Overview
Definition:
Chest tube placement, also known as tube thoracostomy or formal chest drain insertion, is a surgical procedure to insert a tube into the pleural space for drainage of air, pus, blood, or other fluid
The Seldinger technique is a minimally invasive approach utilizing a guidewire to facilitate tube insertion.
Epidemiology:
Pneumothorax, pleural effusion, and hemothorax are common indications for chest tube placement
Incidence varies widely based on underlying pathologies
traumatic pneumothorax is a significant cause in younger populations, while malignant pleural effusions increase with age.
Clinical Significance:
Effective chest tube management is critical for respiratory support and preventing complications such as empyema and respiratory failure
Mastery of insertion techniques, including the Seldinger approach, is essential for surgical residents to manage emergent and elective thoracic conditions.
Indications
Primary Indications:
Primary spontaneous pneumothorax (PSP) with significant symptoms or >20% volume
Secondary spontaneous pneumothorax (e.g., from COPD)
Traumatic pneumothorax or hemothorax
Therapeutic pleurodesis for recurrent malignant pleural effusions
Empyema or complicated parapneumonic effusions
Postoperative drainage after thoracic surgery.
Absolute Indications:
Hemodynamic instability with tension pneumothorax requiring immediate decompression
Large hemothorax requiring evacuation
Persistent air leak unresponsive to conservative measures
Symptomatic pleural effusions causing dyspnea or hypoxemia.
Relative Indications:
Small pneumothorax in asymptomatic patients
Thoracentesis failure
Prophylactic placement in specific trauma scenarios
Managing chylothorax.
Contraindications
Absolute Contraindications:
None absolute when life-saving intervention is required, but relative contraindications must be considered.
Relative Contraindications:
Bleeding diathesis or coagulopathy (correctable)
Local infection at the insertion site
Dense pleural adhesions making insertion technically difficult and risky
Ascites or significant diaphragmatic pathology that could lead to organ puncture
Lack of patient cooperation or inability to tolerate the procedure.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination focusing on respiratory status, pain, and presence of coagulopathy
Review of imaging (CXR, CT scan) to delineate pathology and guide insertion site selection.
Informed Consent:
Discuss the procedure, indications, risks (pain, bleeding, infection, organ injury, re-expansion pulmonary edema, persistent air leak), benefits, and alternatives with the patient or their representative.
Equipment Checklist:
Sterile drapes, gloves, gown, mask, eye protection
Local anesthetic (e.g., lidocaine 1-2%)
Antiseptic solution (e.g., chlorhexidine, povidone-iodine)
Scalpel (e.g., #11 or #15 blade)
Guidewire
Dilator
Trocars (if using pre-packaged kits)
Chest tube (appropriate size: 10-28 Fr for air, 28-36 Fr for fluid/blood)
Puncture needle
Suture material (e.g., 1-0 silk or nylon)
Drainage system (e.g., Pleur-evac, Atrium)
Occlusive dressing
Gauze pads.
Patient Positioning:
Typically supine or semi-recumbent with the arm on the affected side abducted and placed over the head (the "arm-over-head" position)
This opens the intercostal spaces, especially in the anterior and lateral chest wall.
Procedure Steps Seldinger
Site Selection:
Anterolateral chest wall, typically in the 4th or 5th intercostal space in the mid-axillary line, is preferred for most indications (e.g., pneumothorax)
For significant fluid or pus, a more dependent site (e.g., 7th or 8th intercostal space, posterior axillary line) may be chosen.
Skin And Intercostal Muscle Infiltration:
Administer local anesthetic to the skin, subcutaneous tissue, periosteum of the rib, and pleura
Aspirate to ensure the anesthetic is not injected into a blood vessel or pleural space.
Small Incision And Guidewire Insertion:
Make a 1-2 cm incision through the skin using a scalpel
Using a puncture needle, cannulate the pleural space and aspirate to confirm entry (e.g., air or fluid)
Once in the pleural space, a flexible guidewire is advanced through the needle into the pleural cavity, ensuring it is not kinked or coiled.
Dilator Insertion:
The guidewire is then used to guide a plastic dilator over it, widening the tract through the subcutaneous tissue, intercostal muscles, and pleura to the desired size for the chest tube
The dilator is removed, leaving the guidewire in place.
Chest Tube Insertion:
The chest tube is advanced over the guidewire into the pleural space
The guidewire is then carefully removed
If using a kit with a trocar, the trocar and dilator are removed together after the tube is positioned.
Tube Securing And Dressing:
The chest tube is secured to the skin with sutures
A sterile occlusive dressing is applied around the tube insertion site, ensuring a watertight seal
The tube is then connected to a closed drainage system.
Postoperative Care
Drainage System Management:
Monitor the drainage system for air leaks, volume of output, and character of fluid
Ensure the system remains closed and functional, with appropriate suction applied if indicated
Monitor the water seal for bubbling, which indicates an air leak.
Pain Management:
Provide adequate analgesia to ensure patient comfort and facilitate deep breathing and coughing
Consider patient-controlled analgesia (PCA) or scheduled oral/IV analgesics.
Monitoring:
Regular vital sign assessment, including respiratory rate, oxygen saturation, and blood pressure
Serial chest X-rays to assess lung re-expansion, tube position, and identify complications
Auscultate lung sounds for improvement and to detect complications.
Chest Tube Removal:
Removal is typically indicated when the air leak has resolved, pleural fluid output is minimal (<100-200 ml/24h), and the lung is fully re-expanded on imaging
The tube is removed by pulling it out while the patient performs a Valsalva maneuver or exhales forcefully, followed by immediate application of an occlusive dressing
A post-removal CXR is often obtained.
Complications
Early Complications:
Pain at the insertion site
Bleeding (intercostal vessel or lung parenchyma)
Injury to adjacent organs (lung, diaphragm, heart, great vessels, liver, spleen)
Malposition of the tube
Subcutaneous emphysema
Nerve injury
Vasovagal syncope.
Late Complications:
Persistent air leak
Empyema or abscess formation
Tube blockage or kinking
Chronic pain
Pleural scarring or adhesion formation
Re-expansion pulmonary edema.
Prevention Strategies:
Meticulous technique and anatomical knowledge
Appropriate site selection
Careful guidewire manipulation to avoid injuring organs
Adequate local anesthesia
Securement of the tube and dressing to prevent dislodgement
Vigilant monitoring of drainage output and air leaks
Prompt removal when indicated.
Key Points
Exam Focus:
Indications for chest tube insertion and removal
Complications of chest tube placement and their management
Understanding the different types of chest drainage systems and their function
Seldinger technique advantages (smaller incision, less trauma)
Understanding the management of air leaks.
Clinical Pearls:
Always aspirate with the puncture needle before advancing the guidewire to confirm pleural entry and avoid inadvertent organ puncture
Secure the tube adequately to prevent accidental dislodgement
Adequate pain control is crucial for patient compliance and recovery
Consider a smaller bore tube (10-14 Fr) for simple pneumothorax if size allows and a standard size for significant fluid or empyema.
Common Mistakes:
Incorrect site selection leading to inadequate drainage
Failure to confirm pleural entry before guidewire insertion
Forcing the tube, especially over a guidewire, which can cause injury
Inadequate securement of the tube, leading to dislodgement
Neglecting to monitor for complications like empyema or persistent air leaks
Premature removal of the chest tube.