SURGICAL

TUBES
Hadi Munib
OUTLINE
 Introduction
 Chest Tubes
 Tracheostomy
 Endotracheal Tubes
 Nasogastric and Duodenal Tubes
 Gastrostomy and jejunostomy Tubes
 Foley’s Catheter
 References
INTRODUCTION
 Surgical drains are used to monitor for:
 Postoperative leaks or abscesses
 Collect normal physiologic fluid
 To minimize dead space.
 Hospitalists should not manipulate the drains without input from the surgeon who placed
them.
 PHYSIOLOGY, LUNG DEAD SPACE
 Dead space represents the volume of ventilated air that does not participate in
gas exchange. The two types of dead space are anatomical dead space and
physiologic dead space. Anatomical dead space is represented by the volume
of air that fills the conducting zone of respiration made up by the nose, trachea,
and bronchi. This volume is considered to be 30% of normal tidal volume (500
mL); therefore, the value of anatomic dead space is 150 mL. Physiologic or
total dead space is equal to anatomic plus alveolar dead space which is the
volume of air in the respiratory zone that does not take part in gas exchange.
The respiratory zone is comprised of respiratory bronchioles, alveolar duct,
alveolar sac, and alveoli. In a healthy adult alveolar dead space can be
considered negligible. Therefore, physiologic dead space is equivalent to
anatomical. One can see an increase in the value of physiologic dead space in
lung disease states where the diffusion membrane of alveoli does not function
properly or when there are ventilation/perfusion mismatch defects.[1][2][3]
 CHEST
TUBES
 Placed in the pleural space to evacuate air or fluid.
 Indications: Pneumothorax, Hemothorax, or a persistent or large pleural effusion.
 They can be as thin as 20 French or as thick as 40 French (for adults).
 Typically placed at the fifth intercostal spaces in the anterior axillary or mid-axillary line.
 Location may vary according to the indication for placement.
 The tubes can be straight or angled.
 Pneumothorax and Hemothorax usually require immediate chest tube placement.
 Also commonly placed at the endo thoracic surgeries, to allow for appropriate re-expansion of the lung
tissue.
CHEST TUBES
 The tubes are connected to a collecting system with a three-way chamber.
 The water chamber holds a column of water which prevents air from being sucked into the
pleural space with inhalation.
 The suction chamber can be attached to continuous wall suction to remove air or fluid, or it
can be placed on “water seal” with no active suction mechanism.
 The third chamber is the collection chamber for fluid drainage.
CHEST TUBES
 A chest x-ray should be obtained after any chest tube insertion to ensure appropriate location.
 Chest tubes are equipped with a radiopaque line along the longitudinal axis, which should be visible on
x-ray.
 Respiratory variation in the fluid in the collecting tube, called “tidling,” should also be seen in a
correctly placed chest tube
 The tube should be monitored at the bedside to reassure continued appropriate location.
CHEST TUBES
 If the patient has a pneumothorax, air bubbles will be visible in the water chamber (“air leak”)
 Often more apparent when the patient coughs.
 The chest tube should initially be set to continuous suction at –20 mm Hg to evacuate the air.
CHEST TUBES
 Once the “air leak” has stopped, the chest tube should be placed on water seal to confirm the
pneumothorax is resolved (water seal mimics normal physiology)
 If the pneumothorax is not resolved  Tube is placed back at continuous suction and a Chest
X-Ray is taken
 If the patient experiences ongoing or worsening pain, or inadequate drainage, a chest
computed tomographic (CT) scan may be taken to identify inappropriate positioning or other
complications.
CHEST TUBES
 If the patient has a pleural effusion, the chest tube can usually be removed when the output is
less than 100 to 200 mL per day, and the lung is expanded.
 The tube should usually be taken to suction and placed on water seal (to rule out
pneumothorax) prior to tube removal.
TRACHEOSTOMY
 This procedure relieves airway obstruction or protects the airway by fashioning a direct
entrance into the trachea through the skin of the neck.
 Tracheostomy may be carried out as an emergency for acute airway obstruction when the
larynx cannot be intubated.
 The time to do a tracheostomy is when you first think it may be necessary.
