Introduction

Diagnostic and therapeutic aspiration of air anduid via thoracentesis or chest tube placement is one of the most basic and commonly performed pleural procedures. It is primarily performed by interventional pulmonologists, interventional radiologists, and thoracic surgeons; however, due to increasing service demands, there is a need for physicians from other backgrounds to develop competency in performing these procedures. This chapter will focus on the indications, contraindications, necessary equipment and preparation, basic procedural techniques and complications of chest tube, and indwelling pleural catheter (IPC) placement. Literature pertaining to post-procedure management and complications will be reviewed with a primary focus on IPCs. Training tools and methods of determining procedural competency for pleural procedures will also be discussed.

History of Chest Tubes

The frst recorded evidence of chest tube use belongs to Hippocrates. He described irrigation of the pleural cavity with warm wine and oil followed

A. J. Schwalk (*) · A. Rudkovskaia

Internal Medicine, Pulmonary and Critical Care Division, The University of Texas Southwestern Medical Center, Dallas, TX, USA

e-mail: audra.schwalk@utsouthwestern.edu

by the intrapleural insertion of a hollow drainage tube in a patient recovering from empyema [1]. Almost 2000 years after Hippocrates, Dominique Anel described the use of a silver tube with suction generated by a piston syringe to aspirate the contents of a pleural cavity [2]. The frst “water-seal” drainage system was described by Playfair which he used to manage empyema in a 7-year-old child [3]. It was not until the late 1950s that closed chest tube drainage systems became commonplace and the standard of care for managing intrathoracic trauma during the Vietnam War [4].

Overview of Chest Tubes

Chest tubes and IPCs are indicated in the treatment of multiple conditions, namely pneumothorax and pleural effusion from hemothorax, empyema, and malignancy. Various chest tubes and pigtail catheters in a range of sizes are commercially available. Chest tube and pigtail catheter sizes are measured in French gauge (Fr), where 1 Fr equals 1/3 mm. There is signifcant variability in the defnition of small and large bore chest tubes but generally 8–14 Fr is considered small bore and 28–40 Fr large bore. The choice of a chest tube size should be guided by the disease process and is discussed in detail later in the chapter. Larger chest tubes may be necessary to successfully drain air out of the pleural cavity and prevent tension pneumothorax in patients with large air leaks requiring continuous positive airway pressure. In addition,

blood and fbrin clots may occlude a small diameter tube and lead to tension physiology, lung collapse, or re-accumulation of pleural uid, especially when managing traumatic injuries and postoperative complications. Poiseuille’s law states that volume and ow are proportional to the radius to the fourth power (Q r4), which explains why larger tubes are more effective in certain clinical scenarios. Larger chest tubes are associated with more pain and discomfort for patients; therefore, clinical judgment should be used when deciding on a specifc chest tube to balance maximal effectiveness and patient comfort.

Contraindications for Chest Tube Placement

Pleural drainage procedures are relatively simple but can result in high morbidity and mortality in the hands of an inexperienced operator. It is imperative to master the technique and understand the indications and contraindications of these procedures to prevent unnecessary interventions and complications (Table 31.1).

The only absolute contraindications to chest tube placement are lack of informed consent or operator and equipment availability, pleural fusion, and entry site infection. Computed tomography (CT)-guided placement of chest tubes is

Table 31.1  Indications for chest tube insertion in adults

Pleural effusion:

Large malignant or non-malignant pleural effusion requiring slow drainage for symptom relief

Non-malignant or malignant pleural effusion as part of a pleurodesis procedure

Infectious pleural effusion (parapneumonic, empyema)

Chylothorax

Pleural effusion related to post-operative complications

Hemothorax

Pneumothorax:

Large or symptomatic primary spontaneous pneumothorax

Secondary spontaneous pneumothorax

Pneumothorax in patients on positive pressure ventilation

Tension pneumothorax

Large or symptomatic traumatic or iatrogenic pneumothorax

preferred in the setting of multiple loculations, pleural adhesions, and scarring. Relative contraindications include increased risk of bleeding due to thrombocytopenia, uncorrected coagulopathy (INR > 1.7), or therapeutic anticoagulation, all of which should be reversed when feasible [5]. It is important to note that the relative contraindications do not apply to emergencies, like tension pneumothorax or massive hemothorax, when timely intervention is of utmost importance.

