Closed tube thoracotomy drainage presentation

CTTD

1. THORACOSTOMY
DR ADEDOKUN S.I

2. OUTLINE
Introduction
History
Relevant anatomy
Indications
Contraindications
Sizes of NG tube
Procedure
Complications
Tube removal

3. Tube thoracostomy is the insertion of a tube (chest tube)
into the pleural cavity to drain air, blood, bile, pus, or other
fluids
Chest tube allows for continuous, large volume drainage
until the underlying pathology can be more formally
addressed
Needle thoracostomy

4. History
Hippocrates first to consider drainage of the pleural space
Hunter in 1860s, developed a hypodermic needle for pleural
space drainage
Playfaiunderwater seal in 1872
Hewitt described closed tube drainage of an empyema in 1876
In 1917 when it was successfully used to drain postinfluenzal
epidemic empyemas
Used regularly post-thoracotomy in World War II
Emergency tube thoracostomy for acute trauma became
commonplace during the Korean War

5. Relevant Anatomy
Pleural cavity is a potential space between the parietal and
visceral pleura
Normally contains less than 25 mL of pleural fluid (0.3ml/kg)
Negative intrapleural pressure keeps lungs expanded
During inspiration: -8cmH
2O
During expiration: -4cmH
2O
Air, fluid or blood collection disrupt negative pressure and
leads to lung collapse

6. INDICATIONS FOR CHEST TUBES
Spontaneous pneumothorax (large, symptomatic or presence
of underlying lung disease)
Tension pneumothorax (or suspected)
Iatrogenic pneumothorax (progressive)
Penetrating chest injuries
Hemopneumothorax in acute trauma
Patient in extremis with evidence of thoracic trauma
Complicated parapneumonic effusions (empyema)

7. INDICATIONS FOR CHEST TUBES
Pleurodesis for intractable symptomatic effusions, usually
malignant
Chylothorax
Post-thoracic surgery
Bronchopleural fistula

8. Contraindications
Need for emergent thoracotomy is an absolute
contraindications
Relative contraindications:
pulmonary adhesions from previous surgery
pulmonary disease, and/or trauma
Coagulopathy
Diaphragmatic hernias
Skin infection over insertion site

9. CHEST TUBES
Thoracotomy chest tube, Malecotcatheter, Trocar CT
Characteristics of ThorcotomyCT:
Made of clear plastic
Varying internal diameter
Distance markers
Multiple drainage holes
Radiopaque stripe, which outlines the proximal drainage hole
Pliable but not supple enough to kink or obstruct drainage
Diameter can vary from
20 to 40 French (5 to 11 mm internal diameter) for adults,
6 to 26 French (2 to 6 mm) for children

11. Instruments and materials
Surgical gloves and gown
Skin antiseptics solution
Sterile drapes
Gauze swabs
Syringes and needles (23G and 21G), Galli pot
Local anaesthetics
Scalpel, needle holder
Sutures (non-absorbable Nylon 1)
Dressing
#3 Curved Kelly clamps, mosquito artery forceps, curved dissecting scissors, stitch scissors, tooth
and non tooth forceps, sponge holding forceps,
Appropriate sized chest tube
Under-water seal drainage

12. Drainage Canisters
One bottle system
Two bottle system
Separate bottle for collecting drainage and for water seal
Three bottle System
A third for suction control
Plastic Multi-Chamber System
Incorporates the 3-bottle system into one unit

14. TECHNIQUE OF CHEST TUBE PLACEMENT
Consent
Premedications:
Benzodiazepines or opioids
Antibiotics
Patients position
Supine, slightly rotated (45
o
tilted up from hip level) with
ipsilateral arm behind the head
Sit upright leaning over a table with a pillow
Lateral decubitus position

15. Insertion site
•Second intercostal space in the
midclavicular line
•Third to fifth intercostal space in
the midaxillary line
•Posterior apical tube
placement
•Triangle of safety (Mid-axillary
line 4
th
or 5
th
intercostal space)

16. TECHNIQUE
Size of tube:
16 to 20 Fr tubes for pneumothorax or serous effusions
28 to 36 Fr tube for blood, pus, thick fluid or bronchopleural fistula
Preparation of site and drape
Estimate length of tube
Anaesthesia:
Liberally infiltrate with 1 percent xylocaine (10 to 20 ml), 1
st
raise skin wheal (at 1
interspace below chosen space)
Liberally infiltrate the subcut, muscle and tissue in the target space down to parietal
pleauraand periosteum of the adjacent rib.
Aspirate the pleura cavity. Target superior border of the rib below

17. TECHNIQUE
2-3 cm incision over and parallel to the rib below selected
intercostal space
Simple mattress suture placed through the incision
Two techniques for insertion:
Trocar method
Blunt dissection
Rigid trocar
Inserted into the incision site and forced into the pleural space with
direct pressure and a twisting motion
Needs safety mechanism to prevent over-penetation

18. Blunt dissection into the pleural space by a Kelly clamp (obliquely superiorly)
Pressure on the Kelly clamp to secure entry, signaled by a give
Finger inserted to lyse any adhesions and assure that the pleural space has
been entered
Tube is clamped at the tip and distally with Kelly forceps and inserted into
the pleural space
Ensure diagonal subcutaneous tunnel be created on insertion, directed
apically
Direct tube antero-apical for a pneumothorax and postero-basal for fluid
drainage
Direct the radio-opaque line medially.
Forceless entry, fogginess and fluctuation of fluid column in tube are
evidence of correct placement
Secure the tube with either purse string or horizontal mattress
Connect to underwater seal, place bottle below chest level for gravity-aided
drainage
Apply airtight dressing

