A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a
surgical drain that is inserted through the
chest wall
The thoracic wall or chest wall is the boundary of the thoracic cavity.
Structure
The bone, bony human skeleton, skeletal part of the thoracic wall is the rib cage, and the rest is made up of muscle, skin, and fasciae.
The chest wall has 10 lay ...
and into the
pleural space
The pleural cavity, pleural space, or interpleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication bet ...
or the
mediastinum
The mediastinum (from ) is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is an undelineated region that contains a group of structures within the thorax, namely the heart and its vessels, the esophagu ...
in order to remove clinically undesired substances such as air (
pneumothorax
A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...
),
excess fluid (
pleural effusion
A pleural effusion is accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung.
Under normal conditions, pleural fluid is secreted by the parietal pleural capillaries at a rate of 0.6 millilitre per kilog ...
or
hydrothorax
Hydrothorax is a type of pleural effusion in which transudate accumulates in the pleural cavity. This condition is most likely to develop secondary to congestive heart failure, following an increase in hydrostatic pressure within the lungs. More r ...
),
blood
Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the c ...
(
hemothorax
A hemothorax (derived from hemo- lood+ thorax hest plural ''hemothoraces'') is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may incl ...
),
chyle
Chyle (from the Ancient Greek, Greek word χυλός ''chylos'', "juice") is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids (FFAs). It is formed in the small intestine during digestion of fatty foods, and taken ...
(
chylothorax
A chylothorax is an abnormal accumulation of chyle, a type of lipid-rich lymph, in the space surrounding the lung. The lymphatics of the digestive system normally returns lipids absorbed from the small bowel via the thoracic duct, which ascend ...
) or
pus
Pus is an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during bacterial or fungal infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection ...
(
empyema
An empyema () is a collection or gathering of pus within a naturally existing anatomical cavity. For example, pleural empyema is empyema of the pleural cavity. It must be differentiated from an abscess, which is a collection of pus in a newly forme ...
) from the intrathoracic space. An intrapleural chest tube is also known as a Bülau
drain
Drain may refer to:
Objects and processes
* Drain (plumbing), a fixture that provides an exit-point for waste water or for water that is to be re-circulated on the side of a road
* Drain (surgery), a tube used to remove pus or other fluids from ...
or an intercostal catheter (ICC), and can either be a thin, flexible silicone tube (known as a "pigtail" drain), or a larger, semi-rigid,
fenestra
A fenestra (fenestration; plural fenestrae or fenestrations) is any small opening or pore, commonly used as a term in the biological sciences. It is the Latin word for "window", and is used in various fields to describe a pore in an anatomical st ...
ted plastic tube, which often involves a
flutter valve
A flutter valve (also known as the Heimlich valve after its inventor, Henry Heimlich) is a Check_valve, one-way valve used in respiratory medicine to prevent air from travelling back along a chest tube. One can also use a Chest_drainage_managemen ...
or
underwater seal.
The concept of
chest drainage was first advocated by
Hippocrates
Hippocrates of Kos (; grc-gre, Ἱπποκράτης ὁ Κῷος, Hippokrátēs ho Kôios; ), also known as Hippocrates II, was a Greek physician of the classical period who is considered one of the most outstanding figures in the history of ...
when he described the treatment of
empyema
An empyema () is a collection or gathering of pus within a naturally existing anatomical cavity. For example, pleural empyema is empyema of the pleural cavity. It must be differentiated from an abscess, which is a collection of pus in a newly forme ...
by means of incision, cautery and insertion of metal tubes. However, the technique was not widely used until the influenza epidemic of 1918 to evacuate post-pneumonic empyema, which was first documented by Dr. C. Pope, on a 22-month-old infant. The use of chest tubes in postoperative thoracic care was reported in 1922, and they were regularly used post-thoracotomy in
World War II
World War II or the Second World War, often abbreviated as WWII or WW2, was a world war that lasted from 1939 to 1945. It involved the vast majority of the world's countries—including all of the great powers—forming two opposin ...
, though they were not routinely used for emergency tube
thoracostomy
A thoracostomy is a small incision of the chest wall, with maintenance of the opening for drainage. It is most commonly used for the treatment of a pneumothorax. This is performed by physicians, paramedics, and nurses usually via needle thoracostom ...
following acute trauma until the
Korean War
, date = {{Ubl, 25 June 1950 – 27 July 1953 (''de facto'')({{Age in years, months, weeks and days, month1=6, day1=25, year1=1950, month2=7, day2=27, year2=1953), 25 June 1950 – present (''de jure'')({{Age in years, months, weeks a ...
