Tag Archives: chest tube

Practical Tip: Making Sure The Last Chest Tube Hole Is In The Chest

I recently wrote about how the completion chest x-ray can lie after insertion of a chest tube. The chest x-ray image is a 2-D representation of the patient, but you really can’t tell where the tube lies in the third dimension (front to back). That’s how a trauma professional can get suckered into thinking they just put a perfect chest tube in, when in reality they have not.

How can you be sure of the position as you are putting it in? It’s a nuisance to have to reposition it after you’ve taken down your sterile field. Here are a few suggestions, but pay particular attention to the last one. I think it’s the best.

  • Make the incision large enough so that you can visually confirm that the last hole is inside the thoracic cavity. This option is somewhat okay for thinner patients. But it leads to a larger than necessary incision, especially in patients who are obese. Not a great idea.
  • Estimate proper depth before insertion.  Hold the tube over the patient’s chest, and note the distance mark printed on the tube when the tip is placed halfway across the hemithorax (just medial to the nipple). This does take into account the amount of soft tissue on the lateral chest, but is not terribly accurate and you may accidentally contaminate the tube. The usual depth for a patient with normal body habitus is 12-14 cm at the skin. A better choice.
  • Use the “bamboo flute” technique. Once you have entered the pleural space and placed the end of the tube into it, locate and place your finger firmly over the last hole, like you were playing a flute. Keep it there as you slide the tube in until your finger contacts the ribs around the insertion point. It should be at a right angle to the chest wall. Then push it in another 2-4 cm. As long as you have performed a nice dissection down to the chest wall, this technique is close to foolproof. And double-check by making sure that the tube is at least 12-14 cm at the skin. IMHO, this is the best technique.

This is not a chest tube!

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Chest CT vs Chest X-Ray After Chest Tube Insertion

Two days ago, I discussed getting the traditional chest x-ray routinely after chest tube insertion. The answer was yes, it is important even if it appears to be functioning correctly. But yesterday, I also showed you how the chest x-ray can lie.

Remember this image?

Looks perfect! But it’s a 2-D view and you don’t know where the tube is in the anterior-posterior axis. It turns out to be in the patient’s subcutaneous tissues of his back, near his scapula!

So what if this is a trauma activation patient and you are getting ready to send your patient for a chest CT shortly? Should you follow the usual dogma and still get a conventional chest x-ray prior to leaving the trauma bay?

The answer is no! Typically, your trauma activation patient should have rapid access to the CT scanner, so you won’t have to wait very long. And the additional 3-D information is very helpful in making sure the tube is placed exactly where you want it.

Bottom line: If you are planning on obtaining a chest CT anyway in your trauma patient, don’t bother with a conventional chest x-ray first to check chest tube position. But DON’T order a chest CT for this reason alone! Remember, the chest CT is only for detecting aortic injury in blunt trauma. It should not be used for diagnosing fractures, hemothorax, or pneumothorax. Or chest tube position!

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Quiz: Is This A Good Chest Tube?

A blunt trauma activation patient presents with a pneumothorax seen on the initial chest x-ray, obtained in your trauma bay. You professionally insert a large chest tube, and all appears to go well. You shoot a followup chest x-ray and this is what you get:

What do you think of the tube position? Looks great, right?

But if you look carefully, you can see the lung outline in the middle of the right side of the chest. Big-time pneumothorax despite what looks like a perfectly placed tube. There are several possible explanations, and many of you sent me your guesses:

  • The tube is in the lung. This rarely happens to normal lungs. Sure, you can probably do it to an ARDS lung, but otherwise it’s not very likely.
  • The tube is in the fissure. This does happen on occasion, but not often. And many times it works anyway.
  • The tube is occluded or kinked. A PA or AP chest x-ray will show the kink, although bent tubes frequently work anyway. If a hemothorax is present, it is possible that a clot is plugging the tube. Clearing a plugged tube will be the subject of another post.
  • It’s not really a chest tube. Hopefully, this would have been detected when it was placed, but it isn’t always. The chest x-ray above looks great, right? Unfortunately, it’s a 2 dimensional representation of a 3-D object. Where is that tube in the z-axis?

In this case the correct answer is the last one. This is one time when I would actually recommend a lateral chest x-ray. Have a look at the result. You can clearly see the tube snaking around into the soft tissues of the back.

Bottom line: Remember that a perfect x-ray doesn’t necessarily mean a perfect tube. Go through the various possibilities quickly, and make it work.

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Imaging After Chest Tube: Why Do It?

More dogma, or is it actually useful? Any time a chest tube (tube thoracostomy) is inserted, we automatically order a chest x-ray. Even the ATLS course recommends obtaining an image after placement. But anything we do “automatically” is grounds for critical analysis to see if there is a valid reason for doing it.

A South African group looked at the utility of this practice retrospectively in 1004 of their patients. They place 1042 tubes. Here are the factoids:

  • Patients were included if they had at least one chest x-ray obtained after insertion
  • Patients were grouped as follows: Group A (10%) had the tube inserted on clinical grounds with no pre-insertion x-ray (e.g. tension pneumothorax). Group B (19%) had a chest x-ray before and had ongoing clinical concerns after insertion. Group C (71%) had a chest-xray before and no ongoing concerns.
  • 75% of injuries were penetrating (75% stab, 25% GSW), 25% were blunt
  • Group A (insertion with pre-x-ray): 9% had post-insertion findings that prompted a management change (kinked, not inserted far enough)
  • Group B (ongoing clinical concerns): 58% required a management change based on the post-x-ray. 33% were subcutaneous or not inserted far enough (!!)
  • Group C (no ongoing clinical concerns): 32 of 710 (5%) required a management change, usually because the tube was too deep

The authors concluded that if there are no clinical concerns (tube functioning, no clinical symptoms) after insertion, then a chest x-ray is not necessary.

Bottom line: But I disagree with the authors! Even with no obvious clinical concerns, the tube may not be functioning for a variety of reasons. Hopefully, this fact would then be discovered the next day when another x-ray is obtained. But this delays the usual progression toward removing the tube promptly by at least one day. It increases hospital stay, as well as the likelihood of infection or other hospital-associated complication. A chest x-ray is cheap compared to a day in the hospital, which would potentially happen in 5% of these patients. I recommend that we continue to obtain a simple one-view chest x-ray after tube insertion.

Tomorrow: Look at the chest x-ray. Is it a good chest tube?

The next day: What if you placed the chest tube in your resuscitation room and are planning to go to CT for additional imaging? Is it worthwhile getting a chest x-ray, or should you just check the tube with the CT scan?

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