Chest Tube

 

Used to create negative pressure in the chest cavity and allow re-expansion of the lung

 

Modalities

  • Suction

    • actively suctions air and fluid from chest cavity

      • pleurodesis/decortication: 24-72 hrs to optimize visceral/parietal pleura 

      • diaphragm surgery: helps decrease fluid accumulation

      • subcutaneous emphysema

      • difficult dissection or bleeding concern

      • pneumothorax >1cm

  • Water seal

    • allows air and fluid to escape the chest cavity by gravity

      • esophageal surgery: placed near anastomosis in case of leak

  • Clamp

    • simulates the chest tube being removed to assess for silent airleaks

    • silent airleaks: causes increasing pneumothorax or subcutaneous emphysema

 

Pleurovac

  • First Chamber - Collection Chamber

    • blood/fluid collects by gravity and air continues onto 2nd chamber

  • Second Chamber - Waterseal chamber

    • acts as a one way valve to allow air to escape but not to re-enter the chest cavity

    • tidaling: seen in this chamber

      • tells you the system is connected to the chest and patent (occurs secondary to begative pressure in the chest) - NORMAL

      • changes with inspiration and expiration

    • bubbling in this chamber indicates an air leak

  • Third Chamber - Suction control

    • controls the amount of suction based on the height of the water

    • gentle bubbling is normal

 

Air Leaks

  • most common complication after lung resection

  • leakage of air across the alveolar surface of the visceral pleural (alveolar-visceral pleura)

  • examine the entire tubing system and wound for any loose connections or slip in the tube

  • "jacuzzi water" with bubbles

    • continuous

    • intermittent

    • with cough

  • Risk Factors

    • steroids

    • emphysematous lungs

    • re-operation with extensive scar tissue

 

Treatment

  • 80-120cc blood patch into the chest tube self-sealing tubing

    • reposition the patient every 20 minutes for 1 hour

  • surgicel / gelfoam

    • wedged into the airway(s) with leak

    • self dissolving in weeks

  • bronchial blocker (need a pediatric scope)

  • endobronchial valve

    • permits air passage during expiration but not during inspiration

  • Heimlich Valve: one way valve that allows home discharge; must tolerate waterseal

  • re-do surgery

    • locate airleaks and remove that portion of lung tissue

    • biologic glue placed

 

Chest Tube Removal

  • no airleak present

  • serosanginous output (no signs of bleeding present)

  • after epicardial wires have been removed

  • output < 150-400cc over 24 hours

  • off ventilator positive pressure 

... but I would more especially commend the clinician who, in acute diseases, by which the bulk of mankind are cutoff, conducts the treatment better than others.
 
Hippocrates, 400 BC