PowerPoint presentation on Intercostal drainage (ICD) or Chest tube drainage. In this this presentation I have included different methods by which a chest tube can be inserted to drain fluid, pus, air from the Pleural cavity. please do mail me your feedback on this presentation at tinkujoseph2010@gmail.com.
2. WHAT ARE THE ISSUES ?
When to put a drain
Site of insertion
Choosing the drain
Drainage system
Clamping the chest drain
Time & method of removal
Trouble shooting
3. INDICATIONS
Pneumothorax
primary spontaneous ptx
Secondary spontaneous ptx
Tension ptx(after initial needle aspiration)
Malignant pleural effusion
Empyema and complicated parapneumonic pleural
effusion
Traumatic haemo pneumothorax
Postoperative,eg: after oesophageal, cardiac,
pulmonary,mediastinal or pleural surgery.
Treatment with sclerosing agents or pleurodesis
Post pneumonectomy bronchopleural fistula
5. SITE OF INSERTION ?
Exact site depends on the location of abnormality.
5th ICS in mid axillary line is the site used most often.
Earlier it was believed that air can be drained only
through anteriorly placed tube in 2nd ICS in mid-
clavicular line.A tube placed too medially can injure
internal mammary artery causing serious
haemorrhage.
Experience has shown that a tube of proper
size,inserted through 5th ICS in mid axillary line can
drain effectively.
6. TRIANGLE OF SAFETY
Area bordered by the
anterior border of latissmus
dorsi,the lateral border of the
pectoralis major, a line
superior to the horizontal
level of nipple,with its apex
towards axilla
This is the usual site which
corresponds to the 5th or 6th
ICS in mid-axillary line
7. POSITION OF THE PATIENT
A chest tube can be inserted in supine,sitting
or lateral position.
Most preffered is supine position,in which
patient lies flat on the bed,slightly rotated to
the opposite side,with ipsilateral arm behind
her/his head.
Patients who are breathless may be asked to
sit upright in the bed,leaning over a cardiac
trolley with a pillow to place their arms
8.
9. If chest tube is inserted to drain blood,pus or
another fluid, the patient should be seated when
the tube is inserted to ensure that the diaphragm
is in the most dependent position and the fluid is
collected in the lower part of the chest
When chest tube is placed for pneumothorax,the
patient should be in recumbent position if
anterior chest tube is placed, and should be in
decubitus position if an axillary tube is placed
In case of loculated pathology it is good practice
to do an USG or CT guided ICD.
10. MATERIALS REQUIRED
Sterile gloves and gown
Skin antiseptic solution, e.g.
iodine or chlorhexidine in
alcohol
Sterile drapes
Gauze swabs
A selection of syringes and
needles (21–25gauge)
Local anaesthetic, e.g.
lignocaine (lidocaine) 1% or 2%
Scalpel and blade
Suture (e.g. “1” silk)
Instrument for blunt dissection
(e.g. curvedclamp)
11. Guidewire with dilators (if small tube being
used)
Chest tube
Connecting tubing
Closed drainage system (including sterile
water if underwater seal being used)
Dressing
12.
13. GUIDEWIRE TUBE THORACOSTOMY
Easiest way to insert a chest tube.
Usually done under the guidance of either USG or CT.
This procedure uses the Seldinger technique with guide
wires & dilators.
Skin,periosteum and parietal pleura are anesthetized and
incision is made in skin
18 gauge needle attached to a syringe is introduced into
the pleural space. Fluid or air is aspirated to confirm the
diagnosis.
Syringe is removed and J wire is threaded through the
needle in desired direction into the pleural space
Needle is then removed and smallest dilator is been
inserted with a rotating movement, it is advanced into
pleural space.
14. The first dilator is removed leaving the wire in place.
Then the next size dilator is advanced over the guidewire
into the pleural space and removed.
Finally chest tube containing the inserter is been threaded
over the guide wire.
Once tube is in place inserter & guide wire are withdrawn.
Tube is then clamped until it is attached to chest drainage
system.
Tube is been anchored in place by means of purse string
suture.
Incision is sutured without tension to avoid necrosis of skin
Sterile dressing applied.
15.
