Alameda County Medical Center / Highland General Hospital
Trauma Service

Chest Tubes
 
Technique
The tube thoracostomy shall be performed using strict aseptic technique: povidone iodine skin prep, sterile drapes, sterile gloves, gown and mask.  Prep the skin widely: from the sternum medially to the bed surface laterally, and from the axilla superiorly to the costal margin inferiorly.  Anesthesia should be provided using local infiltration of 1% lidocaine + epinephrine solution.  When possible, a small dose of intravenous midazolam (1 - 2 mg) for sedation is appropriate in the non head-injured patient. The minimum acceptable tube size in the adult is 36 French, so as to minimize tube occlusion with clotted blood and thus ensure adequate pleural fluid/blood evacuation.
 
 
The rigid chest tube is mated to the flexible rubber Creech tubing with an intervening ridged plastic connector flange (x).  To avoid disconnection and air leaks, the system is secured with narrow strips of cloth tape in the manner shown.  By not completely wrapping the joint with tape, any obstructing clot within the narrow diameter connector flange can be noted and quickly cleared.
 
Antibiotics
Cefazolin (Ancef) 1 gram iv should be given within 30 minutes prior to tube insertion, and the same dose repeated once in eight hours.  Prolonged antibiotic coverage has not been shown to minimize the incidence of infectious complications in the trauma population requiring emergency tube thoracostomy.
 
Suction
Initially, all chest tubes will be placed to 20 (twenty) cm water suction via the thoracic drain apparatus.  The water level in the suction chamber must be monitored daily and kept at the appropriate by level by adding sterile water to counteract the normal evaporative losses that will diminish the effective interpleural suction force of the chest tube.
 
Water Seal
Disconnecting the chest tube reservoir apparatus from wall suction constitutes placement of the patient on water seal.  This will be done prior to chest tube removal, assuming the three conditions listed below have been met.  Generally, a chest x-ray will be taken to document continued lung expansion after placement on water seal and before actual removal of the tube from the chest.
 
Removal
In the adult, a chest tube is considered ready for removal only after all of the following conditions have been met:
  1. resolution of pneumothorax
  2. < 100 ml of pleural drainage evacuated over the preceding 24 hour period
  3. absence of air leak on valsalva maneuver or forceful cough
After tube removal, a follow-up chest x-ray should be obtained to document continued lung re-expansion.
 
X-rays
Wait at least four hours before obtaining x-rays after making changes to the chest tube (i.e. after changing to water seal, or after pulling the tube from the chest).  This is to allow for sufficient time to transpire and ensure that a slowly reoccurring pneumothorax is not missed.
 
Tube Clamping
The chest tube should never be clamped.  Doing so in a patient with a residual pleural leak, even if small, can lead to a tension pneumothorax and resultant cardiac arrest.
 
References
1.  Luchette FA, Barie PS, Oswaski MF, et.al: Prophylactic Antibiotics in Tube Thoracostomy for Traumatic Hemopneumothorax. Eastern Association for the Surgery of Trauma - Practice Guidelines 2000. Click here to see the EAST guidelines.
 

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