Category Archives: Thorax

When To Remove a Chest Tube

Chest tubes are needed occasionally to help manage chest injuries. How do you decide when they are ready for removal?

Unfortunately, the literature is not very helpful in answering this question. To come up with a uniform way of pulling them, our group looked at any existing literature and then filled in the (many) blanks, negotiating criteria that we could all live with. We came up with the following.

Removal criteria:

  1. No (or a minimal, stable) residual pneumothorax
  2. No air leak
  3. Less than 150cc drainage over the last 3 shifts. We do not use daily volumes, as it may delay the removal sequence. We have moved away from the “only pull tubes on the day shift” mentality. Once the criteria are met, we begin the removal sequence, even in the evening or at night. This typically shaves half a day from the hospital stay.

Removal sequence:

  • Has the patient ever had an air leak? If so, they are placed on water seal for 6 hours and a followup AP or PA view chest x-ray is obtained. If no pneumothorax is seen, proceed to the next step.
  • Pull the tube. See tomorrow’s blog for a video on how to do it.
  • Obtain a followup AP or PA view chest x-ray in 6 hours.
  • If no recurrent pneumothorax, send the patient home! (if appropriate)

Click here to download the full printed protocol.

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Lateral Chest X-Ray For Pneumothorax? Waste of Time!

Pneumothorax is typically diagnosed radiographically. Significant pneumothoraces show up on chest xray, and even small ones can be demonstrated with CT.

Typically, a known pneumothorax is followed with serial chest xrays. If patient condition permits, these should be performed using the classic technique (upright, PA, tube 72″ away). Unfortunately, physicians are used to ordering the chest xray as a bundle of both the PA and lateral views.

The lateral chest xray adds absolutely no useful information. The shoulder structures are in the way, and they obstruct a clear view of the lung apices, which is where the money is for detecting a simple pneumothorax. The xray below is of a patient with a small apical pneumothorax. There is no evidence of it on this lateral view.

Bottom line: only order PA views (or AP views in patients who can’t stand up) to follow simple pneumothoraces. Don’t fall into the trap of automatically ordering the lateral view as well!

Lateral chest xray

 

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How To Troubleshoot Air Leaks in Chest Tube Systems

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:

  • Patient – Take the dressing down and look at the skin entry site. Does it gape, or is their obvious air hissing and entering the chest? If so, plug it with petrolatum gauze. If not, the air is actually coming out of your patient and you must wait it out.
  • Connector – Secure it with Ty-Rap fasteners or tape (see picture). This is a common problem area.
  • Collection system – The one-way valve system is not functioning, or the system has been knocked over. Replace it immediately.

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.

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