Introduction
- Tube thoracotomy is the insertion of a tube into the pleural cavity through a small incision of the chest wall. Closed tube thoracotomy, the chest tube is connected to a closed chest drainage system. It is used to remove air in the case of pneumothorax or fluid such as in the case of pleural effusion, blood, chyle, or pus when empyema occurs from the intrathoracic space. Also called known as a Bülau drain or an intercostal catheter.
Relevant Anatomy
- The intercostal spaces have intercostal muscles, with the neurovascular bundle lying in the costal groove at the inferior margin of the superior rib from above downwards and situated between the second and third layers of muscle.
- The pleural space is the space between the parietal and visceral pleura, and is also known as the pleural cavity. It normally contains about 30-50ml. A small amount of fluid can be reabsorbed by the body. When it is too much, the fluid can’t be reabsorbed.
- The triangle of safety is an anatomical region in the axilla that forms a guide as to the safe position for intercostal catheter (ICC) placement. With the arm abducted, the apex is the axilla, and the triangle is formed by the:
- Lateral border of the pectoralis major anteriorly
- Lateral border of the latissimus dorsi posteriorly
- Inferiorly, by a horizontal line from the nipple (commonly the 5th intercostal space)
Types
The types of closed tube drainage includes;
1. Simple underwater seal drainage without suction
2. Suction drainage system
A traditional chest tube drainage system will have these three chambers
- Collection chamber
- Water-seal chamber
- Wet or dry suction control chamber
Mechanism Of Action
A patient may require a chest drainage system any time the negative pressure in the pleural cavity is disrupted, resulting in respiratory distress. Negative pressure is disrupted when air or fluid enters the pleural space and separates the visceral pleura from the parietal pleura, preventing the lung from collapsing and compressing at the end of exhalation. The Chest Tube device is a passive functioning device that works with the pressure gradient between the positive intrathoracic pressure and the negative pressure in the drainage bottle.
• Each chest tube is connected to an underwater seal drainage system which allows for air or fluid to be drained, and prevents air or fluid from entering the pleural space.
• The tube connected to the drainage system must be sealed so that air or liquid cannot enter the space where the tube is inserted.
Indications
Therapeutic
•Pneumothorax
•Pleural effusion
•Chylothorax
•Hemothorax
•Empyema
•Post-operatively e.g (Thoracotomy, Cardio-thoracic surgery)
DIAGNOSTIC
•Lung damage
•Internal injury after a trauma
Contraindications
• Coagulopathy
• Pulmonary Bullae
• Pulmonary, Pleural, Thoracic Adhesions
• Loculated Pleural Effusion
• Skin infection over insertion site
• Hydrothorax
Prerequisites
•Positive history and clinical findings
•Positive investigations
•Positive test aspiration
•DO NOT PASS A CHEST TUBE WITHOUT A CHEST XRAY
Positioning
The patient should be positioned supine or at a 45 degree angle. Elevating the patient lessens the risk of diaphragm elevation and consequent misplacement of the chest tube into the abdominal space.
•The arm on the affected side should be abducted and externally rotated, simulating a position in which the palm of the hand is behind the patients head
•A soft restraint or silk tape can be used to secure the arm in this location. If a restraint is used, make sure that good blood flow to the hand is present.
Procedure
•Valid indication is established and informed consent is obtained.
• It is a sterile procedure.
• Site is cleaned and sterile drapes are placed around it.
• The Surgeon scrubs
• The patient is placed in a supine position or 45 degree angle
• Revisit available radiograph to check for site of insertion (left or right)
• The Triangle of safety is identified
•10mL of Anaesthetic solution is used to infiltrate from the skin to the pleural.
•Aspiration of air, blood, pus or a combination thereof into the syringe confirms that the needle entered the pleural cavity.
•Using a scalpel, a 4cm skin incision directly overlying the desired intercostal level of entry is made.
•A blunt dissection is made in the subcutaneous tissue
•The course of the insertion is palpated with a finger
•The tube is inserted as close as possible to the upper border of the rib to minimize risks of neurovascular bundle (which run along the inferior border of the ribs)
•Ensure that all fenestrated holes in the chest tube are in the thoracic cavity.
•The chest tube is connected to a drainage device.
•Before securing the tube with stitches, look for respiration-related swing in the fluid level of the water seal device to confirm correct intrathoracic placement.
• Secure with silk or nylon stiches
• Creative an occlusive dressing to place over the chest tube
• Obtain another chest radiograph to ensure correct placement of the tube.
Signs Of A Functioning Chest tube
- Rising fluid level in collection bottle.
- Oscillating movement of fluid within the tube with respiration.
- Bubbling of fluid in the underwater seal system with pneumothorax.
- Volume draining is 100-150ml/day.
- Clamping of chest tube does not cause respiratory distress.
- Chest Xray confirms lung re-expansion.
References
1. Williams NS, Bulstrode CJK and O’Connell. Bailey & Love’s Short Practice of Surgery. 26th Edition. Taylor & Francis group, LLC. Boca Raton. 2013; Pages 46-47
2. Longmore M., et al. Oxford Handbook of Clinical Medicine. 9th Edition Tonbridge. GreenGate Publishing Service. 2014; Pages 780-781
3.Badoe E. A., Archampong E. Q. and da Rocha-Afodu J. T. (2009). Principles and Practice of Surgery Including Pathology in the Tropics. Fourth Edition. Ghana: GHANA PUBLISHING CORPORATION