23. Single port thoracospic tube
thoracostomy
Hopkins rod lens telescope is loaded
into the most proximal port of chest
tube.
Under direct visualisation the chest
tube is placed into the
costodiaphragmatic gutter
25. Direction of tube
Air : anterior and superior (towards apex)
Fluid : posterior and inferior (towards
base)
Any tube position can be effective at
draining air or fluid
An effectively functioning chest tube
should not be repositioned solely
because of position in CXR
26. PHYSICS & PHYSIOLOGICAL
ASPECTS
DISTAL END OF DRAINAGE TUBE 2cm
BELOW WATER
COLLECTION CHAMBER ALWAYS
100cm BELOW THE CHEST
LARGE DIAMETER COLLECTION
CHAMBER (20 cm Diameter)
30. Three bottle chest drainage
system
Controlled amount of suction can be
applied
Applying negative pressure to the
pleural space helps
◦ Re-expansion of underlying lung
◦ Better removal of air/fluid from pleural
space
36. HEIMLICH VALVE
Mechanical oneway valve
Allow air to escape from chest and prevent
air from entering
Adv: Does not require water to operate
Not position sensitive
Early ambulation of the patient
Disadv:
Less patient asessment information
Cannot see changes in IPP
39. Securing chest drain
Purse string
Converts a linear wound to a circular
one
More pain and unsightly scar
Should not be used
40. THAL QUICK CHEST TUBE
ADAPTER
Proximal end attached with three way
stopcock through connecting tube
Used for sclerotherapy (pleurodesis)
41. When to remove chest tube?
Depends on indication
Pneumothorax
Bubbling ceased
Lung fully expanded in CXR
Get CXR12 o24 hrs after last air leak
Pleural drainage
Volume <100 ml in 24 hrs
Serous fluid
Lung re expanded and clinical status improved
No fresh or altered blood coming out of chest
tube
42. Removing the chest tube
Explain the procedure to patient
During peak inspiration
Remove the chest tube in one quick
movement
If on MV : End expiration / diconnect
ventilator
Two people :
Instruct the patient and pull the tube
Occlude the insertion site
Tighten the suture and occlusive dressing
CXR – 12 to 24 hrs after Removal to
44. Complications
Injury to
Neurovascular bundle
Lung parenchyma
Diaphragm, intraperitoneal structures
Heart and major vessels
Massive bleeding
Re-expansion pulmonary Edema
Empyema
Subcutaneous emphysema/hematoma
45. Recommendations for safe chest
drain insertion
Triangle of safety , midaxillary line
Imaging to be used to select site of
insertion
Do not use substantial force
CXR/CT should be available at the
time of insertion except in tension
pneumothorax
47. Repositioning chest drain
Use imaging assistance
Avoid pushing & Pulling
Best is fresh insertion
Avoid previous site, choose new one
48. Bubbling chest tube-
Differentials
Not inserted far enough-one or more
holes ourside pleural space
Air enters from atmosphere
Leaks in system
Bronchopleural fistula
49. AIR LEAKS
Bubbling in water seal
Collected in syringe-blood gas
analyzer
Pco2>20 mmHg (Bronchopleural
fistula)
Pco2<10 mmHg (Atmospheric air)
50. CLAMPING
A bubbling chest tube should never be
clamped
Drainage of a large pleural effusion
should be controlled – to avoid re-
expansion pulmonary edema.
51. Patient care
Encourage deep breaths and cough
Adequate pain relief
Encourage movement
Assess water level, tidalling
Avoid milking and clamping
Ensure collection unit below the level
of chest
Suction can improve the speed of air
and fluid removal
2nd ICS for pneumothorax
Difficult to penetrate pectoralis major
Internal mammary artery injury common
Cosmetically inferior
Supine- most preferred - flat on bed, ipsilateral arm behind head, slightly roated to opposite side
Sitting – breathless – sit upright, lean over cardiac trolley
Most commonly practiced
15 mins before give anxiolytic
3-4 cm incision parallel to intercostal space- deepened upto intercostal fascia
Fascia incised – muscle separated by hemostat-parietal pleura penetrated by hemostat
Hole enlarged with index finger
Chest tube inserted with hemostat
Tube sutured n sterile dressing applied.
Safer than other methods
Disadvantage : ectopic placement of tube
Easy-done under usg/ct guidance-seldinger technique
Stylet removed off the trocar n chest tube inserted.
More chances for lung puncture.
Chemical pleurodesis – bleomycin, tetracyclin(minocycline), povidone-iodine