Chest tube thoracostomy
Introduction
Chest tube thoracostomy, commonly referred to as chest tube insertion, is a medical procedure involving the placement of a tube into the pleural cavity to evacuate air, fluid, or pus. This procedure is critical in the management of various thoracic conditions, including pneumothorax, hemothorax, pleural effusion, and empyema. It is a fundamental skill for healthcare providers, particularly in emergency medicine, surgery, and critical care settings.
Indications
Chest tube thoracostomy is indicated in several clinical scenarios:
- **Pneumothorax**: This condition involves the presence of air in the pleural space, which can compromise respiratory function. It can be spontaneous, traumatic, or iatrogenic. Large or symptomatic pneumothoraces often require chest tube placement to re-expand the lung.
- **Hemothorax**: Accumulation of blood in the pleural cavity, often due to trauma, necessitates drainage to prevent respiratory compromise and facilitate lung re-expansion.
- **Pleural Effusion**: Excess fluid in the pleural space, which can be due to various causes such as congestive heart failure, malignancy, or infection, may require drainage if it is large or causing symptoms.
- **Empyema**: This is an infection in the pleural space leading to pus accumulation, requiring drainage to resolve the infection and prevent fibrosis.
- **Chylothorax**: The presence of lymphatic fluid in the pleural space, often due to trauma or malignancy, may require chest tube placement for management.
Contraindications
While chest tube thoracostomy is a generally safe procedure, certain contraindications must be considered:
- **Coagulopathy**: Patients with bleeding disorders or on anticoagulation therapy may be at increased risk of bleeding complications.
- **Localized infection at the insertion site**: This can increase the risk of introducing infection into the pleural space.
- **Small, asymptomatic pneumothorax**: In some cases, observation may be preferred over intervention.
Procedure
The procedure of chest tube thoracostomy involves several critical steps:
Preparation
Preparation includes obtaining informed consent, ensuring appropriate monitoring, and positioning the patient, usually in a semi-upright position with the arm on the affected side raised above the head to expose the lateral chest wall.
Equipment
Essential equipment includes a chest tube of appropriate size, a sterile thoracostomy tray, antiseptic solution, local anesthetic, and a drainage system.
Technique
1. **Anesthesia**: Local anesthesia is administered to minimize discomfort.
2. **Incision and Dissection**: A small incision is made over the chosen intercostal space, typically the fifth or sixth, along the mid-axillary line. Blunt dissection is used to reach the pleural space.
3. **Insertion**: The chest tube is inserted into the pleural cavity, directed posteriorly and superiorly for air evacuation, and posteriorly and inferiorly for fluid drainage.
4. **Securing the Tube**: The tube is secured with sutures and connected to a drainage system.
5. **Confirmation**: Proper placement is confirmed via chest X-ray.
Complications
Complications of chest tube thoracostomy can include:
- **Infection**: Introduction of pathogens into the pleural space can lead to empyema.
- **Bleeding**: Injury to intercostal vessels or lung parenchyma can cause hemorrhage.
- **Organ Injury**: Incorrect placement can result in injury to the lung, diaphragm, or abdominal organs.
- **Tube Malposition**: Incorrect positioning can lead to ineffective drainage.
Post-Procedural Care
Post-procedural care involves monitoring for complications, ensuring the patency of the drainage system, and managing pain. Regular chest X-rays may be performed to assess the resolution of the underlying condition and the position of the chest tube.
Removal
The chest tube is removed once the underlying condition has resolved, as evidenced by clinical improvement and imaging. Removal involves cutting the securing sutures, instructing the patient to perform the Valsalva maneuver, and quickly withdrawing the tube while applying an occlusive dressing.