Chest Tubes and Thoracentesis Core Course July 2012

Chest Tubes Indications Pneumothorax Tension Spontaneous Iatrogenic consider while on mechanical ventilation Hemothorax Empyema Chylothorax Pleurodesis Bronchopleural fistulas

Pneumothorax

Technique Things to consider before starting! Type of tube (Straight or angled) Size of the tube (what disease are you treating?) Insertion site Lateral or anterior Insertion technique to be employed (standard or Seldinger)

Specific Considerations How to choose a chest tube size? Pneumothorax — A 16 to 24 Fr chest tube. Traumatic pneumothorax — 28 to 40 Fr chest tube drainage of blood in addition to air may be necessary. Malignant effusion — A 20 to 24 Fr chest tube Empyema —28 to 36 Fr chest tube May need more than one tube for loculated areas Hemothorax — 32 to 40 Fr chest Larger caliber helps prevent occlusion

Insertion site Fourth or fifth intercostal space in the anterior axillary or mid-axillary line. Second intercostal space in the mid-clavicular line alternate site dissection through the pectoralis muscle leaves a visible scar loculated anterior pneumothorax with the use of a small bore catheter (10 to 14 Fr) rather than a standard chest tube.

Insertion techniques: Standard vs.Seldinger Standard technique — The following steps are the most common method employed to place a chest tube: Consider conscious sedation with morphine and a benzodiazepine if hemodynamically stable The patient is placed supine Arm of the involved side placed behind the head Prep area with chlorhexidine Drape with sterile towels Anesthetize skin with 1% Lidocaine—anesthetize the entire area, including the tract and rib A 2 cm skin incision is made parallel to the intercostal space Kelly clamp is used for blunt dissection to enter puncture the parietal pleura and enter the chest above the rib in order to reduce the risk of neurovascular injury May need to use additional lidocaine to anesthetize the periosteum The Kelly clamp is then opened to spread the parietal pleura and intercostal muscles. A finger is inserted through the tract into the pleural space to confirm proper position and lack of adhesions between the lung and the pleural surface. Only easily disrupted adhesions should by lysed with the operator's finger, as significant bleeding can occur if more organized adhesions are disrupted. The chest tube is clamped at the proximal end with the Kelly clamp. With the aid of the clamp, the chest tube is inserted through the tract into the pleural space Directed either apically for a pneumothorax or inferiorly and posteriorly for a pleural effusion.

Insertion techniques (cont) The location of the chest tube is confirmed by: visualization of condensation within the tube with respiration drained pleural fluid seen within the tube tube should be inserted with the proximal hole at least 2 cm beyond the rib margin Position of the chest tube with all drainage holes in the pleural space should be assessed by palpation. The skin incision is closed with one or more sutures, and one of the sutures is tied to the chest tube to anchor it. The site is covered with sterile gauze and surgical tape. Some clinicians prefer to cover the site with petroleum-gauze. The chest tube is connected to the pleural drainage system. Connections between the chest tube and pleural drainage system should be tight and taped securely. Chest radiograph should be obtained to confirm tube position and assess lung expansion. The gap in the radiopaque marker in the chest tube, marking the most proximal drainage hole, must be within the pleural space.

Seldinger technique An alternative approach to chest tube placement Chest radiograph should be carefully inspected for adequate separation of the lung and parietal pleura due to pleural air or fluid. The patient is placed supine with the arm of the involved side placed behind the head. The area of insertion is prepped with chlorhexidine and draped with sterile towels. Using one percent lidocaine, a 2 to 3 cm area of skin and subcutaneous tissue is anesthetized along the intercostal space that will be penetrated. Thoracentesis at the intended insertion site is performed with aspiration of air or fluid confirming an appropriate site for chest tube insertion. A 2 cm skin incision is made parallel to the intercostal space, and should be performed immediately above the rib in order to reduce the risk of neurovascular injury should the incision extend more deeply than intended. An introducer needle is inserted into the pleural space with aspiration of air or fluid. A guidewire is placed through the introducer needle into the pleural space. The guidewire may be directed apically for a pneumothorax or inferiorly for a fluid collection. Graduated size dilators are serially passed over the guidewire to dilate a tract for the chest tube. The chest tube itself with its dilator is passed into the pleural space. The guidewire and dilator are removed, leaving the chest tube in place. The chest tube is sutured into place and dressed with sterile gauze.

Seldinger Technique (cont) Disadvantages: Adhesions between the lung and pleural surface cannot be assessed by palpation during tube insertion. If the introducer needle and guidewire are inserted at a point of pleural adhesion, the chest tube may be inadvertently placed into the lung parenchyma.

