January 22, 2010

Chest Tube Insertion Made easy (Step by step)

Indication

1) Pneumothorax

2) Massive pleural effusion

3) Empyema

4) Traumatic Haemopneumothorax

5) Post operative procedure.


Preparation

1) Trolley with dressing pack, chest tube set and suture set.

2) 20mL 1% lidocaine

3) Scalpel (N15)

4) Chest drain (10-14 F, 0r 28-30F for trauma case)

5) Underwater drainage bottle

6) Connecting tubes

7) Suture materials.


Location (Safety triangle)

1) lateral border of the pectoralis major muscle
2) anterior border of the latissimus dorsi
3) Imaginary horizontal level of the nipple


Simply put, area of inserton;
4th to 6th intercostals space
Anterior to mid axillary line

Procedures




1) Prepare the trolley, drainage bottle and other necessary stuff.


2) Locate the safe triangle


3) Infiltrate the pleura with 10-20 mL 1% Lidocaine. make sure either air or fluid can be aspired. if not, do not proceed. wait for 3 minutes.

4) Swab the safe triangle with poviderm

5) Let it dry for a while

6) Put cover to maintain the incision field

7) Make 2cm incision above 6th rib to avoid neurovascular bundle below 5th rib.

8) Puncture pleura with scisor or forcep

9) sweep finger inside chest to clear adherent lung and exclude stomach in chest. (If use bore more than 24F)

10) Insert chest tube with guide of trochar. make sure you already clamps the tube first except in pneumothorax only.

11) remove the metal trochar and advance the tube until feel resistence.

12) Attach the drain to the underwater seal via tubing.

13) then release the clamp. you can see the blood is flowing.

14) ensure that longer tube is under water and you can see the bubbling with patient's inspiration.

15) Suture the incision area with mattress or just across the incision site.

16) Fix the drain with second suture tied around the tube like 'Roman gaiter'

17) remove the clothes.


18) clean the blood at incisional site.

19) Put gauze on incisional site

20) Secure the drain with tape to prevent it from slipping

21) Now it, finish. Request CXR to check the position of chest tube.



Complication
1) Thoracis or abdominal organ injury
2) Damage to long thoracis nerve.

Beware of
1) Retrograde flow into the chest
2) Persistent bubbling (may be there's a leak from the lung)
3) Blockage of tube due to kink or clot
4) Malposition.

Thank you...

Reference:Oxford Handbook of Clinical Medicine 7th edition.

Special thanks to
1) Dr Ibrahim A&E Department
2) Patient.

5 comments:

  1. salam. Dr, saya pelajar perubatan nak minta izin ambil material dari blog ni untuk dibuat nota. nota hanya untuk rujukan peribadi dan bukan untuk disebarkan.

    kerjasama Dr saya dahulukan dengan ucapan terima kasih.

    ReplyDelete
  2. Thanks to your note. My eldest (4y7m) had just done chest tube due to massive pleural effusion. Thanks Allah, he is now recovering.

    ReplyDelete
  3. thank you bos. bila tengok ni senang sikit nak faham. terima kasih kerana berkongsi ilmu.

    ReplyDelete
  4. thanks so much dr. sng skit pham bile tgk ad gmbr skali.

    ReplyDelete

Ya Allah! Permudahkanlah aku untuk menuntut ilmuMu, memahaminya, mengingati dan menyebarkannya. Berkatilah ilmu itu dan tambahkanlah ia. Amin.