Chest Tube Procedural Technique

A thorough pre-procedural evaluation is the key to any successful intervention. History of prior procedures and complications, hemodynamic, and coagulation parameters and active medications should all be carefully reviewed and optimized prior to chest tube placement. Chest tube placement for non-traumatic conditions does not routinely require pre-procedural antibiotic prophylaxis [6]. Relevant images should always be reviewed prior to the procedure. The chest tube insertion site is ideally chosen based on an ultrasonographic image, but the “triangle of safety” is the best insertion site in emergencies or when ultrasound is unavailable. The “triangle of safety” is an anatomic area on the chest identifed by the lateral border of the pectoralis major muscle, the lateral border of the latissimus dorsi, and the nipple line inferiorly (Fig. 31.1). The patient can remain upright while leaning forward on a table during thoracentesis or may be placed in a lateral decubitus or semi-recumbent position for chest tube insertion for pleural effusion drainage. The supine position for tube placement in the second intercostal space in the mid-clavicular line or lateral decubitus position is best for chest tube placement for the treatment of pneumothorax. Of note, inserting a chest tube in the second intercostal space in patients with post-procedural pneumothorax related to pacemaker placement is not recommended due to an increased risk of infection.

The initial steps in chest tube placement are to identify and mark the site of insertion, clean the site with chlorhexidine or other sterilization solution, and place a sterile drape over the area. Next, inject 1% lidocaine (5–7 mg/kg) to anesthetize the subcutaneous, intercostal, and

B

C

A

D

A: Lateral edge of pectoris major; B: base of axilla

C: Lateral edge of latissimus dorsi; D: fifth intercostal space

Fig. 31.1  Illustration outlining the anatomical borders of the “triangle of safety” utilized during chest tube placement to avoid damage to the chest wall and breasts. The “triangle of safety” is bounded anteromedially by the lateral edge of the pectoralis major, inferiorly by a horizontal line at the level of the nipple and posteriorly by the lateral edge of the latissimus dorsi. Illustration by Faris Kudrath

parietal pleural spaces in the intended placement tract. The needle entrance point should be above the rib to minimize risk of injury to the neurovascular bundle. The appearance of uid or air within the syringe signifes entrance into the pleural space in the case of pleural effusion or pneumothorax, respectively. The two most used techniques for chest tube placement are the blunt operative dissection and the percutaneous Seldinger technique, both described below.

The blunt operative dissection technique for placement of larger chest tubes involves the following:

\1.\ Make a 2–3 cm skin incision parallel to the rib. \2.\ Dissect through the subcutaneous tissue and intercostal space using a curved clamp (hemostat or Kelly) until you enter the pleural space on the superior border of the rib. The sensation of a “pleural pop” may be felt as the pleu-

ral space is entered.

Fig. 31.2  Illustration of blunt operative chest tube insertion technique using a curved hemostat to place a large bore chest tube over the superior aspect of the rib to minimize risk of damage to the neurovascular bundle.

Illustration by Faris Kudrath

\3.\ Use the clamp to dilate the pleural insertion site to a size large enough to accommodate insertion of fnger.

\4.\ Insert a sterile gloved fnger into the pleural space and perform a fnger sweep to confrm intrapleural position, remove thin adhesions, and ensure suffcient space for chest tube placement.

\5.\ Grasp the large bore chest tube with the clamp and direct the chest tube through the insertion site into the pleural space. Aim apically and anteriorly for the treatment of pneumothorax and inferiorly in the setting of pleural effusion (Fig. 31.2).

\6.\ Secure the chest tube to the skin with a suture to prevent migration or premature removal.

The percutaneous Seldinger technique is typically used for the placement of small-bore pigtail catheters (Fig. 31.3). The technique involves placement of the catheter over a guidewire after appropriate dilation. A Cook® Wayne Pneumothorax catheter is one of the commercially available sets (Fig. 31.4). There are also

Fig. 31.3  Photo of a small-bore pigtail catheter (Cook® Wayne Pneumothorax) showing curved tip with multiple fenestrations to allow for drainage of pleural uid or air.

Distinct marks are present on the catheter to indicate depth of placement