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).

 

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

 

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

 

b. Transillumination (12)

c. Radiograph (7,21)

2. Provide ventilatory support as needed. Majority of

infants with a pneumothorax requiring chest tube also

need mechanical ventilatory support.

3. Monitor vital signs. Move any electrodes from the operative site to alternative monitoring areas.

4. Position infant with affected side elevated 60 to

75 degrees off the bed, and support the back with a

Fig. 38.7. Anterior versus posterior position of the

tube for drainage of air or fluid. Because air collects

anteromedially in the supine neonate, the posterior tip

is less appropriate.

C

A B

Fig. 38.6. A: Anteroposterior radiograph demonstrates ventral air over the hemidiaphragms and around

the heart (arrowheads). The sometimes difficult question of pneumothorax versus pneumomediastinum is

answered by the decubitus films. B: The left lateral

decubitus radiograph (right side up) shows that the

right-sided gas is a pneumothorax (arrowheads). C: The

right decubitus film indicates that the adventitial air fails

to come up over the lung and is located in the mediastinum (arrowheads). This important distinction is made

obvious by the decubitus radiographs.

Chapter 38 ■ Thoracostomy 261

C

A

B

Fig. 38.8. Sequential radiographs in a patient with right pneumothorax. An air collection in supine neonates (A) is most effectively

treated with an anteromedial chest tube (B, C). The medial extension is falsely exaggerated by the slight right posterior oblique rotation of the chest. Pulling this tube back might put the side holes

outside the pleural space. There is a pneumomediastinum, most evident on the lateral view, not drained by the pleural tube. Note the

nuchal air on all three films.

Fig. 38.9. A: Photograph of a pigtail catheter placed posteriorly for

pleural fluid drainage. B: Serosanguineous pleural fluid collection

into the chest tube set.

A

B

 

258 Section VII ■ Tube Replacement

5. While inserting the chest tube, allow some air to remain

within pleural space as protective buffer between lung

and chest wall (6).

a. Use emergency pneumothorax evacuation only if

patient is critically compromised. If emergency evacuation is used, remove air only until vital signs are stable.

b. Position infant so that point of entry is the most elevated area of the chest.

(1) Allows air to rise to provide protective buffer

(2) Direct tip of the chest tube anteriorly, toward

the apex of the thorax.

6. Consider the possibility that a rapid, complete evacuation may cause an abrupt increase in mean arterial

blood pressure and cerebral blood velocity to undesirable, supranormal levels (16).

7. To avoid further compromising ventilation, avoid positioning infant in lateral decubitus position with more

normal lung dependent for any longer than necessary.

C

A B

Fig. 38.3. Sequential radiographs. A: Anteroposterior

radiograph demonstrating a cystic lucency at the left base

behind the heart (arrows) that resembles the artifact caused

by taking a film through the hole in the top of an incubator.

Note also the coarse, irregular lucencies of interstitial emphysema (PIE) in the left lung. B: Lateral film showing the

lucency to be real (arrows) and, in this case, a pneumomediastinum located most probably in the left inferior pulmonary

ligament. C: PIE and air in the pulmonary ligament are often

harbingers of impending pneumothorax, in this case, a tension pneumothorax. Note low position of endotracheal tube.

Chapter 38 ■ Thoracostomy 259

Fig. 38.4. Radiographic artifact of cystic lucency behind the

heart (arrows) caused by taking film through top of incubator. The

lateral film was negative, therefore excluding a cystic pulmonary

lesion or air in the pulmonary ligament.

A B

Fig. 38.5. A: On this anteroposterior supine film, there is a line that parallels the chest wall (arrowheads), which suggests the presence of a pneumothorax. B: This left decubitus film (right side up) confirms this line to be a skin fold, negative for air. When there is a question of potential adventitial air or of

the anatomic location of real adventitial air, a decubitus film with the side in question up is the most

important radiographic study.

8. To prevent laceration of lung parenchyma, avoid

inserting needles beyond parietal pleura for diagnostic or emergency taps. Use a straight clamp perpendicular to the needle shaft to limit depth of penetration (Fig. 38.10).

9. Do not use purse-string suturing of the incision site

because resulting scars tend to pucker (6,17) (see

Fig. 38.9).

10. Recognize that air leaks are likely to persist after initial

evacuation in the presence of continuing lung disease

or positive-pressure ventilation. Air leaks resolve in 50%

of patients within the first 4 days after chest tube placement, and 83% resolve after 7 days (18).

a. Continue to watch for patency of the chest tube

(Fig. 38.11).

b. Verify the correct position of the tube.

c. Modify positive-pressure ventilator patterns to minimize risk of further air leaks (10).

(1) Decrease inspiratory time.

(2) Decrease mean airway pressure.

F. Technique (See also Procedures

Website)

Insertion of Anterior Tube for Pneumothorax

1. Determine location of air collection.

a. Physical examination

Auscultation of the small neonatal chest may be

misleading because the breath sounds normally

are bronchotubular and may be relatively well

transmitted across an air-filled hemithorax. In addition, a shift of the point of maximal cardiac impulse

toward the other side is unusual in the presence of

noncompliant lungs. Physical findings of acute

260 Section VII ■ Tube Replacement

abdominal distention, irritability, and cyanosis

and/or a change in transthoracic impedance suggest an air leak but not its location (19,20).