16. TROCAR TUBE THORACOSTOMY
Initially requires a 2-4cm incision parallel to superior
border of the rib through the skin and subcutaneous
tissues after LA.
Trocar is inserted between the ribs into the pleural
cavity,with flat edge cephalad to prevent damage to
intercostal vessels
The hand not applying force should be placed next to the
chest wall to control depth of penetration
Once trocar is in pleural space,stylet is removed and
chest tube with its distal end clamped is inserted into
the pleural space.
Tocar is then removed.
17. Alternate trocar method uses a chest tube with a
trocar positioned inside the tube
DISADVANTAGES
More chances for puncturing lung & other vital
organs.
18.
19. OPERATING TUBE THORACOSTOMY
Most commonly practiced
Patient should be given anxiolytic 10-15mins before the
procedure and liberal doses of LA be used.
3-4cm incision is made in the skin parallel to the chosen
intercostal space. The incision should be made down to
the fascia overlying the intercostal muscle.
Once fascia has been incised the muscle fibers are
spread with a blunt tipped hemostat
Incision is then made in the intercostal fascia just above
the superior border of the inferior rib over which tube
will pass
Parietal pleura is then penetrated using blunt tipped
hemostat
20. Hole in the parietal pleura is then enlarged with
operators index finger
Operator should then palpate adjacent pleural space to
detect any adhesions.
Chest tube with its distal end clamped is then introduced
with help of a hemostat into the pleural space
Tube is sutured in place(mattress sutures) as per BTS
guidelines
Site is cleaned and sterile dressing applied
21.
22.
23.
24. ADVANTAGES
Safer then other methods
Adhesions between lung & chest wall can be
removed.
DISADVANTAGES
Insertion of tube ectopically
25. SINGLE PORT THORACOSCOPY
Hopkins rod –lens telescope is loaded into the
most proximal port of chest tube. Under direct
visualization the chest tube is placed into the
costodiaphragmatic gutter and scope is been
removed & tube fixed.
27. CHOOSING THE CHEST DRAIN.
SIZE MATTERS ??
MALIGNANT EFFUSION FOR
PLEURODESIS
SMALL BORE TUBES 10-14F
HEMOTHORAX 28-32F
PNEUMOTHORAX 8-14F(SUCCESS RATE OF 84-97%)
EMPYEMAS 24-28F
28. PLEURAL DRAINAGE SYSTEMS
• ONE WAY(HEIMLICH)VALVE
this drainage system is by far the simplest
Chest tube is attached to a one way flutter valve
assembly, which is constructed so that the flexible
tubing is occluded whenever the pressure inside the
tubing is less than atmospheric pressure & is patent
whenever the pressure inside the tubing is above the
atm pressure
When pleural pressure and pressure in the tube are
negative flutter valve is closed and no air enters
pleural space.
When pleural pressure becomes positive the tube is
patent and air or fluid can egress from pleural space.
29.
30. ADVANTAGE
It is a simple & renders freedom of the patient from a
bulky drainage apparatus
Patients can be sent home with the flutter valve in place
31. ONE BOTTLE COLLECTION SYSTEM
Consists of one bottle that serves as both a
collection container and a water seal.
Chest tube is connected to a rigid straw
inserted through a stopper into a sterile
bottle
Enough sterile solution is instilled into the
bottle so that tip of the rigid straw is
approximately 2cms below the surface of
saline solution.
Bottles stopper must have a vent to prevent
pressure from building up when air or fluid
coming from pleural space enters the
bottle.
32. When pleural pressure is positive,the pressure in
the rigid straw becomes positive,and if the
pressure inside the rigid straw is greater than the
depth to which straw is inserted into the saline
solution,air(or liquid)will enter the bottle and will
be vented to the atmosphere(or collect in the
bottle).
If the pleural pressure is negative,fluid will be
drawn from the bottle into the rigid straw and no
extra air will enter the system.
Thus water in the bottle seals the pleural space
from air or fluid from outside the body
33. • ADVANTAGES:
• Easy to carry & works well for uncomplicated
pneumothorax
• DISADVANTAGES:
• If large amounts of fluid is draining from patients pleural
space level of fluid will rise in one bottle system and
therefore pressure will have to be higher & higher in the
rigid straw to allow additional air or fluid to exit from
pleural space
• If the bottle is inadverently placed above level of the
patients chest,fluid can flow back into the pleural cavity.
