Overview
Definition:
Tube thoracostomy, commonly known as chest tube insertion, is a procedure involving the insertion of a tube into the pleural space to drain air, fluid, or blood
Troubleshooting focuses on identifying and resolving issues that prevent effective drainage or lead to complications.
Epidemiology:
Chest tubes are frequently used in critically ill patients, trauma cases, and those undergoing thoracic surgery
Complications can occur in up to 10-20% of insertions, necessitating prompt troubleshooting.
Clinical Significance:
Effective management of pleural pathology relies on a properly functioning chest tube
Troubleshooting poorly performing tubes is crucial for patient recovery, preventing respiratory compromise, and avoiding further complications, making it a high-yield topic for surgical exams.
Indications For Insertion
Indications:
Drainage of pneumothorax
Drainage of hemothorax
Drainage of pleural effusion (exudative, chylous, purulent)
Empyema management
Postoperative thoracic surgery drainage
Esophageal perforation management.
Contraindications:
Relative contraindications include coagulopathy, severe osteoporosis, and lack of patient cooperation
Absolute contraindications are rare but may include active infection at the insertion site.
Common Troubleshooting Scenarios
Tube Malposition:
Tube inserted into the lung parenchyma, subcutaneous tissue, or mediastinum
Symptoms may include persistent air leak, ineffective drainage, or absent bubbling in the drainage system
Radiographic confirmation is essential.
Tube Blockage:
Occlusion by blood clots, fibrin, or kinking of the tube
Manifests as absent drainage, decreased bubbling, or a large air leak without corresponding drainage
Irrigation or tube replacement may be needed.
Air Leak:
Persistent bubbling in the water seal chamber indicates ongoing air leakage into the pleural space
Can be due to intercostal leakage, bronchopleural fistula, or esophageal leak
Graded by intensity: fine, moderate, gross.
No Drainage:
Absence of fluid or blood return despite documented pleural collection
Causes include tube malposition, blockage, or inadequate suction
Assess drainage system, patient positioning, and consider irrigation or imaging.
Subcutaneous Emphysema:
Air dissecting into the subcutaneous tissues around the insertion site
Usually indicates an air leak that is not being effectively managed or a large persistent air leak
Can be extensive and alarming but often resolves spontaneously.
Pain At Insertion Site:
Commonly due to nerve irritation, infection, or tube movement
Adequate analgesia is paramount
Assess for signs of infection or malposition if pain is severe or persistent.
Diagnostic Approach To Troubleshooting
Patient Assessment:
Evaluate vital signs: respiratory rate, oxygen saturation, heart rate, blood pressure
Assess for dyspnea, chest pain, cough, and sputum production
Monitor chest tube output and bubbling pattern.
Chest Tube Drainage System Evaluation:
Assess the water seal chamber for bubbling and tidaling
Check the collection chamber for output volume, color, and consistency
Ensure suction is functioning and connected appropriately.
Imaging Modalities:
Chest X-ray (AP and lateral views) is crucial to assess tube position, presence of pneumothorax, pleural effusion, and subcutaneous emphysema
Ultrasound can help guide re-insertion or identify loculated collections
CT scan may be needed for complex cases.
Bronchoscopy:
Considered if a bronchopleural fistula is suspected or if there is persistent significant air leak despite optimal management.
Laboratory Investigations:
Complete blood count (CBC) to assess for infection or anemia
Coagulation profile if bleeding is suspected or re-insertion is planned
Pleural fluid analysis if drainage is abnormal.
Management Strategies
Tube Patency Management:
Regular flushing with sterile saline (e.g., 20 mL every 4-8 hours) to prevent clot formation
Gentle milking or stripping of the tube if indicated, but with caution to avoid excessive negative pressure.
Air Leak Management:
If mild, continuous suction may resolve it
If persistent and significant, consider clamping the tube distal to the suspected leak site (patient must be monitored closely for tension pneumothorax)
If bronchopleural fistula, surgical intervention may be required.
Tube Repositioning Or Reinsertion:
If malpositioned on imaging and causing symptoms or ineffective drainage, repositioning the tube within the pleural space or complete reinsertion may be necessary
This should be performed by an experienced clinician.
Suction Optimization:
Ensure adequate negative pressure is applied if indicated (e.g., for pneumothorax or large effusions)
Check connections for leaks in the system
Adjust suction based on clinical response and drainage.
Pain Control:
Adequate analgesia, including systemic or intercostal nerve blocks
Non-opioid analgesics and scheduled pain medication should be utilized
Address any signs of infection at the insertion site promptly.
Complications Of Tube Thoracostomy
Early Complications:
Bleeding (from intercostal artery injury)
Organ injury (lung, diaphragm, liver, spleen)
Nerve injury
Incorrect placement
Subcutaneous emphysema
Pain
Vasovagal syncope.
Late Complications:
Persistent air leak
Empyema
Tube blockage
Recurrent pneumothorax or effusion
Bronchopleural fistula
Chest wall abscess
Chronic pain
Fenestration syndrome.
Prevention Strategies:
Proper patient selection and informed consent
Adequate analgesia and sedation
Meticulous sterile technique
Correct insertion site and angle
Use of ultrasound guidance
Appropriate tube size and type
Regular monitoring and prompt intervention for issues.
Key Points
Exam Focus:
Understanding the principles of effective chest tube drainage
Recognizing signs of a malfunctioning chest tube
Differentiating between air leak, blockage, and malposition
Knowing when to reposition or reinsert a tube
Management of common complications like empyema and bronchopleural fistula.
Clinical Pearls:
Always confirm tube position with X-ray after insertion and if any troubleshooting is needed
Gentle milking is preferred over vigorous stripping
Educate the patient about the chest tube and potential issues
If in doubt about tube function, reassess the patient and obtain imaging.
Common Mistakes:
Failure to confirm tube position radiographically
Over-reliance on flushing without assessing the underlying cause of blockage
Aggressive milking or stripping leading to pain or tube dislodgement
Inadequate pain management
Delaying intervention for persistent air leak or poor drainage.