Category Archives: Tips

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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Trauma Chest Tube Tips

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.

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