CHEST TUBES

Chest tubes Indications Pleural effusions Pneumothorax Hydrothorax Chylothorax Hemothorax Empyema Pneumothorax

Pleural Effusions Fluid in the pleural space Two types Transudative Exudative

Pleural Effusions Transudative Accumulation of fluid when the integrity of the pleural space is intact Less protein and inflammatory cells Hydrostatic and osmotic pressures are abnormal

Pleural Effusions Exudative Inflammation of the lung or pleura More protein and inflammatory cells Types Hemothorax Chylothorax

Pleural Effusion Exudative Causes Neoplastic disease Infectious disease PE GI disease Drugs

Sike! Someone thought this was a pleural effusion. Why isn’t it? This elderly lady presented with delirium, but no other medical history could be obtained. The chest x-ray showed what was assumed (by the medical registrar) to be a right sided pleural effusion. He was keen to drain it. Luckily, the physician decided that he wanted a CT of the chest first, which revealed a large right-sided diaphragmatic hernia. The scout image from the CT is shown, which demonstrates colonic bowel gas and soft-tissue density corresponding to the liver herniating into the right hemithorax. There is also Paget’s disease of the right humerus. Incidentally-discovered posterior diaphragmatic hernias (Bochdalek hernias) are rare (0.17% of patients having an abdominal CT). Of these, right-sided hernias are more common (68%). The great majority are small, with only 27% containing abdominal organs such as bowel, spleen or liver. Reference: Mullins ME, et al. Prevalence of Incidental Bochdalek’s Hernia in a Large Adult Population. AJR 2001; 177:363-366 Credit: Dr Michael Tam ANIMATION: SIKE http://images.google.com/imgres?imgurl=http://radpod.org/wp-content/uploads/2006/11/c_hernia_1.jpg&imgrefurl=http://www.radpod.org/2006/11/29/incidental-diaphragmatic-hernia/&h=898&w=972&sz=170&hl=en&start=4&tbnid=jXOADRpIamp8XM:&tbnh=138&tbnw=149&prev=/images%3Fq%3Dpleural%2Beffusion%2Bdrain%26gbv%3D2%26hl%3Den

Now here’s a pleural effusion. Case Report An eighteen year old male presented to the emergency department with rapidly progressive shortness of breath, chest tightness, and a physical exam significant for tracheal deviation. The patient had a past medical history significant only for tuberculosis diagnosed three years prior. A chest roentgenogram revealed a massive right side pleural effusion with significant tracheal and mediastinal shift (Fig. 1). An attempt to drain this effusion with a thoracostomy tube was not successful in resolving the patient's symptoms and was cytologically non-diagnostic. Video assisted thoracoscopy was performed. Three large cystic masses were seen within the right chest. Due to their massive nature the decision was made to perform a standard posterolateral thoracotomy. The superior cystic mass was found to arise from the superior mediastinum, the middle mass was adherent to the pericardium, and the inferior mass arose from the posterior mediastinum, entering the abdomen at its lower border. A second thoracostomy tube was placed and the surgical incision closed. The patient's postoperative course was uneventful. He was discharged home on the fifth day following surgery. Histopathology confirmed the diagnosis of cystic hygroma (Fig. 3). In an eighteen month period following discharge the patient has required two hospital admissions for chest tube drainage of symptomatic right pleural effusions. Discussion Occult cystic hygroma represent a variant type of cystic hygroma that remains hidden within the thoracic or abdominal cavities. They eventually present in adolescence or adulthood and may grow to enormous size prior to becoming symptomatic 4 . Many are discovered incidentally as abnormal radiographic findings. http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijtcvs/vol6n2/cystic.xml

Pneumothorax Air in the pleural space Can be Traumatic Spontaneous Tension

The symptoms of tension pneumothorax tend to be severe with sudden onset (beginning). They include anxiety, swollen neck veins, weak pulse, and decreased breathing sounds from the lung Chest X ray showing a collapsed right lung (the left side of the image). (© 1990. Reproduced by permission of Custom Medical Stock Photo .) http://www.faqs.org/health/Sick-V3/Pneumothorax.html

Chest tubes Small bore 7 French shown Heimlich valve What is the size range for children and adults? Heimlich valve Used for pneumothorax mostly

Chest tube Insertion 2nd or 3rd intercostal space Midclavicular level

Chest Tube Large bore Up to 40 French For pleural effusions and pneumothorax Use local anesthetic and dissect to the parietal pleura Finger sized hole

Chest Tube Large Bore Insertion Suture into place, use petroleum gauze 4th to 6th intercostal space Midaxillary line Suture into place, use petroleum gauze Get x-ray Hook to drainage system

Drainage systems Gravity Positive pressure Suction Affects air and fluid Positive pressure Increased positive pressure from the air or fluid will try to relieve itself to lower pressure Suction Sub-atmospheric pressure Gravity: self-explanatory Increased positive pressure from the air or fluid will try to relieve itself to lower pressure (in the water) Suction: Use of vacuum speeds the movement of air and fluid

Drainage systems One bottle system Contains 100ml of sterile water Airtight cap Two vent tubes

Drainage systems Two bottle system 1st bottle = drainage 2nd bottle = water seal

Drainage systems Three bottle system 1st bottle = drainage 2nd bottle = water seal 3rd bottle = suction

Drainage systems Trouble shooting Excessive bubbling No bubbling Leak in system No bubbling Re-expansion or occlusion Milk the tubes…maybe

Drainage systems Pleur-evac Three bottle concept in one lightweight, plastic unit Easy to transport Difficult to break Easy to exchange when full Will hold up to 2500 mL of fluid

Drain systems Pleur-evac Right side – calibrated for measurement of fluid evacuation Middle – water seal chamber Left side – suction control

What constitutes stable?? Chest tube removal Requirements No air leak < 100 mL drained in 12 - 24 hours Stable respiratory status What constitutes stable??

Chest tube removal Patient in semi-fowlers Premedicate D/C suction, clamp tube Prep 4x4 gauze of Jelonet and elastoplast tape

Chest tube removal Remove current dressing and remove sutures Clean site with antiseptic solution Patient deep breath, pull out Should come out easily!!!!!! Secure site with the gauze and elastoplast

Chest tube removal Watch patient for signs/symptoms of respiratory distress Get chest x-ray