random chest tube questions

[sponch]

i've had a couple of chest tubes that i've tried to direct posteriorly to evacuate hemothorax but they always end up migrating into the fissure (seen on chest CT later on). any pointers?

are any people out there using pigtails for simple pneumothoraces? what about ptx in blunt traumas that don't have hemothorax concurrently?

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[ESU_MD]

i feel compelled to comment since it is the middle of the nite and I just placed a chest tube and I should be sleeping.

first a disclaimer- everyone has their own (strong) views on the "right" way to place a chest tube.

Hemothorax- use a big tube, 36F or bigger. make an incision big enough to get your finger AND the tube in the chest. this will help you guide it into place under direct feel. DO NOT try to guide it into place on the end of a curved clamp, especially via a small incision- it will end up in the fissure 85% of the time. it is ok to clamp the end of the tube to prevent spilling fluid on your feet

pigtails are nice. i have used them for simple ptx successfully. can be flimsy for fat/muscular patients and kink off in the skin. the stylet is very sharp and often can poke through the tube and pierce something

for simple ptx, i prefer 20f chest tube. small incision. use the trocar as a stylet and it will go to the apex everytime.
make sure you have the proper connector for the small tube. the std. christmas trees are too big.

 

[RichL025]

I'm not sure what I'm doing right, but I've had very few fissure tubes (but *ahem* - not zero ).

One thing that I know helps is like what ESU said - your finger AND the tube in the muscular / pleural hole at the same time, and you direct it posteriorly with your finger.

I've only placed a few pigtails, but that sharp-assed trocar gives me pause - I much prefer placing a small tube, but a couple of my chiefs have directed me to use the pigtail, and I have to admit (espescially in a thin-chest walled person) the end result is neater - less pain, more comfortable, easier to manage and (the last one I placed was for a young female) lesser scar.

The last one I did I avoided the trocar: micro- puncture kit, confirm intra-pleura with a "drop test" (a la Veress) and then an .035 guidewire into the pleura. Then pigtail over wire. Need to do them all like that, but the downside is raiding IR for a lot of gear in the middle of the night.

 

[drdrew267]

Two things I'd like to add...

The width between your ribs is only about 32 French, so stuffing a 34 or higher Fr chest tube is useless as it will be squeezed down naturally by the ribs...

Those sharp trochars on the end of those stupid-ly designed pigtail catheters are seriously dangerous. An ER resident went straight through the lung (and a branch of the PA) using one of those things!

 

[RichL025]

An ER resident went straight through the lung (and a branch of the PA) using one of those things!

ANd then he turned to you and said "He's your patient now!", didn't he

 

[njbmd]

i feel compelled to comment since it is the middle of the nite and I just placed a chest tube and I should be sleeping.

first a disclaimer- everyone has their own (strong) views on the "right" way to place a chest tube.

Hemothorax- use a big tube, 36F or bigger. make an incision big enough to get your finger AND the tube in the chest. this will help you guide it into place under direct feel. DO NOT try to guide it into place on the end of a curved clamp, especially via a small incision- it will end up in the fissure 85% of the time. it is ok to clamp the end of the tube to prevent spilling fluid on your feet

pigtails are nice. i have used them for simple ptx successfully. can be flimsy for fat/muscular patients and kink off in the skin. the stylet is very sharp and often can poke through the tube and pierce something

for simple ptx, i prefer 20f chest tube. small incision. use the trocar as a stylet and it will go to the apex everytime.
make sure you have the proper connector for the small tube. the std. christmas trees are too big.

I agree with this except the use of the trocar with the 20F. I never used that thing and tended to give it to the nurses to stake their houseplants. I have only used pigtails on thin folks. If the patient has a good bit of sub-q fat, the pigtail is not very useful. Less painful for thin/average folks with simple pneumo.

If a person is very muscular, it's going to be a thrash unless you make that hole big enough. This means calculating the max amount of local and using every ml. I do a little nerve block too. I guide the chest "stogies" (36F) with my fingers and not the curved clamp. I just make my hole big enough.

Chest tubes are my favorite non-vascular bedside procedure. I just love a well-placed chest tube.

 

[maverick_pkg]

well being a second year now, the technique has undergone huge amount of refinement with zero fissure chest tubes now.

