Chest tube

A chest tube or chest drain is a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air (pneumothorax) or fluid (pleural effusion, blood, chyle), or pus (empyema) from the intrathoracic space. The procedure is called tube thoracostomy in the United Kingdom. It is also known as a Bülau drain.

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Technique

The free end of the tube is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest. Alternatively, the tube can be attached to a flutter valve. This allows patients with pneumothorax to remain more mobile.

The British Thoracic Society recommends the tube is inserted in an area described as the "safe zone", a region bordered by: the lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi and a horizontal line superior to the nipple^{[citation needed]}. Chest tubes are usually inserted under local anesthesia. The skin over the area of insertion is first cleansed with antiseptic solution, such as iodine, before sterile drapes are placed around the area. The local anesthetic is injected into the skin and down to the muscle, and after the area is numb a small incision is made in the skin and a passage made through the skin and muscle into the chest. The tube is placed through this passage. If necessary, patients may be given additional analgesics for the procedure. Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied to the area. The tube stays in for as long as there is air or fluid to be removed, or risk of air gathering.

Once the drain is in place, a chest radiograph will be taken to check the location of the drain.

Chest tubes can also be placed using a trocar, which is a pointed metallic bar used to guide the tube through the chest wall. This method is less popular due to an increased risk of iatrogenic lung injury. Placement using the Seldinger technique, in which a blunt guidewire is passed through a needle (over which the chest tube is then inserted) has been described.

Indications

• Pneumothorax: accumulation of air in the pleural space
• Pleural effusion: accumulation of fluid in the pleural space
  • Chylothorax: a collection of lymphatic fluid in the pleural space
  • Empyema: a pyogenic infection of the pleural space
  • Hemothorax: accumulation of blood in the pleural space
  • Hydrothorax: accumulation of serous fluid in the pleural space

Contraindications

Contraindications to chest tube placement include refractory coagulopathy, lack of cooperation by the patient, and diaphragmatic hernia.

Complications

Major complications are hemorrhage, infection, and reexpansion pulmonary edema. Injury to the liver, spleen or diaphragm is possible if the tube is placed inferior to the pleural cavity. Injuries to the thoracic aorta and heart have also been described.

Minor complications include a subcutaneous hematoma or seroma, anxiety, shortness of breath (dyspnea), and cough (after removing large volume of fluid).

References

• Intensive Care Medicine by Irwin and Rippe
• The ICU Book by Marino
• Procedures and Techniques in Intensive Care Medicine by Irwin and Rippe