Assisting in Tube Thoracostomy Insertion

Description

Tube thoracostomy (chest tube insertion) is the insertion of one or more flexible tubes into the pleural space to evacuate and remove air, blood and fluid in order to attain full lung expansion.

Equipments

The following are the materials used in a chest tube insertion:

• Chest tube
• Chest tube connector
• Chest drainage system
• Local anesthetic
• Suture materials
• Syringes
• Needles
• Trocar
• Basins
• Skin disinfectant
• Sponges
• Scalpel
• Glove
• Sterile drapes
• Two clamps

Sites

• Pneumothorax  –  second or third interspace along midclavicular or anterior axillary line
• Pleural effusion or Hemothorax – sixth or seventh lateral interspace in the mid axillary line

Procedure

1. Preparatory Phase
   • Assess the patient for pneumothorax, hemothorax, and the occurrence of respiratory distress.
   • Obtain patient’s chest xray, ultrasound or fluoroscopic localization.
   • Assemble the drainage system.
   • Reassure the patient and explain the steps to be carried out during the procedure.
   • Tell the patient he may feel a needle prick and slight pressure during the administration of anesthesia.
   • Get the patient ready by positioning him for an intercostal nerve block or as preferred by the physician.
2. Performance Phase (done by the doctor doing the procedure)
   • Needle or IntraCath Technique – removal of small amounts of air from the lungs
   1. • Skin preparation is done, anesthetized thereafter.
      • An exploratory needle is inserted.
      • IntraCath catheter is inserted through the needle into the pleural space. The needle is removed and the catheter is pushed several centimetres into the pleural space.
      • The catheter is taped into the skin.
      • The catheter is attached to a connecting tube to the drainage system.
   • Trocar Technique – used for the insertion of a large bore tube for removal of a moderate to large amount of air leak or for the evacuation of serous infusion
   1. • A small incision is made over the prepared, anesthetized site. Blunt dissection through the muscle planes in the interspace to the parietal pleura is done.
      • The trocar is directed into the pleural space, the cannula is then removed. A chest tube is inserted that will be connected into tubes going to the drainage system.
3. • Hemostat technique – a large bore test tube is used to drain blood or thick effusions from the pleural space.
   1. • Skin preparation and anesthetic infiltration i performed.
      • An incision is made through the skin and subcutaneous tissue.
      • A curved haemostat is inserted into the pleural cavity and the tissue is spread with the clamp.
      • The tract is explored via an examining finger.
      • The tube is held by the haemostat and directed through the opening up over the rib and into the pleural cavity.
      • The clamp is withdrawn and the chest tube is connected to a chest drainage system.
      • The tube is sutured in place and covered with a sterile dressing.
4. Follow-up Phase
   • Observe the drainage for blood or air.
   • There should be a free fluctuation in the tube on respiration.
   • Secure a follow-up chest x-ray.
   • Look for bleeding, infection, leakage of air and fluid around the tube.