.
Medical uses
*
Pneumothorax
A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...
: accumulation of
air
The atmosphere of Earth is the layer of gases, known collectively as air, retained by Earth's gravity that surrounds the planet and forms its planetary atmosphere. The atmosphere of Earth protects life on Earth by creating pressure allowing for ...
or gas in the pleural space
*
Pleural effusion
A pleural effusion is accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung.
Under normal conditions, pleural fluid is secreted by the parietal pleural capillaries at a rate of 0.6 millilitre per kilog ...
: accumulation of
fluid
In physics, a fluid is a liquid, gas, or other material that continuously deforms (''flows'') under an applied shear stress, or external force. They have zero shear modulus, or, in simpler terms, are substances which cannot resist any shear ...
in the pleural space
**
Chylothorax
A chylothorax is an abnormal accumulation of chyle, a type of lipid-rich lymph, in the space surrounding the lung. The lymphatics of the digestive system normally returns lipids absorbed from the small bowel via the thoracic duct, which ascend ...
: a collection of
lymph
Lymph (from Latin, , meaning "water") is the fluid that flows through the lymphatic system, a system composed of lymph vessels (channels) and intervening lymph nodes whose function, like the venous system, is to return fluid from the tissues to ...
in the pleural space
**
Empyema
An empyema () is a collection or gathering of pus within a naturally existing anatomical cavity. For example, pleural empyema is empyema of the pleural cavity. It must be differentiated from an abscess, which is a collection of pus in a newly forme ...
: a
pyogenic
Pus is an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during bacterial or fungal infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection ...
infection
An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
of the pleural space
**
Hemothorax
A hemothorax (derived from hemo- lood+ thorax hest plural ''hemothoraces'') is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may incl ...
: accumulation of
blood
Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the c ...
in the pleural space
**
Hydrothorax
Hydrothorax is a type of pleural effusion in which transudate accumulates in the pleural cavity. This condition is most likely to develop secondary to congestive heart failure, following an increase in hydrostatic pressure within the lungs. More r ...
: accumulation of
serous fluid
In physiology, serous fluid or serosal fluid (originating from the Medieval Latin word ''serosus'', from Latin ''serum'') is any of various body fluids resembling Serum (blood), serum, that are typically pale yellow or transparent and of a benign ...
in the pleural space
**
Urinothorax
Urinothorax (''pl''. urinothoraces) is defined as urine in the fluid-filled cavity that surrounds the lungs. It is usually caused by obstructive uropathy. It is mainly diagnosed by analyzing the pleural fluid. Treatment involves treating the ...
: accumulation of
urine
Urine is a liquid by-product of metabolism in humans and in many other animals. Urine flows from the kidneys through the ureters to the urinary bladder. Urination results in urine being excretion, excreted from the body through the urethra.
Cel ...
in the pleural space
Contraindications
Contraindications to chest tube placement include refractory
coagulopathy
Coagulopathy (also called a bleeding disorder) is a condition in which the blood's ability to coagulate (form clots) is impaired. This condition can cause a tendency toward prolonged or excessive bleeding (bleeding diathesis), which may occur spo ...
and presence of a diaphragmatic hernia, as well as hepatic hydrothorax.
Additional contraindications include scarring in the pleural space (adhesions).
Complications
The most common complication of a chest tube is chest tube clogging. Chest tube clogging is widely recognized in published surveys of surgeons and nurses. In one study, 100% had seen chest tube clogging, and a majority had seen adverse patient outcomes from chest tube clogging.
In a prospective observational study, over 36% of patients had chest tube clogging after heart surgery. Chest tube clogging can lead to retained blood around the heart and lungs that can contribute to complications and increase mortality. If a chest tube clogs when the patient is still bleeding they can become hypotensive from tamponade, or develop a large hemothorax. If there is not enough to cause a mechanical compression of the heart or lungs, the resulting inflammatory response to the retained blood can lead to pleural and pericardial effusions and contribute to the triggering of postoperative atrial fibrillation in susceptible individuals.
