Chest Tubes

Chapter 16 Chest Tubes

Gwendolyn M. van der Wilden, MSc , David R. King, MD, FACS

1 What is a chest tube?

A chest tube is properly called a tube thoracostomy and is generally used to evacuate the pleural space of air, blood, serous effusion, bile, chyle, pus, or other fluid. This allows reexpansion of the lung and reapposition of the visceral and parietal pleura.

2 Define occult pneumothorax

An occult pneumothorax occurs when air is trapped within the pleural space but is only identified on a computed tomography scan after a normal chest radiograph. It can be spontaneous or caused by blunt and/or penetrating trauma. Approximately 2% to 10% of trauma patients will be seen with an occult pneumothorax. There are generally no associated clinical findings.

An occult pneumothorax requires reimaging to evaluate progression but usually does not require treatment. The need for positive-pressure ventilation (PPV) (i.e., a trip to the operating room for nonchest or nonlung injury) is not an indication for pleural space decompression of an occult pneumothorax.

3 What is a hemothorax and how to treat it?

When blood accumulates in the pleural cavity because of blunt or penetrating injuries, it is called a hemothorax. Before a hemothorax can be detected on a standard chest radiograph, 200 to 300 mL of blood must be present within the pleural space. It takes up to 1 L before systemic signs of shock and hypoperfusion will manifest.

Normally, large chest tubes (32 F-40 F) will be used to evacuate a large-volume hemothorax, and in 85% the bleeding will spontaneously cease and the lung will reexpand. Large amounts of undrained clotted blood (loculated hemothorax) will be evacuated via operative drainage (video-assisted thoracoscopic surgery). Thoracotomy is required only rarely (Box 16-1).

Box 16-1 Indications for Thoracotomy after Trauma

1. Initial chest tube output of 1500 mL of blood (massive hemothorax)

2. Persistent drainage of 200 to 300 mL/hr

4 What are the indications to place a chest tube?

See Table 16-1.

^{Table 16-1} Indications to Place a Chest Tube

In Acute Setting	Nonacute
PTX Spontaneous (when PTX is large or progressive and if the patient is clinically unstable) Iatrogenic (when PTX is large or progressive or the patient is clinically unstable) Tension PTX Caused by penetrating chest trauma Hemothorax Esophageal rupture with leak into pleural space	Drainage of pleural effusions Chylothorax Parapneumonic effusion or empyema Postoperative care (e.g., after coronary bypass, thoracotomy, or lobectomy)

PTX, Pneumothorax.

5 What can go wrong? What are some possible complications?

Box 16-2 Complications of Chest Tube Placement

Insertional

Intercostal vessel laceration

Lung parenchyma perforation

Perforation of visceral organs (lung, heart, diaphragm, and intraabdominal organs)

Positional

Postremoval pneumothorax

Drain dislodgment

Infective

Insertion site wound infection

Intercostal Neuralgia

Reexpansion Pulmonary Edema

6 How do you choose between a pigtail and a chest tube?

See Table 16-2.

^{Table 16-2} Choosing Between a Pigtail and a Chest Tube

Large but stable

Large and unstable

With mechanical ventilation

Traumatic (blood in addition to air)

Malignant pleural effusion

Parapneumonic effusion or empyema

Pigtail (14 or smaller)

Pigtail (14 or smaller)

10-14 or 16-24 (when fluid is viscous)

< div class='tao-gold-member'>

Only gold members can continue reading. Log In or Register to continue

Related

Tags: Critical Care Secrets

Jul 7, 2016 | Posted by admin in CRITICAL CARE | Comments Off

Full access? Get Clinical Tree

Get Clinical Tree app for offline access

Get Clinical Tree app for offline access