|
Iowa Neonatology Handbook: Procedures
Technique for Insertion of a Chest Tube
Iowa Neonatology Fellows
Peer Review Status: Internally Peer Reviewed
Pulmonary air leak is an anticipated risk of mechanical
ventilation. Drainage of air or fluid accumulation in the thorax is
an important and necessary skill and is often performed emergently.
I. Indications.
A. Evacuation of pneumothorax
B. Evacuation of large pleural fluid collections
1. chylothorax
2. empyema
3. hemothorax
A small spontaneous pneumothorax in the absence of lung
disease will most likely resolve without intervention.
II. When evaluating a suspected pneumothorax, auscultation and
transillumination of the chest should be performed. Note that false
positives may result from subcutaneous edema or air. If positive,
consider needle aspiration performed with a 20 or 22 gauge needle
connected to a 30 cc syringe via a 3-way stopcock. After prepping
with alcohol, insert needle 3-5 mm into the chest wall in the fourth
or fifth intercostal space in the anterior axillary line. If the
infant is supine, air may be easier to access via the second
intercostal space in the mid-clavicular line.
III. If pneumothorax is under tension or reaccumulates following
needle aspiration, the insertion of a chest tube (CT) will be
necessary. Appropriate insertion sites include the fourth, fifth or
sixth intercostal spaces in the anterior axillary line. The nipple is
a landmark for the fourth intercostal space.
IV. Insertion. (see figure on next page)
A. A 8, 10 or 12 French CT used depending on the size of
the infant.
B. Position infant supine or with the affected side elevated
45-60 degrees off the bed using a towel or blanket as back
support. This has an advantage of allowing air to rise to the
point of entry and of encouraging the correct anterior direction
of the CT.
C. The skin is prepped with alcohol and sterilely draped.
D. A 1 cm incision is made through the skin on top of the rib
to facilitate entry of the CT. Using a small curved forceps,
separate the tissue down to the pleura.
F. Grasping the end of the CT with the tips of curved forceps,
apply pressure until the pleural space is entered. Do not use the
trocar. Direct CT toward apex of thorax (midclavicle) and advance
CT assuring that side holes are within thorax. Observe for
cloudiness, vapor or bubbling in CT to verify intrapleural
location.
E. The chest tube should be inserted 2-3 cm for a small preterm
infant and 3-4 cm for a term infant. (These are approximate
guidelines only.)
V. After CT insertion connect the tube's distal end to a water
seal system such as a PleurevacR. To apply suction, use 15-20 cm of
water in the PleurevacR column. If multiple CTs are placed, each CT
should be connected to it's own water seal system and suction
source.
Secure CT to skin with suture and cover incision site with
vaseline gauze and/or TegadermR dressing.
VI. After thoracentesis or CT insertion a chest x-ray, A/P and
lateral should be obtained.
VII. If there is a persistent pneumothorax despite a properly
placed CT, consider increasing the column of water by 5 cm increments
up to 30 cm before inserting a second CT.
IX. Prior to removal, the CT should be clamped for 2-4 hours or
longer. If there is no reaccumulation of air, the CT can be
removed.
X. Complications.
A. Misdiagnosis with inappropriate CT placement
B. Malpositioned CT
C. Trauma
1. lung laceration or perforation
2. laceration and hemorrhage of major vessel (axillary,
intercostal, pulmonary, internal mammary)
3. puncture of viscus with path of tube
D. Infection
Reference:
Mehrabani D, Kopelman AE: Chest tube insertion: A simplified
technique. Pediatr 1989;83:784-785.
Section Top | Title Page
|