Supplementary diagnostic procedures are usually

necessary.

Chapter 38 ■ Thoracostomy 257

b. Size of fistula or tear

c. Infant position

The dependent placement of the needle puncture site allows reduction of both the alveolar

size and alveolar to pleural pressure difference

in the region surrounding the leak, thereby reducing and possibly stopping pneumothorax formation (9).

3. Rate of evacuation

a. Directly proportional to

(1) Internal radius of chest tube (r

4

)

(2) Pressure gradient across tube (DP)

(a) Suction pressure applied

The negative pressure applied may effect

intrapleural pressure only in the immediate

vicinity of the tip of the tube (4).

(b) Positive intrathoracic pressure during exhalation and spontaneous or mechanical ventilation

b. Inversely proportional to length of tube and

viscosity

Poiseuille’s law regarding flow across a tube is F =

DPπr

4

/8hl, where F = flow; DP = pressure gradient;

r = radius; h = viscosity; and l = length.

E. Precautions

1. Anticipate which infant is at risk of developing pulmonary air leakage and keep equipment for diagnosis and

emergency evacuation at bedside (6,10,11).

2. Recognize that transillumination may be misleading

(12,13).

a. True positive

(1) Follows shape of thoracic cavity (not corona of

light source)

(2) Varies with respiration and position

(3) Has larger area compared with corona of light

b. False positive

(1) Subcutaneous edema

(2) Subcutaneous air

(3) Severe pulmonary interstitial emphysema

c. False negative

(1) Thick chest wall

(2) Darkly pigmented skin

(3) Area over air accumulation obscured by dressing/monitor probe

(4) Weak light due to fiberoptic deterioration or

voltage turned too low

(5) Room too bright

(6) Abnormal color vision in observer

3. Distinguish pleural air collections from skin folds, thymus, Mach effect*, artifacts, or other nonpleural intrathoracic air collections on radiograph (Figs. 38.3–38.6)

(7,14).

4. Select the appropriate insertion site (Figs. 38.7 and 38.8).

Allen et al. (15) recommend inserting the thoracostomy tube in the anterosuperior portion of the chest

wall, in the first to third intercostal space at the midclavicular line, to ensure anterior placement of the chest

tube tip. However, although an anterior insertion may

be appropriate for the right-angled pigtail tube used by

Allen et al., a properly placed lateral tube will have its

tip anterior but, more important, will not leave a (more

visible) scar on the anterior chest and completely

avoids the nipple (see Fig. 38.9).

a. Reduces complications

b. Facilitates insertion of thoracostomy tube into

appropriate position

(1) Anteromedial tip position for air collections

(2) Posterior tip position for fluid accumulation

(Fig. 38.9A, B).

Fig. 38.2. One model of an underwater drainage system,

demonstrating the three necessary chambers. Systems now

are compact and easy to set up and read. This system is set at

22 cm H2O, which would be necessary only for a rapid rate of

air accumulation.

*Appearance on x-ray of a dark or light line where there is a convex or

concave curve in the body shape of the patient.

 

 

256 Section VII ■ Tube Replacement

(2) Negative pressure of 20 cm H2O evacuates more

than 4 L of air/min in experimental setting (4).

(a) Appropriate starting point for most infants

with lung disease on ventilators is 10 to

15 cm H2O

(b) Potentially inadequate in a case of bronchopleural fistula

(c) Excessive suction pressure may draw tissue

into the side holes of the chest tube and

could also be potentially harmful by changing intrapulmonary air flow in presence

of smaller pleural leak (always start with

10 cm H2O).

Measured rates across bronchopleural

fistulas in infants have indicated ranges

from 30 to 600 mL/min (5). If suction pressure is too high, gas flow to alveoli may be

diverted across a fistula. The pressure and

flow applied to the endotracheal tube also

directly influence flow across a fistula (5).

Because there are many interactive factors

influencing how much air might have to be

evacuated, there can be no single best suction level for all patients; the most effective,

least harmful level has to be determined for

each situation (6).

7. Nonabsorbable suture on small cutting needle, 4.0

8. Cotton-tipped applicators

9. Semipermeable transparent dressing

10. Antibiotic ointment

11. Petroleum gauze

Nonsterile

1. Tincture of benzoin

2. 0.5-inch adhesive tape

3. Transillumination device

4. Towel roll

D. Factors Influencing Efficiency

of Air Evacuation

1. Contiguity of air to chest tube portals; they must be

patent

a. In supine infant, air accumulates in the medial,

anterior, or inferior hemithorax, making low

anterior location for tip of tube ideal for evacuation (7).

b. Negative pressure on chest tube may draw tissue

into side portals and occlude them.

2. Rate of air accumulation is proportional to

a. Airway flow and pressure

Dennis et al. (8) demonstrated in experimental

rabbit models that a positive end-expiratory pressure

level >6 cm H2O resulted in greater air leak than

peak inspiratory pressures up to 30 cm H2O.

Fig. 38.1. Pigtail catheter for pleural drainage (Fuhrman pleural drainage set). (Illustration provided by

Cook Critical Care, Bloomington, Indiana).

 

255

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.