Chest tube insertion and needle decompression
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Chest Tube Insertion and Needle Decompression. AFAMS Resident Orientation April 8, 2012. Outline. Needle Decompression Chest Tube Insertion Indications / Contraindications Equipment Insertion Confirming Placement Managing Chest Tubes Toubleshooting.

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Chest Tube Insertion and Needle Decompression

AFAMS Resident Orientation

April 8, 2012


Outline

  • Needle Decompression

  • Chest Tube Insertion

    • Indications / Contraindications

    • Equipment

    • Insertion

    • Confirming Placement

  • Managing Chest Tubes

    • Toubleshooting


Needle Decompression Indications دیکمپریشن پلورا

  • Emergency Use for Tension Pneumothorax

  • Not indicated for simple pneumothorax, open pneumothorax or flail chest

  • If done in a patient without pneumothorax, increased morbidity

  • موارداستفاده

  • - کمک عاجل برای تنشن نموتوراکس

  • نوت

    درحالاتی که مریض نموتوراکس ساده، نموتوراکس باز،هیموتوراکس یا flail chest داشته باشد موثرواقع نمی ش


Tension Pneumothorax تنشن نموتوراکس

Signs and Symptoms

اعراض وعلایم

صدای تنفس موجود نمی باشد یا تقلیل میابد

بلند شدن صدربه شکل غیرمساویانه

Dyspnea افزایش میابد

ناراحتی / اضطراب

نشانه ها یا تاریخچه جرحه غشای صدر

وریدهای عنق متورم میگردد

ضعیف شدن یا کم عرض شدن فشارنبض

شاک

mediastinal shift (late)

  • Decreased or low breath sounds

  • Unequal chest rise

  • Dyspnea increases

  • Discomfort/anxiety

  • Signs and history of chest injury

  • Jugular veins inflated

  • Weakness of pulse pressure

  • Shock

  • Mediastinal shift (late)


Locations for Needle Decompressionانتخاب ناحیه

  • Preferred

    • 2nd or 3rdintercostal space, mid clavicular line

  • Alternative

    • 5thintercostal space, mid axillary line

    • For patient transportation, other sites are not recommended.

  • Always place needle above the rib!

  • ترجیح داده شده

    • جوف دوم یا سوم بین الضلعی ، خط وسطclavicular

  • الترنیتو

  • جوف بین الضلعی پنجم ، خط وسط axillary

  • برای انتقال دادن مریض ، ناحیه های دیگر توصیه نمی گردد


Chest Tubeچست تیوب

Indications

موارد استعمال و هدف

دریناژ مایع و هوا ازجوف پلورا یا mediastinum

برای تداوی نموتوراکس ، هیموتوراکس ، هیمونموتوراکس و empyema (pus ) استفاده میشود

درجمع نمودن مایعات موثر میباشد

درحمایه تنفس کمک کننده میباشد .

  • Drainage of fluid or air from pleural cavity

  • Is used to treat pneumothorax, heamothorax, hemopneumothorax, and empyema (pus)

  • Is effective to collect fluids.

  • Is helpful to support breathing


Chest Tube Equipment

  • Sterile gown, gloves, mask, drapes, and gauze

  • Chlorhexidine or betadine

  • 22 or 25 Gauge needle, 10 cc syringe, 1-2% Lidocaine

  • Scalpel with 11 blade

  • At least 4 Kelly curved clamps or artery forceps

  • Strong, non-absorbable sutures size 1.0 or greater (silk or nylon)

  • Sterile drainage system


Chest Tube Size

  • Appropriate chest tube size

    • Chest tubes sized by internal diameter

    • Length marked on side of tube

    • Radiopaque strip runs length of tube and encircles the most proximal drainage hole

  • Choosing appropriate size depends on clinical indication for chest tube

    • Stable patient with large pneumothorax: 16-22 French

    • Unstable patient, chronic lung disease, high air leak risk: 24-28 French

    • Empyema, pneumothorax in patient on ventilator: 28-32 French


Chest Tube Procedure

  • Obtain and review a chest x-ray prior to procedure

  • Occlude proximal free end of chest tube with forceps

  • Occlude insertion end of tube with forceps, this will help with insertion of tube

