Chest Tube Insertion Protocol

The proper application of chest tubes begins with establishing a sterile environment similar to that seen in the operating room theater. Masks, sterile gowns, and gloves must be worn at all times throughout the insertion procedure. Local anesthesia should be administered to the patient usually with 1 percent lidocaine (up to 4 mg/kg). Injection of anesthetics should be above, at, and below the planned insertion site. The pleura should be anesthetized as well. In addition, intravenous analgesia should be administered prior to tube insertion. The preferred site of insertion is at the third to fifth inter-costals space, midaxillary line. The size of the chest tube varies depending on the indication for placement. In trauma, a no. 36 French (Fr) chest tube is often used to allow for proper pleural drainage and prevention from clot impediment. Prior to insertion, digital exploration should be performed to avoid lung penetration. The tube should then be directed toward the apex and posteriorly so that the last hole is 2-4 cm into the pleural cavity. The tube should then be connected to an underwater draining system and secured using 0-silk (Fig. 18-13). Petroleum gauze should then be placed around the tube at the insertion site and the tube secured with silk/adhesive tape.5 An essential requirement after chest tube insertion is the postprocedure chest radiograph to assure correct placement.

Although standard protocols have been well established for tube tho-racostomy, complications related to insertion, removal, and failures continue to occur and are reported to range from 9 to 36 percent.6,7 The primary complications include improper placement, iatrogenic injuries to the lung, persistent air leak, and residual pneumothorax or hemothorax. The problems related to chest tube placement may require further intervention and extended hospitalization for the patient. Strategies used to limit complications should include supervised chest tube placement by senior physicians, and an establishment and observance of strict guidelines for placement.

Finally, the development of a skillful approach to chest tube placement will allow for appropriate intervention in an expeditious manner. A failure of a defined technique makes the patient susceptible to further morbidity and possible mortality.

Figure 18-13 Chest tube insertion. The tube should be directed toward the apex and posteriorly so that the last hole is 2-4 cm into the pleural cavity. The tube should then be connected to an underwater draining system and secured using 0-silk.
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