Introduction
A flexible tube that can be placed through the chest wall between the ribs and into the pleural space is called a chest tube, also known as a thoracostomy tube. Thoracostomy tubes are often composed of silicone or PVC (polyvinyl chloride). The majority have radiopaque stripes and are fenestrated on the sides of the insertion end. The distal end of the tube is attached to a pleura-evac system after implantation. A pleura-evac consists of three chambers: a suction chamber, a water seal chamber, and a collection chamber.
Doctors use a chest tube to reduce pressure in the chest cavity and promote lung regrowth. It aids in clearing the intrathoracic space of air (pneumothorax), blood (hemothorax), fluid (pleural effusion or hydrothorax), chyle (chylothorax), or purulence (the process of absorption). While treating a tension pneumothorax, chest tubes are frequently placed shortly after the patient has stabilized from needle decompression. A thoracostomy tube can also be used in other, less frequent, and infrequently advised ways.
What Are the Contraindications of Chest Tubes After Insertion?
The relative contraindications of chest tube insertion include trauma, pulmonary illness, and pulmonary adhesions from prior surgery. Furthermore, coagulopathy and diaphragmatic hernias may be contraindicated.
What Is the Technique of Chest Tubes Insertion?
- Placement: To avoid damaging the intercostal bundle, a thoracostomy tube is often positioned between the midline and anterior axillary line in the fourth or fifth intercostal space, tracking above the rib (artery, vein, nerve). The fourth intercostal gap is often located at the inframammary fold in females and nipple level in males. Tracking up and over one rib gap is desired. Upon removing the thoracostomy tube, a soft tissue "flap" stops outside air from tracking back into the thoracic cavity, creating a persistent or recurrent pneumothorax. The placement of a chest tube can be guided by computed tomography or ultrasound. These imaging techniques are more beneficial for patients who are more complex or who have had surgery or an infection. They run a more significant chance of developing scars as a result. Before placing a patient in a trauma or elective surgery environment, preventative antibiotics should be given. After installation, it is customary to perform follow-up imaging (chest radiography) to ensure that the thoracostomy tube is positioned correctly. Often, a straight line is set towards the apex for pneumothorax. A straight tube is usually inserted posteriorly and towards the height of the lungs for hemothorax or pleural effusion, or a right-angled tube can be inserted near the base of the lungs and diaphragm.
- Discontinuation: Avoid cutting off the tube immediately after removal. Doing so creates a pressure gradient inside the chest that may cause air to track intrathoracic and lead to a subsequent pneumothorax. There are various techniques to stop this from happening. One way is to schedule the interruption such that it coincides with the patient's breathing. The suggested treatment is an occlusive dressing made of vaseline or xeroform gauze; alternatively, a U-stitch can be placed around the incision site and tightened once the tube is stopped. Another technique involves having the patient hold their breath, close their lips, and blow on their thumb as if they were inflating a balloon.
What Are the Complications of Chest Tubes After Insertion?
A few complications are mentioned below:
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Injuries to Intraabdominal Organs: During the insertion of a chest tube, there is a risk of unintentional injury to intraabdominal organs such as the spleen or liver. This can occur if the chest tube is placed too low or inserted at an incorrect angle, causing it to penetrate the diaphragm and enter the abdominal cavity.
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Injuries to Intrathoracic Organs: Similarly, the insertion of a chest tube can lead to injuries to intrathoracic organs, including the heart or thoracic aorta. These injuries may occur if the chest tube is incorrectly placed or if there are anatomical abnormalities that increase the risk of inadvertent damage to these structures.
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Bleeding: There is a possibility of bleeding during or after chest tube insertion. This can occur due to damage to blood vessels in the chest wall or as a result of injury to organs such as the liver or spleen. In some cases, significant bleeding may require additional interventions, such as blood transfusion or surgical repair.
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Superficial Site Infection: Infections at the site where the chest tube is inserted can occur. These infections are usually superficial and manifest as redness, swelling, warmth, and tenderness around the insertion site. Prompt attention and appropriate antibiotic treatment can resolve these infections.
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Deep Organ Space Infection: In rare cases, an infection can extend beyond the superficial site and involve the deep tissues or organs surrounding the chest tube. This can result in more severe symptoms such as fever, chills, increased drainage from the chest tube, and worsening pain. Deep organ space infections often require more aggressive treatment, including drainage procedures and intravenous antibiotics.
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Tube Dislodgement: Chest tubes can become dislodged or accidentally removed, especially if they are not adequately secured. If a chest tube becomes dislodged, it may impair the proper drainage of air or fluid from the chest, leading to potential complications such as pneumothorax or pleural effusion. Prompt assessment and repositioning or reinsertion of the chest tube are necessary to prevent further complications.
What Is the Clinical Significance of Chest Tubes Insertion?
A chest tube removes air, blood, and infectious fluids, saving lives.
- Management of Chest Tube: The standard care of chest tubes has yet to be established scientifically or by specialists. It is not a precise science; it is frequently physician-specific, depending on their education and personal experience. The general idea of how to handle a thoracostomy tube is based on the visceral and parietal pleura's good opposition, depending on the reason for the installation of the line. Suction, water seal, and clamping are the three methods for managing a chest tube.
Steroid use, emphysematous lungs, a prior operation with extensive scar tissue, or significant lung damage are all conditions that put a patient at high risk for developing a persistent air leak. When a new air leak is noticed, the patient's wound, pleura-evac, connecting tubing, and chest tube should all be checked for any loose connections or tube dislodgment. There should not be any fenestrated holes outside of the body. Suction is typically the first method of managing a chest tube for most purposes, excluding specialized thoracic procedures. If there is no air leak or pneumothorax on a chest X-ray, the line can be positioned to water seal.
The criteria for a thoracotomy include an initial sanguineous output of 1500 cc or an average of 200 cc/hr over 4 hours if the thoracostomy tube is implanted for traumatic hemothorax. When there is no visible air leak, the output is serosanguinous. Bleeding is not present, the result is less than 150 cc to 400 cc over 24 hours (this range is broad because it is disputed among researchers), there is no or a mild pneumothorax on chest x-ray, and the patient is minimally dependent on positive pressure from the ventilator, the chest tube can be removed. A thoracic surgical specialist must be contacted if a patient continues to leak after receiving the previously mentioned treatment.
The literature moves from thoracostomy tube therapy to early video-assisted thoracic surgery (VATS) for post-traumatic retained hemothorax. If there is a retained hemothorax following the placement of the first thoracostomy tube, some trauma or CT surgeons are now immediately transporting patients to VATS. If people believe the hemothorax has developed into a clot, they may install a second chest tube rather than administer TPA (Tissue Plasminogen Activator) through the line.
Conclusion
Most hospitals now frequently employ chest tubes. A chest tube may be put into a patient for several reasons, and management does call for a team effort. Besides doctors, a chest tube and the drainage kit must be understood by nurses and respiratory therapists. Chest tubes need to have their dressings changed frequently, the connections need to be secure, and the drainage kit needs to be working. Nurses must be able to examine the patient and handle chest tube disconnections or dislodgments. Regular chest X-rays and listening to the patient's chest are standard procedures.
