From the Guidelines
The proper technique for inserting a thoracostomy tube involves positioning the patient, identifying the insertion site, administering local anesthesia, making an incision, and guiding the tube into the pleural space, with suction applied after 48 hours if necessary, as recommended by the BTS guidelines 1. When inserting a thoracostomy tube, it is essential to prioritize proper technique to minimize complications and ensure effective drainage. The procedure should begin with positioning the patient in a supine or semi-recumbent position with the arm raised above the head. The appropriate insertion site should be identified, typically the 4th or 5th intercostal space in the mid-axillary line for pneumothorax or the 5th or 6th intercostal space for fluid drainage. Some key points to consider when inserting a thoracostomy tube include:
- Administering local anesthesia using 1-2% lidocaine, infiltrating the skin, subcutaneous tissue, intercostal muscles, and pleura
- Making a 2-3 cm incision parallel to the rib, then using blunt dissection with a curved clamp to create a tract over the top of the rib to avoid neurovascular structures
- Puncturing the pleura with the clamp, then inserting your finger to confirm entry into the pleural space
- Guiding the chest tube through the tract into the pleural space, directing it posteriorly and superiorly for air or anteriorly and inferiorly for fluid
- Securing the tube with sutures (typically 0 or 2-0 silk), applying an occlusive dressing, and connecting to a drainage system
- Confirming proper placement with a chest X-ray According to the BTS guidelines 1, suction should not be applied directly after tube insertion, but can be added after 48 hours for persistent air leak or failure of a pneumothorax to re-expand. High volume, low pressure (–10 to –20 cm H2O) suction systems are recommended 1. The American College of Chest Physicians also provides guidance on the management of spontaneous pneumothorax, including the use of chest catheters and small-bore catheters 1. However, the most recent and highest quality study, the BTS guidelines 1, should be prioritized when making decisions about thoracostomy tube insertion and management.
From the Research
Proper Technique for Inserting a Thoracostomy Tube
The proper technique for inserting a thoracostomy tube, also known as a chest tube, is crucial to avoid complications and ensure effective drainage of the pleural space. According to 2, 3, the most appropriate site for chest tube placement is the 4th or 5th intercostal space in the mid- or anterior- axillary line.
Key Considerations
- The use of a steel trocar for chest tube insertion is not recommended, as it can lead to complications such as hemothorax, dislocation, lung lacerations, and injury to organs in the thoracic or abdominal cavity 2, 3.
- Small-bore chest tubes (≤14F) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients and pleural effusions in general 4.
- Large-bore chest drains may be useful for very large air leaks, as well as post-ineffective trial with small-bore drains 4.
- Chest tube insertion should be guided by imaging, either bedside ultrasonography or computed tomography 4, 5.
- The Seldinger technique or blunt dissection should be used instead of the trocar technique 4.
Insertion and Management
- A chest tube is used to drain the contents of the pleural space to reconstitute the physiologic pressures within the pleural space and to allow the lungs to fully expand 2, 3, 6.
- The evaluation of the patient should be performed primarily with a clinical examination, a chest X-ray, and sonography, but the gold standard of diagnostic testing is computed tomography (CT) 5.
- Therapy should be carried out with mild suction of approximately 20 cmH2O, and clamping the chest tube before removal showed no beneficial effect 5.
- The removal of drains can be safely performed, either at the end of inspiration or at the end of expiration 5.