 If time allows, the following should be undertaken:
 Inspection and palpation of the neck to assess the laryngotracheal anatomy in the individual
patient;
 Indirect or direct laryngoscopy;
 Assessment of pulmonary function by auscultation.
 In patients who have suffered severe head and neck trauma and who may have an
unstable cervical spine fracture, cricothyroidotomy may be more suitable.
TRACHEOSTOMY
 The advantage of an elective surgical procedure is that there is complete airway control at all
times, unhurried dissection and careful placement of an appropriate tube.
 Close cooperation between the surgeon, anesthetist and scrub nurse is essential, and attention
to detail will markedly reduce possible complications and morbidity from the procedure.
 The patient is positioned with a combination of head extension and placement of an
appropriate sandbag under the shoulders.
 There should be no rotation of the head
ELECTIVE TRACHEOSTOMY
 A transverse incision may be used in the elective situation.
 The tracheal isthmus is divided carefully and oversewn and tension sutures placed either side
of the tracheal fenestration in children.
 A Bjork flap may be used in adults
EMERGENCY VS. ELECTIVE
TRACHEOSTOMY INCISIONS
TRACHEOSTOMY
 Currently, there is no accordance for the use of tracheostomy as an alternative for
emergency airway management because it is considered a time-consuming procedure,
too slow to resolve the acute difficult airway.
 A surgical cricothyroidotomy should be considered as the technique of choice,
especially in cases of hypoxemia.
 Cricothyroidotomy could present some difficulties or contraindication, such as
impossible visual or digital recognition of the cricoid cartilage, tumor mass, anatomical
abnormalities.
 In these cases, emergency tracheostomy could represent the only solution to secure the
airway.
 Other theoretical advantages of PDT in these settings include the fact that it is an
effective airway for ventilation, suctioning and bronchoscopy; mitigates the damage to
vocal cords and does not require conversion in a more stable airway
TRACHEOSTOMY
TUBES
Most modern tracheostomy tubes are made of plastic.

 Tubes of various sizes with varying curves, angles, cuffs, inner tubes and speaking
valves are available.
 After a newly fashioned tracheostomy is created, a cuffed tube is used initially to
protect the airway from secretions or bleeding.
 This may be changed after 3–4 days to a non-cuffed tube.
 The pressure within the tube cuff should be carefully monitored and should be low
enough so as not to occlude circulation in the mucosal capillaries, which promotes
scar tissue formation and subglottic stenosis.
 When in position, the tube should be retained by double tapes threaded through the
flanges and passed around the patient’s neck.
 TRACHEOSTOMY TUBES
 All forms of tracheostomy and cricothyroidotomy bypass the upper airway and
have the following advantages:
 The anatomical dead space is reduced by approximately 50%;
 The work of breathing is reduced;
 Alveolar ventilation is increased;
 The level of sedation needed for patient comfort is decreased and, unlike
endotracheal intubation, the patient may be able to talk and eat with a tube in
place.
TRACHEOSTOMY
TUBES
 Several Disadvantages include:
 Loss of heat and moisture exchange in the upper respiratory tract;
 Desiccation of tracheal epithelium, loss of ciliated cells and metaplasia;
 The presence of a foreign body in the trachea stimulates mucous production; where no
cilia are present, the mucociliary stream is therefore impeded;
 The increased mucus is more viscid and thick crusts may form and block the tube;
 Although many patients with a tracheostomy can feed satisfactorily, there is some
splinting of the larynx, which may prevent normal swallowing and lead to aspiration;
this aspiration may be silent.
NASOGASTRIC AND
DUODENAL TUBES
 Nasogastric tubes are often used in the non-operative management of small
bowel obstruction or ileus.
 Should be placed in the most dependent portion of the gastric lumen, and
confirmed by chest or abdominal x-ray.
 NGTs are sump pumps and have a double lumen, which includes an air port to
assure flow.
 The tube may be connected to continuous wall suction or intermittent suction,
set to low (<60 mm Hg) to avoid mucosal avulsion
NASOGASTRIC TUBES
 NGT output should decrease during the resolution of obstruction
 Symptoms of nausea, vomiting, and abdominal distention should
concomitantly improve.
