Breathing Skills 1:
Chest Tube Insertion
When a chest tube is critically important to the patient’s care, follow this procedure to assure correct tube position and appropriate tube function.
- Feel the 5th intercostal space at the sternum to identify the correct level at which to insert the chest tube. Identify the intersection between the anterior axillary line and a line drawn across the chest from the 5th intercostal space. This will be the site of insertion unless the diaphragm may be riding high, as in pregnancy or gastric or bowel distension. If this is the case, measure from the 3rd or 4th intercostal space at the sternum. Feel the underlying rib. Double glove because glove damage is common during chest tube insertion.
- Use generous quantities of 1% lidocaine to infiltrate the area if the patient is awake. If the patient has broken ribs and is awake, the procedure will be very painful despite the lidocaine, so administer etomidate 0.1 to 0.2 mg/kg IV. It takes effect in 30 sec and wears off in 3 to 5 min. The patient may need BVM ventilation during this time.
- Make a 3 cm incision over and in line with the selected rib with a #10 scalpel. Carry this incision into the subcutaneous fat. Use a curved blunt forcep (Carmalt clamp) to tunnel over the selected rib. Force the clamp over the top of the rib and into the chest. If the patient has broken ribs this is very painful so you may want to spread the jaws of the clamp as you work through the intercostal space so less pressure is needed. Spread the interspace widely. Insert a finger into the chest to make sure that the lung is not adherent to the chest wall at that point. Use your little finger for this if the opening is tight. If the patient is very muscular, adequately opening the interspace may be difficult. If that is the case, replace the Carmalt clamp with the jaws of a double curved renal pedicle clamp (Guyon-Paen) and spread so that you can see a path into the chest.
- Select a 36 French chest tube and place it on the chest so that you will know when it has been inserted far enough. Arm it by placing the jaws of another Carmalt clamp through its distal side hole. Replace your finger in the chest with the chest tube and direct it cephalad and posterior attempting to reach the apex of the chest. If the chest tube comes with a trocar, insert the trocar now but not so far that it protrudes from the end. This stiffens the tube and eases correct placement. Disconnect temporarily from positive pressure ventilation so that the lung collapses. Reconnect the ET tube as soon as the tube is in position. Suture the tube in place using an 0 silk suture, or other large braided suture, tightly around the tube leaving two long limbs of suture to wrap around the tube. Finish closing the incision with skin staples.
- If the chest tube fills with blood, quickly clamp it with the Carmalt clamp. Alert the team that a blood collector should be attached to the chest suction apparatus for possible autotransfusion unless the injury suggests that there may be abdominal injury with contamination of the chest cavity with bowel or gastric contents.
- Apply a sterile dressing over and under the chest tube. Attach the chest tube to suction. It is very important that all connections of the tubing be secure. A convenient method is to use nylon cable ties available from your hardware store. These are tightened using a clamp or a banding gun. When disconnecting the chest suction apparatus from its vacuum source when it is necessary to move the patient, do not clamp the chest tube; rather be sure that the water level in the water seal column remains higher than the opening of the contained tube. Tension pneumothorax can develop if the tube is clamped, especially if there is an air leak in the lung. When space is limited, as in a helicopter, a Heimlich flutter valve may be substituted for the chest suction apparatus.
- If the patient is bleeding massively from the chest through the chest tube and the blood pressure falls precipitously, the blood in the chest may have had a beneficial tamponade effect. In that case, clamp the chest tube and observe for effect.
An emergency chest tube tray should contain: a needle holder and large silk suture on a cutting needle; a # 10 scalpel; two Carmalt clamps; and a 36 French chest tube with or without a trocar. The trocar is used only for stiffening the tube to ease positioning.
The renal pedicle clamp and the Heimlich valve attachment may be wrapped separately. Gloves for double gloving and lidocaine for local anesthesia may also be kept separately.
- Close the skin tightly around the tube using a surgeon's knot and a square knot. Closing the skin tightly will help prevent an air leak into the chest around the tube. Placing the chest tube at one end of the incision simplifies this closure. Leave two long limbs of suture.
- Form two half-hitches with limb A of the suture.
- Tighten and push the two half-hitches of limb A against the incision. If left loose, in and out motion of the chest tube may occur.
- Form two half-hitches with limb B of the suture. Tighten the half-hitches as before and tie limb A and limb B together using a surgeon's knot and two square knots.
- Close the remainder of the incision with skin staples to save time. Test the security of the tube before applying a dressing.
Reference
- Silver M, Bone RC. The technique of chest tube insertion. J Crit Illness 1986; 1(2):45-51.