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Khodayar Rais-Bahrami

Mhairi G. MacDonald

38 Thoracostomy

Thoracostomy Tubes

Pulmonary air leak is an anticipated risk of mechanical

ventilation. Thoracostomy tubes are used in neonatal

intensive care units for evacuation of air or fluid from

the pleural space. The procedure is often performed

because of an emergency. In addition to recognizing

pathologic states that necessitate chest tube insertion,

intensive care specialists are frequently involved in

placement, maintenance, troubleshooting, and discontinuation of chest tubes. As with any surgical procedure,

complications may arise. Appropriate training and competence in the procedure may reduce the incidence of

complications. This chapter reviews current indications

for chest tube placement, insertion techniques, and

equipment. Guidelines for chest tube maintenance and

discontinuation are also discussed.

A. Indications

1. Evacuation of pneumothorax

a. Tension

b. Lung collapse with ventilation/perfusion abnormality

c. Bronchopleural fistula

2. Evacuation of large pleural fluid collections

a. Significant pleural effusion

b. Postoperative hemothorax

c. Empyema

d. Chylothorax

e. Extravasated fluid from a central venous catheter

3. Extrapleural drainage after surgical repair of esophageal atresia and/or tracheoesophageal fistula

B. Relative Contraindications

1. Small air or fluid collection without significant hemodynamic symptoms

2. Spontaneous pneumothorax that, in the absence of

lung disease, is likely to resolve without intervention

C. Equipment

Sterile

1. General all-purpose tray with no. 15 surgical blade and

curved hemostats (See Appendix B, Table B.1)

2. Gloves

3. Surgical drapes

4. Transparent, sterile bag for tip of transillumination

device

5. Thoracostomy tube: Techniques of insertion differ with

each type. See original references for description of

technique variations (1–3).

a. Polyvinyl chloride (PVC) chest tube with or without

trocar, in sizes 8, 10, and 12 French (Fr)

b. Pigtail catheter for pleural effusion drainage

(Fig. 38.1)

(1) PVC with pigtail at 90-degree angle to shaft (1)

(a) 8 to 10 Fr

(b) Total length 10 cm

(c) Insertion with or without trocar

(2) Polyurethane modified vascular catheter with

pigtail in same plane as shaft (2)

(a) 8.5 Fr

(b) Total length 15 cm

(c) Insertion guide wire and dilator for insertion

by Seldinger technique

(3) Cook catheter (C-PPD-500/600-MP8561; Cook,

Bloomington, Indiana) (3)

(a) 5 and 6 Fr

(b) Cutting needle tip joined to a biopsy needle shaft with a collar that prevents the

catheter from sliding up the needle during

insertion

6. Evacuation device

a. Infant thoracostomy tube set: Several commercial

units are appropriate for infants (Fig. 38.2).

(1) Evacuation rate (4)

(a) With single tube, capacity depends on level

of water in chamber (cm H2O).

(b) With multiple tubes, capacity also depends

on applied vacuum.