Here’s a 9 minute video demonstrating my easy technique for inserting a chest tube. I’ve included some helpful tips and tricks to make this a quick and easy procedure.
I’ve written a lot about chest tubes, but there’s actually a lot to know. And a fair amount of misinformation as well. Here’s some info you need to be familiar with:
- Chest trauma generally means there is some blood in the chest. This has some bearing on which size chest tube you choose. Never assume that there is only pneumothorax based on the chest xray. Clot will plug up small tubes.
- Chest tubes for trauma only come in two sizes: big (36Fr) and bigger (40Fr). Only these large sizes have a chance in evacuating most of the clot from the pleural space. The only time you should consider a smaller tube, or a pigtail type catheter, is if you know for a fact that there is no blood in the chest. The only way to tell this is with chest CT, which you should not be getting for diagnosis of ordinary chest trauma. Having said this, there is some more recent literature that suggests that size might not matter as much as we think.
- When inserting the tube, you have no control of the location the tube goes once you release the instrument used to place it. Some people believe they can direct a tube anteriorly, posteriorly, or anywhere they want. They can’t, and it’s not important (see next tip).
- Specific tube placement is not important, as long as it goes in the pleural space. Some believe that posterior placement is best for hemothorax, and anterior placement for pneumothorax. It doesn’t really matter because the laws of physics make sure that everything gets sucked out of the chest regardless of position except for things too big to fit in the tube (e.g. the lung).
- Tunneling the tube tract over a rib is not necessary in most people. In general, we have enough fat on our chest to ensure that the tract will close up immediately when the tube is pulled. A nicely placed dressing is your insurance policy.
- Adhere to an organized tube management protocol to reduce complications and the time the tube is in the chest.
And finally, amaze your friends! The French system used to size chest tubes is the diameter of the tube in millimeters times three (3.14159, pi to be exact). So a 40Fr chest tube has a diameter of 13.3mm.
I’m dedicating the coming fortnight (that’s two weeks to you non-Brits) to the lowly chest tube. It’s taken for granted, but there is a lot a variability on how we insert, manage, and pull out these devices. Here’s what’s coming, starting tomorrow:
- Videos on how to insert a chest tube and pigtail catheter
- A video on how to pull a chest tube properly
- Chest tube tips and tricks
- A practice guideline for chest tube management
- Troubleshooting chest tubes
- Collection systems gone bad
- Lateral chest x-ray for pneumothorax: waste of time?
- When to remove a chest tube
- Autotransfusing blood from the collection system
I’ve been somewhat old school when it comes to chest tubes. Unlike some, I don’t believe that you have any control of where a chest tube goes if you are placing it in a closed chest. Only in the OR with an open one. And I’ve got plenty of x-rays to prove it.
And I used to think that chest tube size mattered when dealing with hemothorax. In theory, you need a big tube to get clots out, right?
Well, maybe not! The trauma group at the University of Arizona Tucson has previously done work on using 14 French pigtail catheters in lieu of a full-size tube. They will be presenting their extended experience with this concept at EAST 2017.
They have maintained a prospectively collected database of information on trauma patients with chest tubes for many years. This study focused only on those who had blood in their chest, either hemothorax (HTX) or hemopneumothorax (HPTX). They also looked at trends in their selection of chest drain tubes.
Here are the factoids:
- Nearly 500 patients were treated with a tube for HTX or HPTX during the 7 year study period, 2/3 with a chest tube and 1/3 with a pigtail
- Pigtails had more fluid drain initially (430cc vs 300cc, significant), and 1 less treatment day (4 vs 5, also significant)
- Failure rate and insertion-related complications were the same (about 22% and 6%, respectively)
- The group found that their use of pigtails steadily and significantly increased over the years
Bottom line: I’m coming around. The literature does appear to be tilting toward smaller tubes, and this longer-term study helps confirm that. How can this be? Although this is speculation on my part, it probably has to do with the fact that any size tube will drain liquid blood. And probably no size of tube will successfully get all the clot out.
And certainly, smaller tubes are much better tolerated and do not require the degree of sedation that a mega-tube does. The authors suggest that a multi-center trial should be carried out to confirm this. For my part, I’m going to review the literature we have to date and consider modifying my own chest tube policy (see links below).
Questions and comments for the authors/presenters:
- Where did you typically insert the pigtails? Anterior chest or classic chest tube position? Was it consistent?
- Was/is the selection of tube type an attending surgeon specific choice, or did you implement a policy to direct them?
- Did patient injury pattern or body habitus have any part in tube selection?
- What about removal failures? That is, how many had to have a tube replaced, and how many went on to require VATS or other surgical procedure for drainage?
- I enjoyed this provocative paper!
- Sample chest tube management protocol
- Pigtails vs chest tubes – 2013
- Chest tube size – medium vs large tubes
Reference: A prospective study of 7-year experience of using percutaneous 14-French pigtail catheter for traumatic hemothorax at a Level I trauma – size still does not matter. Quick Shot #4, EAST 2017.
Yesterday I presented the problem of the malpositioned chest tube, specifically one that is not completely in the pleural space. This one is way out:
So what do the doctor books say? Well, the first thing you will discover if you try to look it up is that THERE IS NO LITERATURE ON THIS COMMON PROBLEM! There are a few papers on tubes placed in the fissure and tubes inserted into the lung parenchyma. But there are only a few mentions of tubes with holes still outside the chest.
I’ve gotten a number of comments, including “you can push them in a little”, “take it out and put in another”, and “never push them in.” Since we don’t have any science to guide us, we have to use common sense. But remember, I’ve shown you plenty of examples where something seems reasonable, but turns out to be ineffective or downright harmful.
There are three principles that guide me when I face this problem:
- Prevention is preferable to intervention
- Do no (or as little as possible) further harm
- Be creative
Tomorrow, I’ll finish this series and provide some tips and guidelines to help manage this problem using the principles outlined above.