A common complication after thoracic surgery that arises within 30–50% of patients are air leaks. If a chest tube clogs when there is an airleak the patient will develop a pneumothorax. This can be life-threatening.
Here, digital
chest drainage systems can provide real time information as they monitor
intra-pleural pressure and air leak flow, constantly.
Keeping vigilant about chest tube clogging is imperative for the team taking care of the patient in the early postoperative period.
Major insertion complications include
hemorrhage
Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...
,
infection
An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
, and reexpansion
pulmonary edema
Pulmonary edema, also known as pulmonary congestion, is excessive edema, liquid accumulation in the parenchyma, tissue and pulmonary alveolus, air spaces (usually alveoli) of the lungs. It leads to impaired gas exchange and may cause hypoxemia an ...
. Injury to the
liver
The liver is a major Organ (anatomy), organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of proteins and biochemicals necessary for ...
,
spleen
The spleen is an organ found in almost all vertebrates. Similar in structure to a large lymph node, it acts primarily as a blood filter. The word spleen comes . or
diaphragm
Diaphragm may refer to:
Anatomy
* Thoracic diaphragm, a thin sheet of muscle between the thorax and the abdomen
* Pelvic diaphragm or pelvic floor, a pelvic structure
* Urogenital diaphragm or triangular ligament, a pelvic structure
Other
* Diap ...
is possible if the tube is placed inferior to the pleural cavity. Injuries to the thoracic
aorta
The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes ...
and
heart
The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide t ...
can also occur.
When chest tubes are placed due to either blunt or penetrating trauma, antibiotics decrease the risks of infectious complications.
Minor complications include a subcutaneous
hematoma
A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillary, capillaries. A he ...
or
seroma
A seroma is a pocket of clear serous fluid (filtered blood plasma). They may sometimes develop in the body after surgery, particularly after breast surgery, abdominal surgery, and reconstructive surgery. They can be diagnosed by physical signs, ...
, anxiety, shortness of breath, and cough (after removing large volume of fluid). In most cases, the chest tube related pain goes away after the chest tube is removed, however, chronic pain related to chest tube induced scarring of the intercostal space is not uncommon.
Subcutaneous emphysema
Subcutaneous emphysema (SCE, SE) occurs when gas or air accumulates and seeps under the skin, where normally no gas should be present. ''Subcutaneous'' refers to the subcutaneous tissue, and ''emphysema'' refers to trapped air pockets resembling t ...
indicates backpressure created by undrained air, often caused by a clogged chest tube or insufficient negative pressure. If a patient has subcutaneous emphysema, it is likely their chest tube is not draining and consideration should be given if it should be unclogged or another tube should be placed so that the air leaking from the lung can be adequately drained.
Device
Characteristics
Chest tubes are commonly made from clear plastics like
PVC and soft
silicone
A silicone or polysiloxane is a polymer made up of siloxane (−R2Si−O−SiR2−, where R = organic group). They are typically colorless oils or rubber-like substances. Silicones are used in sealants, adhesives, lubricants, medicine, cooking ...
. Chest tubes are made in a range of sizes measured by their external diameter from 6 Fr to 40 Fr. Chest tubes, like most catheters, are measured in
French catheter scale
The French scale, French gauge or Charrière system is commonly used to measure the size of a catheter. It is most often abbreviated as Fr, but can often be seen abbreviated as Fg, FR or F. It may also be abbreviated as CH or Ch (for Charrière, i ...
. For adults, 20 Fr to 40 Fr (6.7 to 13.3mm external diameter) are commonly used, and 6 Fr to 26 Fr for children. Conventional chest tubes feature multiple drainage fenestrations in the section of the tube which resides inside the patient, as well as distance markers along the length of the tube, and a radiopaque stripe which outlines the first drainage hole.
Chest tubes are also provided in right angle, trocar, flared, and tapered configurations for different drainage needs. As well, some chest tubes are coated with
heparin
Heparin, also known as unfractionated heparin (UFH), is a medication and naturally occurring glycosaminoglycan. Since heparins depend on the activity of antithrombin, they are considered anticoagulants. Specifically it is also used in the treatm ...
to help prevent thrombus formation, though the effect of this is disputed.
