Fig. 38.13. Securing a chest tube. A: Make the incision site airtight with the tube. Do not use a pursestring suture around the incision because it will form a puckered scar. The initial incision should be made

small enough to require only a single suture. B: After painting the tube and skin with benzoin, encircle the

suture around the tube or attach a tape and suture it to the skin.

Chapter 38 ■ Thoracostomy 265

3. Make a skin incision 0.5 to 0.75 cm in length, just

behind the anterior axillary line in the fourth to sixth

intercostal space and following direction of rib.

a. Fourth or fifth space for high posterior tube tip

b. Sixth space for low posterior tube tip

4. Take care to position forceps tip immediately above a

rib to avoid the intercostal vessels that run under the

inferior surface of the rib. Penetrate the pleura as

described for an anterior chest tube.

5. Insert tube only deeply enough to place side holes

within pleural space.

6. Collect drainage material for culture, chemical analysis, and volume.

7. Connect to an underwater seal drainage system that

includes a specimen trap.

8. Strip tube regularly.

9. Monitor and correct any imbalance caused by loss of

fluid, electrolytes, protein, fats, or lymphocytes.

Removal of Thoracostomy Tube

1. Ascertain that tube is no longer functioning or needed.

a. Evaluate as suggested in Fig. 38.11.

b. Leave chest tube connected to water seal without

suction for 4 to 12 hours. Do not clamp tube.

(1) Transilluminate to detect reaccumulation.

(2) Obtain radiograph.

c. Document absence of significant drainage.

2. Assemble equipment.

Sterile

a. Antiseptic solution

b. Gloves

c. Scissors

d. Forceps

e. Petroleum gauze cut and compressed to 2-cm

diameter

f. Gauze pads, 2 × 2 inch

A B C

D

Fig. 38.14. Tape bridge. A: Two tape towers. B,

C: Bridge under the tube and towers overlapping on

top. D: Additional cross tape to keep the chest tube

flat without kinking.

Table 38.1 Clues to Recognize

Thoracostomy Tube Perforation

of the Lung

1. Bleeding from endotracheal tube

2. Continuous bubbling in underwater seal

3. Hemothorax

4. Blood return from chest tube

5. Increased density around tip of tube on radiograph

6. Persistent pneumothorax despite satisfactory position on frontal view

7. Tube lying neither anterior nor posterior to lung on lateral view

8. Tube positioned in fissure

Clues to Thoracostomy Tube

Positioned in Fissure

Table 38.2

1. Major interlobar fissure

a. Frontal view: Upper medial hemithorax

b. Lateral view: Oblique course posterior and upward

2. Minor fissure (on right)

a. Horizontal course toward medial side of lung

Clues to Thoracostomy Tube

Positioned in Fissure

266 Section VII ■ Tube Replacement

Nonsterile

1-inch tape

3. Cleanse skin in area of chest tube with antiseptic.

4. Release tape and suture holding tube in place. Leave

wound suture intact if skin is not inflamed.

5. To prevent air from entering chest as tube is withdrawn

until petroleum gauze is applied, palpate pleural entry

site and hold finger over it. After removing tube,

approximate wound edges and place petroleum gauze

over the incision. Keep pressure on the pleural wound

until dressing is in place.

6. Cover petroleum gauze with dry, sterile gauze. Limit

taping to as small an area as possible so that transillumination will be possible.

7. Remove sutures when healing is complete.

G. Complications

1. Misdiagnosis with inappropriate placement

2. Burn from transillumination devices (27)

3. Trauma

a. Lung laceration or perforation (28) (Fig. 38.16)

b. Perforation and hemorrhage from a major vessel

(axillary, pulmonary, intercostal, internal mammary) (15) (Fig. 38.17)

c. Puncture of viscus within path of tube (Fig. 38.18)

d. Residual scarring (17) (Fig. 38.19)

e. Permanent damage to breast tissue (17)

f. Chylothorax (29)

4. Nerve damage

a. Horner syndrome caused by pressure from tip

of right-sided, posterior chest tube near second

thoracic ganglion at first thoracic intervertebral

space (30)

b. Diaphragmatic paralysis or eventration from phrenic

nerve injury (31)

Fig. 38.15. Insertion of a posterior chest tube. With the infant

supine, the incision is in or just below the anterior axillary line,

with the tube entry into the pleura more posteriorly Take care to

enter pleural space over the top of a rib.

A B

Fig. 38.16. Postmortem examination of infants who died with uncontrolled air leaks. A: Perforation of

the right superior lobe by a chest tube inserted without a trocar, demonstrating that virtually any tube can

penetrate into the lung. B: Perforation of the left upper lobe by a chest tube (arrow).