Lecture on Chest Tube Insertions

Introduction

• Purpose: Guide on successful chest tube insertions.
• Settings: Floor or operating room.
• Overview: Considerations, positioning, landmarks, and techniques.

Pre-Insertion Considerations

• Patient Stability: Determine if procedure can be safely done on the floor or requires operating room.
• Purpose: Air or fluid drainage.
  • Air: Tube directed apically.
  • Fluid: Tube directed posteriorly (postural, apical, or basal).
• Patient History:
  • Prior chest tubes or surgeries can cause adhesions.
  • Elevated hemidiaphragm, diaphragmatic paralysis, or significant consolidation/atelectasis can lead to incorrect placement.
• Anticoagulation Status: Check if reversal is needed.
• Ventilation: Consider if patient is on positive pressure ventilation.
• Pain Management:
  • Medication 30 minutes prior.
  • Local anesthesia for each layer, especially for awake patients.

Preparation

• Ensure all supplies are ready:
  • Extra stitch, chest tube atrium, local anesthesia.
• Have assistance available:
  • At least a nurse; ideally another resident.
• Patient Positioning:
  • Thorax flat or flexed.
  • Arm over the head, bump under back.

Landmark Identification

• Landmarks:
  • Tip of the scapula.
  • Anterior superior iliac spine.
  • Mid-axillary line: place chest tubes in front for comfort.
  • Nipple or inframammary/pectoral crease for insertion line.
  • 12th rib to approximate diaphragm position.
• Special Considerations: Loculated collections, casting, or hardware.

Procedure Planning

• Plan incision before prep and drape.
• Use a marking pen for incision planning.
• Keep landmarks visible during draping.

Incision and Insertion

• Incision: Adequate size for finger and tube insertion (approx. 2.5 cm).
• Timeout: Verify patient, laterality, equipment, and help.
• Techniques:
  • Proper knife grip for controlled incision.
  • Local anesthesia for awake patients.
  • Blunt dissection to chest wall.
  • Finger sweep to ensure no adhesions.
  • Guide tube appropriately (apical or posterior).

Securing the Tube

• Use large silk suture, take large skin bites, and tie multiple knots.
• Create a small waist on the tube without impeding drainage.
• Use a second suture for closing any space.
• Connect chest tube to atrium and band securely.
• Use Vaseline and gauze for dressing, secure with Tegaderm/tape.
• Post-Procedure: Confirm position with x-ray.

Summary

• Know indications and risks (bleeding, surgery, elevated hemidiaphragm).
• Be prepared and have assistance.
• Position patient and identify landmarks.
• Carefully place and secure the tube.
• Confirm placement and effectiveness with x-ray.

Conclusion

• Emphasize importance of preparation, planning, and execution for successful chest tube insertion.