19. TECHNIQUE
Securing the tube:
Loose ends of the mattress suturewrapped around the end of
the tube and tied off
Covering the incision with airtight petroleum-laden gauze
Bacteriostatic ointment covered with dry gauze
Postop chest Xray, PA, lateral to check
Tube position
Resolution of collection
Re-expansion of lungs

20. Post-procedure
Pain control
Vital signs
Patient position
Gravity vs suction
Incentive spirometry
Keep dressing dry and intact
Palpate for subcutaneous emphysema
Antibiotics

21. Timing of chest tube removal
Depends on indications
Pneumothorax
Bubbling movement has ceased
Lung fully expanded on chest radiogram
Pleural fluid drainage
Volume less than 100ml in 24 hours
If serous fluid
Lung re-expanded and clinical status improved
No fresh or altered blood coming out of the chest tube

22. Removal of the chest tube
Explain the procedure to the patient
End expiration or end inspiration
Occlude insertion site
Knot the sutures and occlusive dressing
Chest X-ray after 12-24 hours of removal

23. Complications
Organ-specific complications
Diaphragm injury
laceration, perforation
muscle dysfunction
Phrenic neuropraxia from TT causing nerve compression
maintaining the tip of the tube at least 2 cm from the vertebral line
predisposing factors
Hemidiaphragm paralysis, late pregnancy, obesity, massive ascites and
intraabdominal tumors.

24. Complications
Lung injury
most commonly injured
Risk factors
decreased lung compliance
consolidation of the underlying parenchyma
significant pleural adhesions
use of a trocar
inability to sufficiently explore the pleural space prior to tube placement
Infarction
excessive pleural suction, aspiration of a lung

25. Complications
Pulmonary artery canalization
Rare
Rapid drainage of pulsatile, dark red blood
Shortness of breath, tachycardia, and hypotension
Volume replacement
Clamp the TT
Surgical repair of the injured artery
Delayed lung perforation
Duration of TT dwelling
Tube repositioning maneuvers
Prolonged use of suction

26. Complications
Cardiac/vascular injury
Rare
Can lead to mortality if not recognized
Tube compression of critical structures causing vascular
compromise
Penetrating cardiac injury during tube insertion

27. Bronchopleural fistula
Abnormal connection btw pleural space and bronchial tree
Rare
Acute BPF is difficult to manage, high morbidity, mortality
Signs and symptoms
dyspnea, hypotension, subcutaneous emphysema, cough, and
persistent air leak
Diagnosis confirmed via
bronchoscopy, bronchography, or computed tomography
Treat life-threatening conditions: massive air leaks or tension
pneumothorax

28. Bronchopleural fistula
Application of sealants via bronchoscopy
Sclerosing and occluding methodologies
balloons, stents, adhesives (biologic and non-biologic)
Direct open repair (with or without tissue flap)
Partial pneumonectomy
Video assisted thoracoscopy

29. Organ-specific complications
Esophagealinjury
Gastric injury
Bowel injury
Hepatic injury
Splenic injury

30. Recurrent pneumothorax
Premature TT removal (before full lung re-expansion)
Occult air leak
Air entering the pleural space during removal
Asymptomatic, shortness of breath, tension pneumothorax
Observe asymptomatic
Insert new chest tube in symptomatic cases

31. Complications Cont’d
Intercostal arterial hemorrhage
Arteriovenous fistula, including chest wall (intercostals)
Chylothorax
Fibrothorax

32. Technical complications
Non-functioning tube
disconnection of the tube from the suction mechanism,
mechanical obstruction (i.e., blood clot)
tube kinking,
dysfunctional closed system apparatus
Contralateral pneumothorax
Subcutaneous placement
Persistent leakage around chest tube
Unintended tube dislodgement

33. Physiologic complications
Re-expansion pulmonary edema
Incidence 1-14%
Mortality rate: 20%
Asymptomatic, cardio-respiratory collapse and shock
Exact pathophysiology unknown
increased endothelial permeability
Oxygen free radicals
multiple inflammatory mediators
Risk factors
Younger age (<40),
longer duration of lung collapse (>4 days),
Large pneumothorax (>30% of a single lung)
Little or no negative pressure in at risk group

34. Physiologic complications
Vagusnerve irritation, including hemodynamic collapse

35. Infectious complications
Insertion site infection, including necrotizing fasciitis,
osteomyelitis
Empyema

36. Miscellaneous complications
Tube erosion
Delayed esophageal erosion
Erosions of the aorta and subclavian artery
Horner’s syndrome:
Injury to the sympathetic pathways
High insertion in the posterior chest wall

37. Indications for surgery
persistent severe air leak
failure of the lung to re-expand following insertion of one or
more thoracostomy tubes
persistent, massive pleural effusion drainage for both benign
and malignant conditions
initial sanguineous output of 1500 cc or an average of 200
cc/hrover 4 hours consecutive hours

38. Conclusion
Thoracostomy via needle or tube is a lifesaving procedure
that every clinician must master to limit accompanying
complications

39. Refernces
Ravi C, McKnight CL. Chest Tube. [Updated 2021 Oct 9]. In:
StatPearls[Internet]. Treasure Island (FL): StatPearls
Publishing; 2021 Jan-.
KwiattM, Tarbox A, SeamonMJ, Swaroop M, CipollaJ, Allen
C, et al. Thoracostomy tubes: A comprehensive review of
complications and related topics. Int J CritIllnInjSci
2014;4:143-55.
K. Scott MiUer, M.D.;tand StevenASahn, M.D., F.C.C.P. Chest
Tubes: Indications, Technique, Management and
Complications. CHEST I 91 I 2 I FEBRUARY, 1987:258-264.