This unit has been knocked over. Note the blood in both collection columns on the right. In this case, the water seal and pressure chambers have also been compromised (area on the left).
Collection systems that have been knocked over frequently malfunction and should be changed immediately! (It’s also impossible to accurately measure tube output after this happens)
An air leak is a sure-fire reason to keep a chest tube in place. Fortunately, many air leaks are not from the patient’s chest, but from a plumbing problem. Here’s how to locate the leak.
To quickly localize the problem, take a sizable clamp (no mosquito clamps, please) and place it on the chest tube between the patient’s chest and the plastic connector that leads to the collection system. Watch the water seal chamber of the system as you do this. If the leak stops, it is coming from the patient or leaking in from the chest wall.
If the leak persists, clamp the soft Creech tubing between the plastic connector and the collection system itself. If the leak stops now, the connector is loose.
If it is still leaking, then the collection system is bad or has been knocked over.
Here are the remedies for each problem area:
Note: If you are using a “dry seal” system (click here for more on this) you will not be able to tell if you have a leak until you fill the seal chamber with some water.
Yesterday, I demonstrated how to insert a standard chest tube. Today Jessie Nelson MD, from our Department of Emergency Medicine, demonstrates how to insert a small pigtail type catheter.
Check out this 10 minute video!
Traditionally, hemothorax and pneumothorax in trauma has been treated with chest tubes. I’ve previously written about some of the debate regarding using smaller tubes or catheters. A paper that will be presented at the EAST meeting in January looked at pain and failure rates using 14Fr pigtail catheters vs 28Fr chest tubes.
This was a relatively small, prospective study, and only 40 of 74 eligible patients were actually enrolled over 20 months at a Level I trauma center in the US. Pain was measured using a standard Visual Analog Scale, as was complication and failure rate, tube duration and hospital stay.
The following interesting findings were noted:
Bottom line: There may be some benefit in terms of tube site pain when using a smaller catheter instead of a chest tube. But remember, this is a very small study, so be prepared for different results if you try it for your own trauma program. If you do choose to use a smaller tube or catheter, remember to do so only in patients with a pure pneumothorax. Clotted blood from a hemothorax will not be completely evacuated.
Reference: A prospective randomized study of 14-French pigtail catheters vs 28F chest tubes in patients with traumatic pneumothorax: impact on tube-site pain and failure rate. EAST Annual Surgical Assembly, Oral paper 12, 2013.
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.