264 Section VII ■ Tube Replacement

c. After puncturing pleura, open hemostat just wide

enough to admit chest tube.

13. Leaving hemostat in place, thread tube between

opened tips to the predetermined depth (Fig. 38.12E).

a. Alternatively, insert closed tips of mosquito hemostat into side port of tube to its end. The disadvantage of this method is that the forceps will have to be

withdrawn from the opening in the chest; it is common that the intercostal muscles then render the

opening undetectable (22,23).

b. Direct chest tube cephalad toward apex of the thorax

(midclavicle), and advance tip to midclavicular line,

ensuring that all side holes are within the pleural space.

c. Observe for humidity or bubbling in the chest tube,

to verify intrapleural location.

14. Connect tube to vacuum drainage system and observe

fluctuations of meniscus and pattern of bubbling (Fig.

38.11). Avoid putting tension on tube.

15. Secure chest tube to skin with suture (Fig. 38.13A).

a. Use one suture to close the end of the skin incision

and make an airtight seal with the chest tube. Tie

the ends of the suture around the tube in alternating

directions, without constricting the tube.

Using a traditional purse-string suture to secure the

tube leaves an unsightly scar and is, therefore, not recommended. Unless the skin incision has been made

unnecessarily long, a single suture is usually sufficient.

b. Apply tincture of benzoin to chest tube near chest

wall and to skin several centimeters below incision.

When tacky, encircle tube with a 2-inch length of

tape, leaving the tab posterior (Fig. 38.13B).

c. Place suture through skin and tab of tape to stabilize

the chest tube in a straight position (Fig. 38.13B).

d. Alternatively, secure tube with a tape bridge (Fig.

38.14) or clear adhesive dressing (the latter may not

be optimal; chest tubes tend to function optimally

when allowed to exit from the skin at as close to a

90-degee angle as possible).

16. Apply antibiotic ointment or petroleum gauze around

skin incision. Cover with a small semiporous transparent dressing.

It is important not to cover the wound with a heavy

dressing, as this restricts chest wall movement, obscures

tube position, and makes transillumination more difficult. If the position of tube is in doubt, secure with a

temporary tape bridge before covering with dressing,

until the correct position is confirmed.

17. Verify proper position of tube.

a. Anteroposterior and lateral radiographs (6,24–26)

Both views are recommended to detect anterior

course of tube. See Tables 38.1 and 38.2 for radiographic clues on malpositions. A malpositioned tube

tip results in an increased risk of complications and/

or poor air evacuation. A chest radiograph should

confirm that the side holes are within the chest cavity.

b. Pattern of bubbling (Fig. 38.11)

18. Strip tube if meniscus stops fluctuating or as air evacuation decreases. Take extreme care not to dislodge tube

by holding tube firmly with one hand close to chest wall.

Insertion of Posterior Tube for

Fluid Accumulation

The technique is similar to that for an anteriorly positioned

tube, with the following differences.

1. Position infant supine, elevating the affected side by 15

to 30 degrees from the table. Secure the arm over the

head (Fig. 38.15).

2. Prepare skin over lateral portion of hemithorax from

anterior to posterior axillary line.

A

B