Thoracostomy Tube Placement and Drainage

Chapter 32 Thoracostomy Tube Placement and Drainage



Nadja E. Sigrist, Dr.Med.Vet., FVH, DACVECC



KEY POINTS



• Chest tubes are used to remove air or fluid from the pleural space.

• The diameter of a chest tube should be similar to the size of the mainstem bronchus. Smaller diameter tubes can be used for a simple pneumothorax; larger diameters are used to drain viscous fluid such as purulent exudate.

• Chest tubes are best inserted in an anesthetized and intubated animal. Sedation and local anesthesia may be sufficient in some cases.

• Several tubes and placement techniques exist.

• Thoracic radiographs are recommended following tube placement.

• Suction can occur on a continuous or intermittent basis.

• Patients with chest tubes need 24-hour monitoring.

• Strict aseptic placement and management are required.


INTRODUCTION


Therapeutic drainage of the pleural space dates back more than 200 years, and the technique of chest tube placement for various indications has been adapted and perfected since then.1 Thoracostomy tubes, also known as chest tubes or thoracic drains, are used to evacuate air or fluid or both from the pleural space. The reader is also referred to Chapter 31 for a discussion of thoracentesis. In many cases, tube thoracostomy can be lifesaving. The technique, however, requires familiarity with pulmonary and pleural anatomy and physiology. Indications, insertion technique, maintenance, and complications are discussed in this chapter.



INDICATIONS


The purpose of a chest tube is the removal of air or fluid from the pleural space in order to relieve pulmonary collapse and restore pleural subatmospheric pressure. Pneumothorax and pleural effusion are usually managed initially with thoracentesis, which can be repeated several times (see Chapter 31, Thoracentesis). Placement of a thoracostomy tube should be considered if repeated thoracentesis is required for ongoing air leakage or fluid production, if thoracentesis is insufficient for the severity of the disease (e.g., tension pneumothorax), if ongoing fluid production is expected (e.g., chylothorax), if suction as well as lavage is planned (e.g., pyothorax), or following thoracic surgery (Box 32-1).2-6



Box 32-1 Indications for Chest Tube Placement



• Tension pneumothorax

• Ongoing air leakage despite repeated thoracentesis

• Pyothorax

• Chylothorax

• Penetrating chest injury

• After thoracic surgery

• Performance of pleurodesis

In the unstable patient with ongoing pneumothorax or pleural effusion, there are no absolute contraindications to thoracostomy tube placement. Relative contraindications in stable patients are coagulopathies or pleural adhesions.2



THORACOSTOMY TUBE PLACEMENT



Material


There are numerous commercially available thoracostomy tubes. They come in various sizes and materials. Each has its advantages and disadvantages regarding material, price, and tissue compatibility.7


Thoracostomy tubes are commercially available as single tubes and complete thoracostomy kits. Other tubes can be modified to perform as thoracostomy tubes; however, several criteria must be fulfilled. The tube must be sterile, elicit minimal tissue reaction in situ, have multiple fenestrations at the distal end, and be able to withstand the generation of negative pressure during suctioning without collapsing.8-10 A radiopaque line along the tube helps localize its position on radiographs. Most commercially available chest tubes come with a stylet to aid insertion into the pleural space and may have an open or closed end.


Adapters such as Christmas tree connectors, tubing with a Luer-Lok, a noncollapsing extension set, and a three-way stopcock are used to connect the tube to the suction device. It is advisable to have a tube thoracostomy set available in the ready area of the hospital (Box 32-2).2



Box 32-2 Tube Thoracostomy Emergency Set



• Instrument set with hemostat, straight Kelly or Carmalt clamp, forceps, needle holder, scalpel holder, suture scissors

• No. 10 and 15 scalpel blades

• Two 30-cm extension sets

• Two three-way stopcocks

• Christmas tree adapters, two of each size

• 20- and 50-cc syringes, one of each

• Thoracostomy tube of appropriate size

• Sterile gauze

• Antibiotic ointment

• 3-0 and 1-0 monofilament suture

A key to chest tube size selection is the flow rate of either air or liquid that can be accommodated by the tube.7 This depends on the diameter and length of the tube and viscosity and rate of formation of the fluid. In humans, chest tube size is selected based on the type of lung disease and whether mechanical ventilation is required. Pleural drainage catheter flow capabilities vary significantly.7


Generally chest tube size is chosen with consideration of the nature of the pleural disease and the width of the patient’s intercostal space. An unnecessarily large chest tube is likely to be associated with increased pain and discomfort. Aspiration of pleural effusion, especially pyothorax, generally is aided by a larger tube diameter in order to remove clots, cell debris, and fibrin, but thoracostomy tubes for drainage of a pneumothorax do not need to be of maximal diameter.



Anesthesia


Patients requiring chest tube placement should be supplemented with oxygen and be preoxygenated for anesthesia induction.2 Analgesia is maintained by infiltration of a local anesthetic at the site of insertion, a regional nerve block, or by general anesthesia including analgesics.10 Animals can be sedated, however the author prefers general anesthesia with the animal intubated in order to control ventilation and oxygenation. A rapid induction protocol is recommended10 (see Chapters 162 and 163, Sedation of the Critically Ill Patient and Anesthesia of the Critically Ill Patient, respectively). If possible, thoracentesis under local anesthesia is performed before chest tube placement to make the animal a better anesthesia candidate.


