Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
CHEST TUBE
dr. Feizal Faturahman
The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
OVERVIEW
• Chest tube thoracostomy involves placing a hollow plastic tube between the
ribs and into the chest to drain fluid or air from around the lungs.
• The tube is often hooked up to a suction machine to help with drainage.
• The tube remains in the chest until all or most of the air or fluid has drained
out, usually within a few days
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
INDICATIONS
1. Emergency
a. Pneumothorax
In all patients on mechanical ventilation
When pneumothorax is large In a clinically unstable patient
For tension pneumothorax after needle decompression
When pneumothorax is recurrent or persistent
When pneumothorax is secondary to chest trauma
When pneumothorax is iatrogenic, if large and clinically significant
b. Hemopneumothorax
c. Esophageal rupture with gastric leak into pleural space
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Cont…
2. Non-emergency
a. Malignant pleural effusion
b. Treatment with sclerosing agents or pleurodesis
c. Recurrent pleural effusion
d. Parapneumonic effusion or empyema
e. Chylothorax Postoperative care (e.g., after coronary bypass,
thoracotomy, or lobectomy)
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
CONTRAINDICATIONS
• There are no absolute contraindications
• Relative contraindications include a risk of bleeding in patients taking
anticoagulant medication or in patients with a predisposition to bleeding or
abnormal clotting profiles.
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
EQUIPMENT
a scalpel with size 11 blade;
several dissecting instruments, such as curved Kelly clamps or artery forceps;
a 10-ml syringe and a 20-ml syringe;
one small-gauge needle (size 25) and one larger-gauge needle for deeper
anesthetic infiltration (size 18–21);
a needle driver;
scissors;
one packet of strong, nonabsorbable, curved sutures of size 1.0 or larger, made
from silk or nylon4;
a chest tube of appropriate size.
A commercially available pleural drainage system, such as the Pleur-evac
(Teleflex Medical), should also be ready for connection after the chest tube is
inserted
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Cont…
Table 1. Sizing of Chest Tubes on the Basis of Indication
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Cont…
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
DRAINAGE CANISTER
1. Drainage canister typically used to collect chest tube contents (air,blood or
effusions)
2. Have 3 chambers :
The drainage collection chamber
The water seal chamber
The suction control
3. Needs to stay below the level of the patient’s chest.
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
PRE-TREATMENT EVALUATIONS
1. Monitor patient’s cardiorespiratory status & oxygen saturations throughout the
procedure.
2. Monitor patient's Patient's position :
Supine
Sit upright
Lateral decubitus position
3. Premidicate patient for pain control.
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
INSERTION SITE
1. Triangle of safety (Mid Axillary line at 4th or 5 th ICS)
Anterior border of latissimus dorsi
Lateral border of pectoralis major muscle
Line superior to horizontal level of nipple
Apex below axilla
2. Mid clavicular line 2nd ICS
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
PROCEDURE
1. Determine the site of insertion. Locate the triangle of safety; bounded by the lateral
border of the pectoris major, 5th or 6th intercostal space, imaginary vertical line between
the anterior and mid axillary lines.
2. Surgically prepare and drape the chest at the predetermined site of the tube insertion.
(Wear sterile gloves, gown, hair cover, face shield/ googles & apply sterile drapes to the
area)
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Cont…
3. Locally anaesthetized the skin and rib periosteum.
4. Make a 2-3cm transverse incision at the predetermined site and bluntly dissect through
the subcutaneous tissues, just over the top of the rib.
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Cont…
4. Use this to bevel or balance the dissecting instrument as you dissect the intercostal
muscles.
5. Once you reach the parietal pleura, gently push the dissecting instrument through it. You
may also digitally penetrate the pleura to avoid puncturing adjacent lung tissue, using
your index finger to explore the tract. Once your finger enters the pleura, withdraw the
Kelly clamp.
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Cont…
7. Once the distal tip of the tube has passed through the incision, unclamp the Kelly clamps
or forceps and advance the tube manually.
8. Aim the tube apically for evacuation of a pneumothorax and basally for evacuation of any
fluid.
9. Mattress or interrupted sutures should be used on both sides of the incision to close the
ends. Use the loose ends of the sutures to wrap around the tube and tie them off,
anchoring the tube to the chest wall.
10. Tape the tube to the side of the patient and wrap a petroleum-based gauze dressing
around the tube.
11. Cover this gauze with several pieces of regular sterile gauze, and secure the site with
multiple pressure dressings.
12. Connect the distal end of the chest tube to a sterile pleural drainage system, such as the
commercially available Pleur-evac.
13. Once the tube is connected, unclamp the distal end; if there is a pneumothorax, bubbling
may be seen.
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
CHEST RADIOGRAPH
CONFIRMATION
1. Obtain an anterior-posterior chest radiograph to confirm placement, by
identifying the radio-opaque line along the tube.
2. If the proximal drainage hole is outside the pleural space, drainage may be
ineffective and an air leak may result.
3. In this circumstance, the tube should be removed and a new chest tube
inserted.
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
COMPLICATIONS
1. Bleeding and hemothorax due to intercostal artery perforation
2. Perforation of visceral organs (lung, heart, diaphragm, or intraabdominal organs)
3. Perforation of major vascular structures such as the aorta or subclavian vessels
4. Intercostal neuralgia due to trauma of neurovascular bundles
5. Subcutaneous emphysema
6. Reexpansion pulmonary edema
7. Infection of the drainage site, pneumonia, and empyema.
8. There may be technical problems such as intermittent tube blockage from clotted blood,
pus, or debris, or incorrect positioning of the tube, which causes ineffective drainage.
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
TIMING OF CHEST-TUBE REMOVAL
1. It depends on the indication for insertion of the chest tube.
2. For a pneumothorax, bubbling must have ceased and the lung must be fully expanded on
chest radiograph before the tube can be removed.
3. If placement was for any pleural fluid drainage, once the drainage volume is less than 200
ml in a 24-hour period,3,5 the fluid is serous, the lung has re-expanded on the chest film,
and the patient’s clinical status has improved, the chest tube may be removed.
4. If the patient’s condition fails to improve after chest-tube insertion, a respirologist or a
thoracic surgeon should be consulted for more definitive management, such as
fibrinolytic therapy or surgical decortication
Reference: https://www.ncbi.nlm.nih.gov/books/NBK431091/
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
TECHNIQUE OF TUBE REMOVAL
1. The major concern with removal of a chest tube is the risk of pneumothorax during
removal.
2. Physician practice differs with respect to the point in the respiratory cycle at which the
tube is removed: during end-inspiration or end-expiration.
3. Two people may need to participate so that one can instruct the spontaneously breathing
patient and pull the tube while the other can quickly occlude the insertion site.
4. Cut the skin sutures, using sterile technique.
5. Have additional strong nylon or silk sutures ready in case additional sutures are required
to seal the hole.
6. Sterile petroleum-based and regular gauze should also be ready.
Reference: The New England Journal of Medicine 357;15 www.nejm.org
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
TECHNIQUE OF TUBE REMOVAL
7. Instruct the spontaneously breathing patient to perform a forced Valsalva maneuver or to
inhale to total lung capacity after a full exhalation.
8. If the patient is being fully mechanically ventilated, removal should be timed to end-
expiration.
9. One operator can pull the tube out while the other quickly occludes the site with gauze,
adds additional sutures to close the opening, and secures the site with a pressure dressing.
10.A chest radiograph 12 to 24 hours after removal is recommended.
Reference: https://www.ncbi.nlm.nih.gov/books/NBK431091/
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
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