 Persistently high output in a patient with other indicators of bowel function
(eg, flatus) may suggest Post-Pyloric Placement.
DUODENAL
TUBES
 Small-bore tubes used when post-pyloric feeding is desired.
 Small-bore duodenal tubes are placed through the nares.
 They are very narrow caliber and require a long wire or insertion.
 The wire should be removed as soon as placement is confirmed by x-ray.
 Very soft and flexible.
 The wire used for placement is very stiff, increasing the risk of inadvertent insertion
into the airway.
 In patients who are intubated or who have undergone tracheostomy placement,
nasoenteric feeding tubes should be placed under bronchoscopic or uoroscopic guidance
to ensure that the tube is properly positioned
GASTROSTOMY AND
JEJUNOSTOMY TUBES
 Gastrostomy tubes are most commonly used for feeding but may also be used for
decompression of functional or anatomic gastric outlet obstruction.
 They are indicated when patients need prolonged enteral access (such as prolonged
mechanical ventilation or head and neck pathology that prohibits oral feeding).
 Rarely used for gastropexy, to tack an atonic or patulous stomach to the abdominal
wall or to prevent recurrence of paraesophageal hernias.
 These tubes can be placed percutaneously by interventional radiologists.
 Endoscopically by surgeons and gastroenterologists, or via laparoscopy or laparotomy
by surgeons [difficult anatomy or who are having laparotomy]
GASTROSTOMY TUBES
 Due to the stomach’s generous lumen, gastrostomy tubes rarely clog.
 IF they do get clogged, carbonated liquids, meat tenderizer, or enzymes may
help dissolve the obstruction.
 If a gastrostomy tube is left to drainage, this can result in significant fluid and
electrolyte losses; a daily electrolyte panel should be checked and repeated as
needed.
JEJUNOSTOMY
TUBES
Used exclusively for feeding and are usually placed 10 to 20 cm distal to the
ligament of Treitz.
 These tubes are indicated in patients who require distal feedings, due to gastric
dysfunction or following a surgery in which a proximal anastomosis requires time
to heal.
 These tubes are more susceptible to clog and can be more difficult to manage
because the lumen of the small bowel is smaller than the stomach.
 Some prefer not to put pills down the tube to mitigate this risk.
 Routine flushes (30 mL every 4-6 hours) with water or saline are also helpful in
mitigating the risk of clogging.
 If they get clogged? Similar to Gastrostomy Tubes
GASTROSTOMY AND
JEJUNOSTOMY TUBES
 Percutaneous tube sites should be examined frequently for signs of infection.
 The tubes are typically well secured intra-abdominally, it is possible for them to become
dislodged.
 If a tube has been in place for more than 2 weeks, it can be replaced at the bedside with a tube
of comparable caliber.
 If the tube has been in place less than 2 weeks, it requires replacement with radiographic
guidance, as the risk of creating a false lumen is high.
FOLEY’S
CATHETER
A sterile tube that is inserted into the bladder to drain urine.

 It is also called an indwelling urinary catheter.
 The tip of the catheter has a small balloon filled with solution that holds the
catheter in your bladder.
 The tube has two separated  lumens, running down its length.
 One lumen, open at both ends, drains urine into a collection bag.
 The other has a valve on the outside end and connects to a balloon at the inside tip.
Th balloon is inflated with sterile water when it lies inside the bladder to stop it
from slipping out.
 The different properties of the surface coatings determine whether the catheter is
suitable for 28-day or 3-month indwelling duration.
FOLEY’S
CATHETER
Indwelling urinary catheters should not be used to monitor stable people who are able

to urinate or for the convenience of the patient or hospital staff.
 Urethral trauma is the only absolute contraindication to placement of a urinary
catheter.
 Examination findings such as blood at the urethral meatus, or a high riding prostate
necessitate a retrograde urethrogram prior to insertion
REFERENCES
 Chapter 46: Surgical Tubes; Principles and Practice of Hospital Medicine
 CHAPTER 47 Pharynx, larynx and neck; Bailey’s and Love Short Practice of Surgery
THANK YOU!