  • Place patient in supine position, move ipsilateral arm behind patient’s head


Locate Site of Entry

  • Triangle of Safety

    • Lateral border of pectoral major muscle

    • Mid-axillary line

    • Horizontal line from the nipple

  • 4th or 5thintercostal space


Preparation of the Incision Site

  • Clean region with betadine or chlorhexidine

  • Apply analgesia

    • 25G needle form superficial wheel

    • Inject subcutaneous tissue

  • Using longer needle inject lidocaine into

    • Deeper subcutaneous tissue

    • Numb the periostium of the rib below insertion site


Preparation of Insertion Site

  • After anesthetizing the periostium advance needle overtop of the rib

  • Aspirate every 1-2 cm and inject lidocaine

  • Using scalpel make 2 cm incision parallel but just above the rib


Formation of Tract

  • Insert Kelly clamp through incision

  • Use blunt dissection technique and advance over rib

  • Kelly clamp will “pop” through parietal pleura


Formation of Tract

  • Use index finger to trace tract created by Kelly clamp

  • Using forceps direct tube through tract using finger as guide


Advancing Tube

  • Advance tube toward lung apex in patients with pneumothorax

  • Advance tube toward base in patients with hemothorax, chylothorax or pleural effusion

  • Advance tube until you are sure all drainage holes are inside parietal pleura


Securing Chest Tube

  • Secure tube to skin using heavy suture

  • Mattress or several simple interrupted sutures to close the hole around the tube

  • Use the free ends of the suture to wrap around the tube several times

  • Tie the free ends of the suture around the tube


Preventing Air Leak

  • Surround the tube with petroleum based sterile gauze

  • Cover the gauze with several pressure dressings


Confirming Placement

  • Confirm proper placement of chest tube with chest x-ray.

  • Using the radio opaque stripe, make sure all drainage holes are contained inside the pleura.

  • If they are not, replace the tube, DO NOT ADVANCE existing tube


Proper and Improper Chest Tube Placement

Improper Placement

Proper Placement


Connecting the Chest Tube to Drainage

  • Connect the chest tube to a sterile draining system

  • Unclamp the tube

  • Place drainage system at least 40 inches below the patient


Complications

  • Bleeding

  • Traumatic organ injury or perforation

  • Intercostal neuralgia from damage to intercostals neurovascular bundle

  • Subcutaneous emphysema

  • Re-expansion pulmonary edema

  • Infection of the drainage site

  • Empyema


Managing Chest Tubes

  • Pain

    • Often referred to ipsilateral shoulder

  • Pain Control

    • Epidural

    • Toradal IV


Managing Chest Tubes: Drainage System

  • Three functional chambers to a drainage system

  • 1st Chamber: collects fluid/air from patient

    • Fluid accumulates in 1st Chamber

1


Managing Chest Tubes: Drainage System

  • 2nd Chamber: Air rises from 1st chamber enters 2nd chamber from below

    • Water seal will “bubble”

    • Height of water in 2nd chamber indicates amount of suction

2


Managing Chest Tubes: Drainage System

  • 3rd Section is an atmospheric vent

    • Manually venting through a pressure relief valve

    • It equilibrates collection chamber with atmospheric pressure

3


Example of Drainage System

3

1

2


Managing Chest Tubes: Suction

  • Amount of suction depends on indication

    • Spontaneous air leak: start at -10 cm water and use least amount needed to maintain full expansion

    • Collapsed lung due to PTX: use low gradient to avoid re-expansion pulmonary edema

    • Fluid Drainage: start at -20 cm of water


Troubleshooting: Air Leak

  • Continuous bubbling in water seal chamber

  • Leak is between patient and water seal

  • Actions:

    • Tighten loose connections

    • Locate Leak

  • If that doesn’t work …


Troubleshooting: Air Leak

  • Clamp tube near chest wall

    • If bubbling stops then leak is inside thorax

      • Get CXR

      • Call Attending Physician

    • If bubbling continues then air leak is between clamp and drainage system

  • Slowly move the clamp from the thorax to the collection system

    • If bubbling stops at any point in time you have found the leak in the tube

      • Replace Tube

    • If bubbling doesn’t stop, leak is in collection system

      • Replace collection system


Troubleshooting: Tension Pneumothorax

  • Patient is in respiratory distress even with chest tube in place

  • First: make sure chest tube is not obstructed

    • Clamped

    • Occluded

    • Kinked


Troubleshooting: Tension Pneumothorax

  • Drain tubing contents into a separate drainage bottle

  • Make sure water seal is connected

  • Make sure water-seal is not broken

  • If patient has signs of tension PTX, call attending and prepare for a second chest tube placement


Conclusions

  • Tension Pneumothorax is a life threatening event that can be quickly treated with needle decompression

  • Chest tubes are used to treat many pulmonary conditions

  • Proper technique will minimize complications

  • Careful management of chest tubes will expedite their removal and improve patient status


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