Tube Thoracostomy Module

Vic V. Vernenkar, D.O.

Dept. of Surgery
St. Barnabas Hospital

Indications
1. Drainage of hemothorax, or large pleural
effusion of any cause
2. Drainage of large pneumothorax (greater
than 25%)

Indications
3. Prophylactic placement of chest tubes in
a patient with suspected chest trauma before
transport to specialized trauma center
4. Flail chest segment requiring ventilator
support, severe pulmonary contusion with
effusion

Contraindications

1. Infection over insertion site

2. Uncontrolled bleeding diathesis

Materials
1. Chest tube; OR Fuhrman catheter
2. Chest tube suction unit (PleurevacR), tubing,
wall suction hookup
3. Chest tube tray to include scalpel blade and
handle, large Kelly clamps, needle driver, scissors
4. Packet of 0 or 1.0 silk suture on a curved needle

Materials
Tape, gauze
2% lidocaine with epinephrine, 20 cc
syringe, 23-gauge needle for infiltration
Sterile prep solution; Mask, gown and
gloves

Size
Adult male

28-38F

Adult Female

28F

Child

18F

Infant

12-14F

Preprocedure patient education

1. Obtain informed consent
2. Inform the patient of the possibility of
major complications and their treatment
3. Explain the major steps of the procedure,
and necessity for repeated chest radiographs

Procedure
1. Examine the patient and assess need for
placement of a thoracostomy tube. Obtain
pre-procedure chest X-ray
VERIFY SITE OF INSERTION!!!!!!
2. Select site for insertion: mid-axillary line,
between 4th and 5th ribsthis is usually on a
line lateral to the nipple

Procedure
3. Don mask, gown and gloves;
4.Prep and drape area of insertion. Have
patient place ipsilateral arm over head to
open up ribs
5. Widely anesthetize area of insertion with
the 2% lidocaine. Infiltrate skin, muscle
tissues, and right down to pleura

Chest tube insertion

After infiltrating insertion site with local
anesthetic, make a 3-4 cm incision through
skin and subcutaneous tissues between the
4th and 5th ribs, parallel to the rib margins

Incising the Chest wall

Insertion
-Continue incision through the intercostal
muscles, and right down to the pleura
-Insert Kelly clamp through the pleura and
open the jaws widely, again parallel to the
direction of the ribs (this creates a
pneumothorax, and allows the lung to fall
away from the chest wall somewhat

Opening the Incision with Kelly

Insertion
Insert finger through your incision and into the
thoracic cavity. Make sure you are feeling lung (or
empty space) and not liver or spleen
-Grasp end of chest tube with the Kelly forcep
(convex angle towards ribs), and insert chest tube
through the hole you have made in the pleura.
After tube has entered thoracic cavity, remove
Kelly, and manually advance the tube in

Using a Kelly to Guide Insertion

Insertion

-Clamp outer tube end with Kelly

-Suture and tape tube in place
-Attach tube to suction unit
-Obtain post procedure chest Xray for
placement; Tube may need to be advanced
or withdrawn slightly

Complications, Prevention, and

Management
1. Puncture of liver or spleen. This is entirely
preventable; Insertion site is in the nipple line, between
4th and 5th ribs!
2. Bleeding; This usually ceases
3. Cardiac puncture. Again preventable, carefully control
the tube going in, DO NOT USE TUBES WITH
TROCARS
4. Passage of tube along chest wall instead of into chest
cavity. In this case, widen and deepen the dissection
between the ribs, and make sure the insertion of the tube
follows this path

Documentation in the Medical

Record
1. Consent if obtained, time out
2. Indications and contraindications for the procedure on
this patient
3. Procedure used
4.Any complications, or none
5.Who was notified of any complication (family, attending
physician)
6. Order of STAT portable X-ray
IF YOU PUT IN THE CHEST TUBE YOU MUST CHECK
THE RESULTS OF THE X-ray in an expeditious and timely
manner

Items for Evaluation of Person

Learning This Procedure
1. Anatomy of the chest, lungs, pleura
2. Indications, and contraindications of this
procedure
3. Use of sterile technique and universal
precautions
4. Technical ability
5. Appropriate documentation
6. Understanding of potential complications and
their correction