Before sedation or anesthesia is administered, all materials should be ready and the chest wall should be clipped if the animal will tolerate it with minimal stress. Maintaining sternal recumbency during the procedure may be necessary to avoid respiratory compromise.



Techniques


Thoracostomy tube placement can be classified as either closed or open.11 The key point in placement is the generation of a subcutaneous tunnel between the skin incision and the point of entry into the pleural space to create an airtight seal around the tube.8


Strict aseptic rules are required with all techniques.1 The lateral thorax is clipped from behind the scapula to the last rib and surgically prepared. The animal ideally is placed in lateral recumbency, pending sufficient ventilation and oxygenation in this position. Once the area is prepared and appropriate anesthesia or analgesia has been provided, the area is draped. The material including tube, adapter, and suction device and a small surgery pack should already be prepared.


Several techniques for closed placement of a chest tube exist.2,8,9,11,12 The author prefers the following (Color Plate 32-1).8,12 The skin over the lateral chest is pulled cranially by an assistant. While the skin is held in this position the appropriate intercostal space is identified, usually the seventh, eighth, or ninth. The length of tube to insert into the thorax is estimated at this time by holding the chest tube along side the chest with the tip aligned to the second rib, without compromising sterility. A small skin incision, slightly larger than the diameter of the tube, is made overlying the desired intercostal space midway between the dorsal midline and the center of the lateral thorax. The subcutaneous tissue and muscle layers are bluntly dissected with a hemostat. The pleura is then penetrated bluntly using a large hemostat or Carmalt forceps (see Color Plate 32-1, A). During this maneuver, the anesthetist is asked to stop ventilation in order to minimize injury to the lung.13 Also, injury to the underlying organs is minimized by holding the hemostat close to the tip with the nondominant hand to avoid overpenetration.


Once the pleura is penetrated, the tips of the hemostat are opened, thereby creating an opening for the thoracostomy tube (see Color Plate 32-1, B). Before insertion, the trochar can be retracted slightly so that the sharp tip is protected by the tube. The tip of the tube is introduced into the thorax and is then advanced toward the uppermost elbow. Once the tip of the tube is well inside the thorax, the hemostat can be removed. The thoracostomy tube should be inserted so that the tip is roughly at the level of the second rib. It is essential that all tube fenestrations are within the thoracic cavity.2 The stylet is then withdrawn and the hemostat or a tube clamp can be used to clamp the tube off.


Alternatively, the tube is connected directly to the suction device. As the skin is released and retracts caudally over the tube, a subcutaneous tunnel is created. The Mac technique can be used to rule out kinking of the tube: the tube is twisted 180 degrees in each direction and then released. If the tube spins back into its position, this is indicative of kinking.14 Depending on the urgency for pleural evacuation, suction is instituted prior to or after securing the tube. A purse-string suture is placed around the skin incision if the fit is not firm. The tube is then fixed using a finger-trap suture pattern.15 A single interrupted suture is placed through the skin at the site of insertion. This suture may pass through the periosteum of the rib (this requires additional local anesthetic) and is tied in a gentle loop, leaving equal and long suture tags. The sutures tags are used to perform the finger trap by placing a single knot on top of the tube, then crossing underneath the tube followed by another single knot on top of the tube and so on. After four to six finger traps, the tube is once more anchored to the skin, therefore minimizing the chance of dislocation (see Color Plate 32-1, C). The tube is then connected to the suction system of choice.


Antibiotic ointment is applied to the insertion site and the area is covered with sterile gauze. A bandage is applied to secure the thoracostomy tube to the chest wall and minimize risk of accidental removal.8


If no assistant is available to pull the skin forward, the subcutaneous tunnel can be made with a large hemostat or Carmalt forceps. The skin incision is made more caudally (eighth to tenth intercostal space), and the hemostat is tunneled cranially through the subcutaneous tissues’ two intercostal spaces, to the desired insertion point at the level of the sixth to eighth intercostal space. At this point, the pleural space is entered and the tube is inserted as described earlier.2,11


A thoracostomy tube with a sharp-ended stylet can be placed without the aid of a hemostat11; however, the technique of perforating the pleura by punching the distal end of the stylet is not recommended because of increased risk of injury to intrathoracic organs. A combination of blunt dissection through the intercostal space with hemostats and penetration of the pleura with the stylet is preferable.


An alternative for thoracostomy tube placement is the Seldinger technique.2 The tube is inserted into the thorax with the use of a guidewire that has been inserted through a small needle. After removal of the needle, the guidewire stays in place and the modified tube is advanced over the wire. Once the tube is placed, the guidewire is removed and the tube is secured as described above. Care is taken not to compromise the lumen of the catheter with the finger-trap suture. The Seldinger technique has the advantage of a smaller incision and might therefore be less painful and leakage less likely.


Open insertion of a thoracostomy tube is performed during thoracotomy, with the advantage that the tube is placed safely under direct visualization. Under certain circumstances, such as when an animal has an open penetrating chest injury, a thoracostomy tube can be inserted directly into the thoracic cavity through the wound. The wound is then sealed with nonadhesive dressing and the thorax is evacuated immediately. Proper wound debridement and lavage and placement of a new and sterile thoracostomy tube are required as soon as the patient is stable enough for anesthesia.

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Sep 10, 2016 | Posted by in SMALL ANIMAL | Comments Off on Thoracostomy Tube Placement and Drainage

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