9 The most common site of insertion is the “safe triangle,” which as the name implies, is the safest entry into the chest.10,11 The boundaries of this triangle are identified by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, and a line superior to the horizontal level of the nipple and an apex below the axilla (Fig. 9-1). In this space, the likelihood of damaging vital structures during insertion is considerably low.12 As the diaphragm can rise to the fifth rib at nipple level during expiration, chest tubes should be placed above this level to avoid inadvertent damage to abdominal structures.
Table 9-2Essential Steps for Inserting A Pleural Chest Tube ||Download (.pdf) Table 9-2Essential Steps for Inserting A Pleural Chest Tube
|1. Infiltrate overlying area with local anesthesia |
|2. Make a 3–4 cm incision through the skin and subcutaneous tissues between the fourth and fifth ribs, parallel to the rib margins |
|3. Bluntly dissect through the intercostal muscles down to the pleura |
|4. Insert Kelly clamp through the pleura and spread jaws parallel to the direction of the ribs |
|5. Introduce forefinger into the thoracic cavity |
|6. Insert chest tube and secure with nonabsorbable suture |
The “Safe Triangle” for pleural chest tube insertion.
An incision 1.5 to 2 cm in length is made parallel to the rib. A Kelly clamp or an artery forceps is used bluntly to dissect through the subcutaneous layers and intercostal muscles. The path of dissection should aim toward the upper superior intercostal space. A dissection plane is created through the subcutaneous tissue layers and the intercostal muscles on the superior surface of the rib. Adhering to the superior surface will avoid inadvertent injury to the neurovascular bundle located at the inferior surface. The blunt bevel of the dissecting instrument is used to gently puncture through the parietal pleura. Digital penetration (usually with the index finger) is followed to avoid puncturing any adjacent lung tissue. Once entry into the pleura is confirmed, the Kelly clamp is withdrawn and the tube is inserted along the established tract. When thoracostomy is needed to drain an apical pneumothorax, an anticlockwise wrist maneuver will permit the tube to slide away from the fissure and lie in the desired position in the apex of the lung. Mattress or interrupted sutures are used on both sides of the incision to close the ends (Fig. 9-2). The loose ends of the sutures are wrapped around the tube and tied to anchor the tube to the chest wall. The tube is then taped to the side of the patient and wrapped by a petroleum-based gauze dressing. Several pieces of regular sterile gauze and multiple pressure dressings are used to secure the chest tube in place. A chest x-ray is obtained to confirm placement.13
Securing the chest drain. The chest tube is secured by placing a stitch around the incision, using heavy suture (0/or 1/), as shown in (A). Mattress or interrupted sutures are used to secure the stitch and both ends of the incision (B). The loose ends of the sutures are wrapped around the tube and tied to anchor it to the chest wall (C).
The tube is then connected to a water seal drainage container. This allows the air and fluid to be evacuated and avoids inadvertent suction into the chest cavity. The water seal container connected to the chest tube also permits one-way movement of air and liquid from the pleural cavity. Traditionally, the underwater seal drainage apparatus comprises a series of up to three reusable glass bottles connected to one another and attached to the chest tube (Fig. 9-3). The water seal drainage container normally is filled with approximately 250 to 350 mL of sterile water to a marked level. The first bottle provides the collection chamber. The second, the water seal valve. It has an afferent tube that is kept below water level. Fluid and air can egress from the tube. The vacuum produced by inhalation draws fluid into the tubing but does not allow air to be re-introduced into the pleural cavity. The intrapleural vacuum can be countered by the application of suction to the third bottle, the suction control. In addition to the afferent and efferent tubes, the suction control bottle has a third tube open to air. The depth at which the tube penetrates below the fluid level determines the degree of suction; hence the familiar measure of surgical suction in centimeters. Currently, commercially available clear plastic disposable containers are used instead. These consist of either a single chamber with an underwater seal (Fig. 9-4) or a three-chamber container with a collection chamber, suction chamber, and water seal chamber in the middle (Fig. 9-5).
A typical water seal drainage system is comprised of up to three reusable glass bottles. In (A), a single bottle is used both for collection of the drainage and water seal without suction. In (B), a second bottle has been added for suction. In (C) three bottles are used, one each for collection, water seal, and suction, respectively.
A single-chamber chest tube drainage container with markings for a basic underwater seal.
A three-chamber chest tube drainage container system.