Used to start out with a bigger incision so that I could guide the tube with my finger. Always gives good results. Nowadays though, I use a smaller incision, and dont use my finger at all while inserting. The trick (taught by our thoracic surgeon) is to use a long curved hemostat and squeeze the end of the chest tube with it. Then while inserting the curved tip of the hemostat should be pointing inwards while inserting. As soon as you cross the ribs, turn the hemostat by 180 degrees such that the curved tip now points towards the axilla/chest wall and slide it in as much as possible. Then let the hemostat go and continue sliding the chest tube in. Perfect results using this technique.

Peds surgery gave me another perspective. We used to put all chest tubes using the seldinger technique (even in fat 17 year olds), varying from 12f to 20f, even for hemothoraces. Had good results there as well, so not sure if 36f is requried all the time. Have put pigtails in obese people too, although ultrasound guided, and they give fine results as well.

 

[Blade28]

Hemostat? Or Kelly?

 

[maverick_pkg]

mostly kelly but have occasionally used other stuff so used the term hemostat as a generalization.

put a 8f pigtail for hemothorax on an obese 50yr old today. Pigtails work fine as well

 

[Bitsy3221]

I have found that as you insert the tube you rotate it simultaneously; helps guide it into place and prevents kinking.

 

[Blade28]

Don't forget that once the chest tube is in the pleural space, it's hard to "direct" it - its orientation is mainly determined by the direction of the tract in the subcutaneous tissue (i.e. when you tunnel over the rib).

 

[Dr. V]

Don't forget that once the chest tube is in the pleural space, it's hard to "direct" it - its orientation is mainly determined by the direction of the tract in the subcutaneous tissue (i.e. when you tunnel over the rib).

Yep, "struggle" is an understatement if trying to place a posterior chest tube with a tunnel that goes PA. Even if it does go posterior it will be kinked.

Another thing, if placement is crucial then a larger tube is less compliant and easier to direct. One of the smaller tubes is so soft that it can pretty much go anywhere if the lung is completely down.

 

[geekgirl]

I have found that as you insert the tube you rotate it simultaneously; helps guide it into place and prevents kinking.

agree with the spin technique. cut down. enter the chest. finger in, verify position. direct tube with kelly then spin as it goes in. somehow it works.

also - even for hemothorax, there is no need for a huge tube. if it can't be drained through a 24 or 28fr they are likely gonna need a VATS anyway. so save yourself and them the pain of a big tube. or so say our thoracic guys.

 

[SLUser11]

well being a second year now, the technique has undergone huge amount of refinement with zero fissure chest tubes now.

Used to start out with a bigger incision so that I could guide the tube with my finger. Always gives good results. Nowadays though, I use a smaller incision, and dont use my finger at all while inserting. The trick (taught by our thoracic surgeon) is to use a long curved hemostat and squeeze the end of the chest tube with it. Then while inserting the curved tip of the hemostat should be pointing inwards while inserting. As soon as you cross the ribs, turn the hemostat by 180 degrees such that the curved tip now points towards the axilla/chest wall and slide it in as much as possible. Then let the hemostat go and continue sliding the chest tube in. Perfect results using this technique.

Peds surgery gave me another perspective. We used to put all chest tubes using the seldinger technique (even in fat 17 year olds), varying from 12f to 20f, even for hemothoraces. Had good results there as well, so not sure if 36f is requried all the time. Have put pigtails in obese people too, although ultrasound guided, and they give fine results as well.

I use a sort of Indiana Jones and the Temple of Doom technique, where I pierce their skin with my bare hand......feel around for adhesions.....then place the tube.

The problem is that you have to chant in an ancient foreign language during placement, and it really helps to have some sort of large drum and shirtless drummer.......so it really depends on what your facility can offer. Where I'm at, it's hard to get the drummer on nights and weekends......

 

[SLUser11]

agree with the spin technique. cut down. enter the chest. finger in, verify position. direct tube with kelly then spin as it goes in. somehow it works.

also - even for hemothorax, there is no need for a huge tube. if it can't be drained through a 24 or 28fr they are likely gonna need a VATS anyway. so save yourself and them the pain of a big tube. or so say our thoracic guys.

Isn't that sort of a self-fulfilling prophecy? We use small chest tubes (that can clot off easily) because the patient will need VATS anyway. Also, if they're going to need VATS anyway, why struggle to make a small incision, etc, when they're destined for 2-3 more incisions for the surgery.

My personal opinion is that for hemothorax, you should use a big tube (36-ish). One of our previous trauma guys, who was big in developing ATLS, etc, demanded that all traumas get a 40 french tube.

I've also had some luck with the large blake drains (28 french or so), since they don't clot off as much. I've only used them in thoracotomies, though....no bedside placements.