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

Chest Tube Insertion and Needle Decompression

AFAMS Resident Orientation

April 8, 2012


Outline

Outline

  • Needle Decompression

  • Chest Tube Insertion

    • Indications / Contraindications

    • Equipment

    • Insertion

    • Confirming Placement

  • Managing Chest Tubes

    • Toubleshooting


Needle decompression indications

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

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 decompression

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 tube

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

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

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

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

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

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

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

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 tract1

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

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

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

Preventing Air Leak

  • Surround the tube with petroleum based sterile gauze

  • Cover the gauze with several pressure dressings


Confirming placement

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

Proper and Improper Chest Tube Placement

Improper Placement

Proper Placement


Connecting the chest tube to drainage

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

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

Managing Chest Tubes

  • Pain

    • Often referred to ipsilateral shoulder

  • Pain Control

    • Epidural

    • Toradal IV


Managing chest tubes drainage system

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 system1

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 system2

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

Example of Drainage System

3

1

2


Managing chest tubes suction

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

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 leak1

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

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 pneumothorax1

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

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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