Tag Archives: chest tube

What To Do? Chest Tube Repositioning

So you’re faced with a chest tube that “someone else” inserted, and the followup chest xray shows that the last drain hole is outside the chest. What to do?

Well, as I mentioned, there is very little written on this topic, just dogma. So here are some practical tips on avoiding or fixing this problem:

  • Don’t let it happen to you! When inserting the tube, make sure that it’s done right! I don’t recommend making large skin incisions just to inspect your work. Most tubes can be inserted through a 2cm incision, but you can’t see into the depths of the wound. There are two tricks: 
  1. In adults with a reasonable BMI, the last hole is in when the tube markings show 12cm (bigger people need bigger numbers, though)
  2. After insertion, get into the habit of running a finger down the radiopaque stripe on the tube all the way to the chest wall. If you don’t feel a hole (which is punched through the stripe), this will confirm that the it is inside, and that the tube actually goes into the chest. You may laugh, but I’ve seen them placed under the scapula. This even looks normal on chest xray!
  • Patient with a high BMI may not need anything done. The soft tissue will probably keep the hole occluded. If there is no air leak, just watch it.
  • If the tube was just put in and the wound has just been prepped and dressed, and the hole is barely outside the rib line, you might consider repositioning it a centimeter or two. Infection is a real concern, so if in doubt, go to the next step.
  • Replace the tube, using a new site. Yes, it’s a nuisance and requires more anesthetic and possibly sedation, but it’s better than treating an empyema in a few days.

Related posts:

What To Do? Chest Tube Repositioning – Part 2

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

Monday, I’ll finish this series and provide some tips and guidelines to help manage this problem using the principles outlined above.

What To Do? Chest Tube Repositioning

It happens from time to time. Your patient has a hemothorax or pneumothorax and you insert a chest tube. Well done! But then the xray comes back:

The last hole in the drain is outside the chest! What to do???

Here are the questions that need to be answered:

  • Pull it out, leave it, or push it in?
  • Does length of time the tube has been in make a difference?
  • Does BMI matter?

Leave comments below regarding what you do. Hints tomorrow and answers on Monday!

Chest Tube Management Protocol – Pediatric

Yesterday I described a protocol for deciding when to remove a chest tube in adults. Today, I’ll go over a variant of this algorithm for children. In general, it’s very similar. The major change is in the volume criterion. In adults, we decided upon an (arbitrary) value of 150cc per three shifts. We chose a time interval of 3 shifts vs 1 day to speed up the process.

Suppose you use the 1 day rule for looking at chest tube output. Typically, this would be evaluated in the morning, and the process of pulling the tube or applying water seal, followed by delayed xrays, could lead to a very late discharge. If the output is checked every shift and the most recent three are summed, the patient could meet criteria later in the day and have the tube pulled in the evening. This would allow for an earlier discharge the following day, shaving 12 hours or more off of the hospital stay. This may not make much of a difference to the hospital (although for busy ones it does), but it’s huge for patient comfort and satisfaction.

Click this image or the link below for a full-size version.

Note that the output criterion has been changed to 2cc/kg over three shifts. This adjusts for the varying sizes of the children that we treat. Otherwise things are basically the same.

Related posts:

Chest Tube Management Protocol – Adult

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 blanks, negotiating criteria that we could all live with. We came up with the following. Click the image to see a full-size version, or click the link below.

Removal criteria:

  • No (or a minimal, stable) residual pneumothorax
  • No air leak
  • Less than 150cc drainage over the past 3 shifts. We do not use daily numbers, 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.

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. If there was no air leak, skip this step.
  • Pull the tube. Click here to see a video demonstrating the proper technique.
  • 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.