Chest tube have an end hole (proximal, toward the patient) and a series of side holes. The number of side holes is generally 6 on most chest tubes. The length of tube that has side holes is the effective drainage length (EDL). In chest tubes designed for pediatric heart surgery, the EDL is shorter, generally by only having 4 side holes.
Channel style chest drains, also called Blake drains, are so-called
silastic Silastic (a portmanteau of ' silicone' and 'plastic') is a trademark registered in 1948 by Dow Corning Corporation for flexible, inert silicone elastomer.
Composition
The Silastic trademark refers to silicone elastomers, silicone tubing and some c ...
drains made of silicone and feature open flutes that reside inside the patient. Drainage is thought to be achieved by capillary action, allowing the fluids to travel through the open grooves into a closed cross section, which contains the fluid and allows it to be suctioned through the tube.
Though these chest tubes are more expensive than conventional ones, they are theoretically less painful.
Chest drainage system
A
chest drainage system is typically used to collect chest drainage (air, blood, effusions). Most commonly, drainage systems use three chambers which are based on the three-bottle system. The first chamber allows fluid that is drained from the chest to be collected. The second chamber functions as a "water seal", which acts as a one way valve allowing gas to escape, but not reenter the chest. Air bubbling through the water seal chamber is usual when the patient coughs or exhales but may indicate, if continual, a pleural or system leak that should be evaluated critically. It can also indicate a leak of air from the lung. The third chamber is the suction control chamber. The height of the water in this chamber regulates the negative pressure applied to the system. A gentle bubbling through the water column minimizes evaporation of the fluid and indicates that the suction is being regulated to the height of the water column. In this way, increased wall suction does not increase the negative pressure of the system. Newer drainage systems eliminate the water seal using a mechanical check-valve, and some also use a mechanical regulator to regulate the suction pressure. Systems which employ both these are dubbed "dry" systems, whereas systems that retain the water seal but use a mechanical regulator are called "wet-dry" systems. Systems which use a water seal and water column regulator are called "wet" systems. Dry systems are advantageous as tip-overs of wet systems can spill and mix with blood, mandating the replacement of the system. Even newer systems are smaller and more ambulatory so the patient can be sent home for drainage if indicated.
The free end of the tube is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest. Alternatively, the tube can be attached to a
flutter valve
A flutter valve (also known as the Heimlich valve after its inventor, Henry Heimlich) is a Check_valve, one-way valve used in respiratory medicine to prevent air from travelling back along a chest tube. One can also use a Chest_drainage_managemen ...
. This allows patients with
pneumothorax
A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...
to remain more mobile.
More recently digital or
electronic chest drainage systems have been introduced. An onboard motor is used as vacuum source along with an integrated suction control canister and water seal. These systems monitor the patient and will alert if the measured data are out of range. Due to the digital control of the negative pressure, the system is able to objectively quantify the presence of a pleural or system leak. Digital drainage systems allow clinicians to mobilize patients early, even for those on continuous suction, which is difficult to accomplish with the traditional water-seal system under suction.
Recently published clinical data indicates, that application of such systems can also lead to a reduction in complications.
Technique
Thoracostomy
It can be inserted in an area described as the "safe zone", which is a region bordered by the lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi and a horizontal line superior to the nipple. This should translate to the tube being inserted into the fifth intercostal space slightly anterior to the mid axillary line.
Chest tubes are usually inserted under
local anesthesia
Local anesthesia is any technique to induce the absence of sensation in a specific part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It ...
. The skin over the area of insertion is first cleansed with
antiseptic
An antiseptic (from Greek ἀντί ''anti'', "against" and σηπτικός ''sēptikos'', "putrefactive") is an antimicrobial substance or compound that is applied to living tissue/skin to reduce the possibility of infection, sepsis, or putre ...
solution, such as iodine, before
sterile
Sterile or sterility may refer to:
*Asepsis, a state of being free from biological contaminants
* Sterile (archaeology), a sediment deposit which contains no evidence of human activity
*Sterilization (microbiology), any process that eliminates or ...
drapes are placed around the area. The local anesthetic is injected into the skin and down to the muscle, and after the area is numb a small incision is made in the skin and a passage made through the skin and muscle into the chest. The tube is placed through this passage. If necessary, patients may be given additional
analgesics
An analgesic drug, also called simply an analgesic (American English), analgaesic (British English), pain reliever, or painkiller, is any member of the group of drugs used to achieve relief from pain (that is, analgesia or pain management). It i ...
for the procedure. Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied to the area. Once the drain is in place, a
chest radiograph
A chest radiograph, called a chest X-ray (CXR), or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common film taken in med ...
will be taken to check the location of the drain. The tube stays in for as long as there is air or fluid to be removed, or risk of air gathering.