34. TWO BOTTLE COLLECTION SYSTEM
Preferred when substantial amounts of fluid is draining
from pleural space
With this system, bottle adjacent to the patient acts as a
collection bottle for drainage, and second bottle
provides the water seal and the air vent.
Degree of water seal does not increase as the drainage
accumulates.
35. SUCTION & THREE BOTTLE COLLECTION
SYSTEMS
Applying negative pressure to the pleural space
helps in facilitating reexpansion of the underlying
lung or to expedite removal of air or fluid from
pleural space
Suction at a fixed level, usually -15 to -20cm
H2o,can be applied to the vent on a one or two
bottle collection system with an Emerson pump
In this system, suction is poorly controlled.
36. Controlled amount of
suction can be applied to a
three bottle collection
system.
A vent on suction control
bottle is connected to a
vent on the water seal
bottle.
Suction control bottle has a
rigid straw. Suction is
connected to a second
vent on the suction control
bottle.
37. When suction is applied to
suction control bottle, air enters
this bottle through it rigid straw if
the pressure in the bottle is more
negative than the depth to which
straw is submerged.
Amount of negative pressure in
the system is equal to the depth
to which rigid straw in the
suction control bottle is
submerged below the surface as
long as bubbles are entering
suction control bottle through its
rigid straw.
38. Air enters the suction control bottle
from the atmosphere while its rigid
straw is submerged at 20cm
H2o.Thwe pressure in the suction
control bottle is -20cm H20.
Same pressure exists in water seal
bottle,since these two bottles are in
direct communication.The pressure in
drainage bottle is less negative than in
other bottles
In this case depth of water seal is
2cm,so pressure in the drainage
collection bottle and pleural space is -
-18cm H20.
Amount of negative pressure in the
system can be adjusted by changing
the position of rigid straw or depth of
water in suction bottle.
39. INTRINSIC NEGATIVE PRESSURE IN CHEST TUBES
If the distance from patients chest to the
top of collection apparatus is 50cms and
tube is filled with liquid, there will be a
negative pressure of 50cm H2o in the
pleural space if no suction applied
Actual negative pressure applied to the
pleural space from the entire system is
the net vertical distance that the liquid
occupies the tube(A-B)minus the level of
fluid in the water seal(C) plus negative
pressure applied through
suction(D).negative pressure in chest is
A-B-C+D
If there is no liquid in the tube, actual
applied pressure will be suction pressure
minus the depth of the water seal.
40. PLEUR EVAC UNIT
The drainage system
is disposable,molded
plastic unit with
three chambers
duplicating the
classic three bottle
system
41.
42.
43. CHOICE OF DRAINAGE SYSTEM
Cost
Indication of the chest drain
Type of patient
Water seal should be easily visualized
Tube should be functional when no suction is applied
Volume of collection chamber should be adequate and
markings should be such that drainage is easily
quantitated.
Pop up valve to provide safety if pressure builds up in
the system.
44. INJECTION OF MATERIALS THROUGH
CHEST TUBES
Injection of a fibrinolytic or DNAase in a patient with a
loculated complicated parapneumonic effusion
Tetracycline derivative or a different sclerosing agent
through the chest tube in patients with malignant
pleural effusion
This is usually done by taking chest tube apart and
injecting material through a Toomey syringe.
This procedure compromises the sterility of the system
and increases chances of pneumothorax.
45. THAL QUICK CHEST TUBE ADAPTER
This unit consists of two adapters
separated by flexible tubing with a
clamp.
On the proximal end there is a
sideport with a short segment of
connecting tubing to which
attached a three way stopcock.
When one wishes to inject
anything through the chest
tube,the tube is clamped and
material is injected through the
three way stop cock
Indicated when a sclerosing or
fibrinolytic agent is been injected.
46. SECURING THE DRAIN
Mattress suture
1 zero mersilk
Complicated “purse string” sutures must not
be used as they convert a linear wound into a
circular one that is painful for the patient and
may leave an unsightly scar.A suture is not
usually required for small gauge chest tubes.
