262 Section VII ■ Tube Replacement

Fig. 38.10. Chest wall in cross-section. If there is need to use a

needle or trocar to enter the pleural space, its depth of penetration

should be limited by a perpendicular clamp.

Fig. 38.11. Evaluation of a chest tube: Flow chart to determine how well a chest tube is evacuating pleural air leak and when the tube

should be removed.

towel roll. Secure arm across the head, with shoulder

internally rotated and extended (Fig. 38.12A).

This position is very important because it allows air

to rise to the point of tube entry within the thoracic cavity, outlines the latissimus dorsi muscle, and encourages the correct anterior direction of the tube.

5. Prepare the skin with an antiseptic solution over the

entire lateral portion of chest to the midclavicular line,

and allow skin to dry.

6. Drape surgical area from third to eighth ribs, and from

latissimus dorsi muscle to midclavicular line (Fig.

38.12B). Using a transparent drape allows for visualization of landmarks.

7. Locate essential landmarks (Fig. 38.12C).

a. Nipple and fifth intercostal spaces

b. Midaxillary line

c. Skin incision site is at point midway between midaxillary and anterior axillary lines, in the fourth or fifth

intercostal space. A horizontal line from the nipple

is a good landmark for identifying the fourth intercostal space. Keep well away from breast tissue (22).

8. Remove trocar from tube.

Using a trocar during tube insertion is not recommended because of the greater risk of lung perforation.

Dissection to the pleura should be performed, with

puncture of the pleura by the tip of the closed forceps,

not by a trocar. If a trocar is to be used after dissecting

to the pleura, there should be a straight clamp perpendicular to the shaft at 1 to 1.5 cm from the tip to avoid

penetrating too deeply (Fig. 38.10).

9. Estimate length of insertion for intrathoracic portion

of tube (skin incision site to midclavicle). This should

be approximately 2 to 3 cm in a small preterm infant

and 3 to 4 cm in a term infant. (These are approximate

guidelines only.)

10. Infiltrate skin at incision site with 0.125 to 0.25 mL of

1% lidocaine.

11. Using a no. 15 blade, make incision through skin

approximately the same length as chest tube diameter,

or no more than 0.5 to 1 cm (Fig. 38.12C).

12. Puncture pleura immediately above the fifth rib by

applying pressure on the tip of the closed forceps with

index finger (Fig. 38.12D).

a. Place the forefinger as shown in Fig 38.12D and not

further forward on the forceps, to prevent the tip

from plunging too deeply into the pleural space.

b. A definite “give” will be felt as the forceps tip penetrates

the pleura; there may also be an audible rush of air.

Chapter 38 ■ Thoracostomy 263

Fig. 38.12. Insertion of a soft chest tube. A: Position the infant with back support so the point of tube entry will be highest. Fix arm over

the head without externally rotating it. Note the midaxillary (MA) line and the line from the nipple through the fourth intercostal space

(ICS). B: Drape so head of the infant is visible. C: Same landmarks without the drape, showing the incision in the fourth ICS in the MA

line with entry into the chest at the intersection of the nipple line and the MA line. D: Turning the hemostat to puncture into the pleura

in the fourth ICS. E: With the index finger marking the fourth ICS puncture site, the tube may now be passed between the hemostat

blades, along the tunnel into the pleural space.

A

B

C

D

E