Chest tubes can also be placed using a trocar, which is a pointed metallic bar used to guide the tube through the chest wall. This method is less popular due to an increased risk of iatrogenic lung injury. Placement using the
Seldinger technique
The Seldinger technique, also known as Seldinger wire technique, is a medical procedure to obtain safe access to blood vessels and other hollow organs. It is named after Sven Ivar Seldinger (1921–1998), a Swedish radiologist who introduced th ...
, in which a blunt guidewire is passed through a needle (over which the chest tube is then inserted) has been described.
Protocols to maintain chest tube patency by preventing chest tube clogging are necessary.
Postoperative drainage
The placement technique for postoperative drainage (e.g.
cardiac surgery
Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease (for example, with coronary artery bypass grafting); to corr ...
) differs from the technique used for emergency situations. At the completion of open cardiac procedures, chest tubes are placed through separate stab incisions, typically near the inferior aspect of the sternotomy incision. In some instances multiple drains may be used to evacuate the mediastinal, pericardial, and pleural spaces. The drainage holes are placed inside the patient and the chest tube is passed out through the incision. Once the tube is in place, it is sutured to the skin to prevent movement. The chest tube is then connected to the drainage canister using additional tubing and connectors and connected to a suction source, typically regulated to -20 cm of water.
Dressings
After suturing,
dressings are applied for hygienical reasons covering the wound. First, a y-slit
compress
compress is a Unix shell compression program based on the LZW compression algorithm. Compared to more modern compression utilities such as gzip and bzip2, compress performs faster and with less memory usage, at the cost of a significantly l ...
is used around the tube. Second, a compress (10 x 10 cm) is placed on top and finally an
adhesive plaster is added in a way that tension is avoided. A bridle rein is recommended to fix the tube to the skin. This tape bridge will prevent the tube from moving backwards and the possibility to cause clogging. It also prevents pain as it reduces tension on the fixation stitch. Alternatively, a large adhesive plaster that functions like a tape bridge may be used.
Management
Chest tubes should be kept free of dependent loops, kinks, and obstructions which may prevent drainage. In general, chest tubes are not clamped except during insertion, removal, or when diagnosing air leaks.
Chest tube clogging with blood clots of fibrinous material is common. When this occurs, it can result in retained blood around the heart or lungs that can lead to complications such as hematoma that needs to be drained, effusions, empyema, or, in the long term, fibrothorax. Thus its critical to maintain chest tube patency. Manual manipulation, often called milking, stripping, fan folding, or tapping, of chest tubes is commonly performed to clear chest tube obstructions. However these approaches are controversial. No conclusive evidence has demonstrated that any of these techniques are more effective than the others, and no method has shown to improve chest tube drainage.
Furthermore, chest tube manipulation has proved to increase negative pressure, which may be detrimental, and painful to the patient.
For these reasons, many hospitals do not allow these types of manual tube manipulations.
One option is active chest tube clearance without breaking the sterile field. According to a consensus of multiple experts in cardiac surgery, anesthesia and critical care in 2019 the ERAS Guidelines for Perioperative Care recommends active clearance of chest tubes to prevent retained blood and other complications.
Makeshift efforts such as open chest tube clearing that involves breaking the sterile environment separating the chest tube from the drainage canister tubing to suction it out should not be performed.
Side of placement
In December 2018 the ''
European Respiratory Journal
The ''European Respiratory Journal'' is a monthly peer-review
Peer review is the evaluation of work by one or more people with similar competencies as the producers of the work (peers). It functions as a form of self-regulation by qualified ...
'' published correspondences that raise the possibility of improving mobility as well as patient outcomes by placing a chest tube more optimally.
References
Further reading
* Catheter drainage is used for empyemas after chest-tube failure:
* Commonly used after Percutaneous CT-Guided Lung Biopsies:
External links
*
{{DEFAULTSORT:Chest Tube
Medical drains
Emergency medical procedures
Intensive care medicine
Pulmonology
Thoracic surgical procedures