47.
48. CHEST DRAIN DRESSING
Large amounts of tape and padding to dress the
site are unnecessary and concerns have been
expressed that they may restrict chest wall
movementor increase moisture collection.
A transparent dressing allows the wound site to
be inspected by nursing staff for leakage or
infection.
An omental tag of tape has been described
which allows the tube to lie a little away from
the chest wall to prevent tube kinking and
tension at the insertion site.
49. • Omental tag to support
the tube while allowing
it to lie a little away
from the chest wall.
50.
51. CLAMPING
A bubbling chest tube should never be
clamped.
Drainage of a large pleural effusion should
be controlled to prevent the potential
complication of re-expansion pulmonary
oedema.
In cases of pneumothorax, clamping of the
chest tube should usually be avoided.
52. BUBBLING CHEST TUBE-DIFFRETIALS
• If tube is not inserted far enough into pleural
space – one or more of holes in chest tube will
be outside pleural space
• Air enters from atmosphere
• In debilitated patients – with poor tissue turgor –
negative pleural pressure will cause air to enter
pleural space around chest tube at insertion site
• Leaks in the system.
53. HOW TO DIFFERENTIATE- AIR LEAKS
• Measuring the level of pco2 in the air coming
from chest tube
• Collected in syringe – blood gas analyzer
• Pco2 >20mmHg (Bronchopleural fistula)
• Pco2 <10mmHg (Atmospheric air)
54. If a chest tube for pneumothorax is
clamped, this should be under the
supervision of a respiratory physician or
thoracic surgeon, the patient should be
managed in a specialist ward with
experienced nursing staff, and the
patient should not leave the ward
environment.
If a patient with a clamped drain
becomes breathless or develops
subcutaneous emphysema, the drain
must be immediately unclamped and
medical advice sought.
55. COMPLICATIONS
Injury to the neurovascular bundle in the ICS
Injury to lung parenchyma
Injury to diaphragm and consequent injury to
intraperitoneal structures may occur
Injury to heart and other vessels
Massive bleeding
Re expansion pulmonary oedema due to rapid
evacuation of fluid from the pleural cavity
Empyema
Skin excoriation and inflammation
Subcutaneous emphysema & subcutaneous haematoma
56.
57. REMOVAL OF THE DRAIN
Original indication
Clinical progress
Daily drainage should be <100ml.
There should be no air leak
No fresh or altered blood should be draining
from chest tube
Radiological status-lung should be fully
expanded.
End expiration/valsalva
58. REPOSITIONING CHEST DRAINS
Use imaging assistance
Avoid pushing & pulling drains
Best is a fresh insertion
Avoid a previous site, choose a new one
59. Procedure for chest tube removal
Gather supplies and explain procedure to patient
The clinician will remove the dressing and sutures
During peak exhalation, the clinician will remove the
chest tube in one quick movement
Immediately apply a sterile gauze dressing containing
petroleum to prevent air from entering pleural space
Monitor patient’s respiratory status
Arrange for chest X-ray to confirm lung reexpansion
Monitor patient’s respiratory status and SpO2 for 1-2
hours after removal
60. PATIENTS REQUIRING ASSISTED
VENTILATION
During the insertion of a chest tube in a patient on a high
pressure ventilator (especially with positive end
expiratory pressure (PEEP), it is essential to disconnect
from the ventilator at the time of insertion to avoid the
potentially serious complication of lung
penetration, although as long as blunt dissection is
carried out and no sharp instruments are used, this risk is
reduced.
63. RECOMMENDATIONS FOR SAFE PRACTICE OF CHEST
DRAIN INSERTION
1. Site: safe triangle in the midaxillary line
2. Imaging to be used to select appropriate site of
insertion
3. USG guided insertion can ensure safety placement
4. Do not use substantial force
5. Small bore drains to be placed under imaging guidance
with a guide wire(dissection not required)
6. Blunt dissection for large tube bore
7. CXR available at time of insertion except in case of
tension pneumothorax
BTS GUIDELINESS
64.
65. For more details and
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