CHEST TUBE REMOVAL Remove when: Original indication for placement is no longer present Tube becomes nonfunctional. The following criteria should be met prior to removing the chest tube: The lung should be fully expanded Daily fluid output should be less than 100 to 200 mL/day An air leak should not exist, either during suction or coughing Once these criteria are met, the chest tube can be placed on water seal. CXR on water seal after 6 hours Some will clamp the chest tube for four to six hours, then confirm the absence of pneumothorax prior to removing the chest tube. Mechanical ventilation does not prevent removal of CT if no air leak is present. Following inspiration, the patient performs a Valsalva maneuver and the tube is removed with simultaneous covering of the insertion site with the gauze dressing

COMPLICATIONS Are rare, 1-3% Chest tube malposition — Chest tube malposition is the most common complication of tube thoracostomy Lung parenchyma perforation Empyema Subcutaneous tube placement Perforation of the ventricle or atrium, and abdominal organs (spleen, liver, stomach, colon) Other complications include cardiogenic shock from chest tube compression of the right ventricle, mediastinal perforation with contralateral hemothorax and pneumothorax bleeding from intercostal artery injury infection at the chest tube site Reexpansion pulmonary edema — Potentially life-threatening complication of tube thoracostomy It usually occurs unilaterally after rapid reexpansion of a collapsed lung in patients with a pneumothorax Can also follow evacuation of large volumes of pleural fluid (>1.0 to 1.5 liters) or after removal of an obstructing tumor. The incidence of edema appears to be related to the rapidity of lung reexpansion. Patients typically present soon after the inciting event, although presentation can be delayed for up to 24 hours in some cases. A mortality rate as high as 20 percent has been described. Treatment is supportive, mainly consisting of supplemental oxygen and, if necessary, mechanical ventilation. The disease is usually self-limited. Prevention — drain only 1-1.5 liters of fluid at a time; if need to take more, wait 2-4 hours between drainages

Thoracentesis INTRODUCTION Diagnostic thoracentesis Bedside procedure Percutaneous introduction of needle into chest cavity to remove pleural Laboratory assessment of pleural fluid can provide valuable diagnostic and prognostic information Interpretation of pleural fluid studies can be reviewed on UpToDate.

INDICATIONS for Diagnostic thoracentesis Establish the cause of a pleural effusion. When an effusion is suspected on physical examination Confirm by radiographic Thoracentesis is not generally required in patients: Small amount of pleural fluid And a secure clinical diagnosis (eg, with viral pleurisy) Thoracentesis should be considered in patients with suspected CHF in the following circumstances: A unilateral effusion is present, particularly if it is left-sided Bilateral effusions are present, but are of disparate sizes There is evidence of pleurisy The patient is febrile The cardiac silhouette appears normal on chest radiograph The alveolar-arterial oxygen gradient is widened out of proportion to the clinical setting

CONTRAINDICATIONS There are no absolute contraindications to diagnostic thoracentesis Relative contraindications to the procedure: Anticoagulation or a bleeding diathesis PT or PTT greater than twice normal Platelet count less than 25,000/mm3 Serum creatinine concentration greater than 6 mg/dL Active skin infection at the point of needle insertion A very small volume of pleural fluid <1 cm distance from the pleural fluid line to the chest wall on a decubitus radiograph risk of thoracentesis generally outweighs the usefulness of pleural fluid analysis Mechanical ventilation does not increase the risk for developing a pneumothorax compared with nonventilated patients. however, mechanically ventilated patients are at increased risk of developing tension physiology or persistent air leak (bronchopleural fistula) if a pneumothorax does occur.

TECHNIQUE Diagnostic Thoracentesis How to select the site of needle insertion: Ultrasound guidance should be employed Small volume or loculated Seat patient same during ultraound and procedure Chest radiograph should be available in the procedure room for review, Physical examination should guide selection of the puncture site. The operator should adhere strictly to sterile technique. 1% lidocaine should be used to anesthetize the skin The needle should be inserted 1 to 2 interspaces below the level where the percussion note becomes dull and fremitus is absent. When the effusion is free-flowing, a site midway between the spine and the posterior axillary line should be selected, as the ribs are easily palpated in this location. The needle should be passed over the superior aspect of the rib to decrease the risk of injury to the neurovascular bundle which traverses. A "dry" thoracentesis may result from: An absence of pleural fluid incorrect needle placement Use of an inappropriately short needle Routine performance of a chest radiograph after thoracentesis is not indicated. 1 percent of 488 asymptomatic patients who underwent thoracentesis had a pneumothorax Those with post-procedural SOB or chest pain should get a CXR

COMPLICATIONS Pain at the puncture site Bleeding Pneumothorax (12-30%) Hematoma Hemothorax Hemoperitoneum Pneumothorax (12-30%) Empyema Soft tissue infection Spleen or liver puncture Make sure sitting upright Vasovagal events Seeding the needle tract with tumor Retained intrapleural catheter fragments have been reported.

The End Any Questions?