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Chest tubes are placed to empty the pleural space of air or fluid which prohibits full lung expansion. The function of these tubes is dependent on adequate placement, effective drainage and frequent re-evaluation of the patient and the chest drainage system. Knowledge of the principles of chest tube drainage is important to evaluate adequately the function of a tube thoracostomy.
Chest tubes are inserted for a variety of reasons, and a number of complications have been associated with their use. We report a case of traumatic hemopneumothorax in which the chest tube crossed the mediastinum into the contralateral lung causing a pneumothorax. Its position was not apparent on portable chest radiographs.
Chest tubes and their accompanying pleural drainage units continue to present challenging questions regarding their optimal use. Appropriate chest tube size selection to accommodate the clinical situation is key, especially in the setting of large pleural air leaks lest a tension pneumothorax ensue. Connection of an appropriate pleural drainage unit to the chest tube is equally important to obviate impeding airflow after successful evacuation by the chest tube. Large-bore chest tubes are generally required for patients with pneumothoraces, regardless of etiology, if the patient is mechanically ventilated, or for patients requiring drainage of viscous pleural liquids such as blood. Smaller bore tubes may be adequate in patients with limited production of pleural air or of free-flowing pleural liquid. Chest tubes may be removed successfully at either end expiration or end inspiration, and potentially as soon as </=200 mL/fluid output per day is achieved. Additional prospective studies are needed to provide evidence-based answers to the many questions remaining regarding chest tube placement, ongoing management, and removal.
A chest tube can be used to change a tracheostomy tube just as a Seldinger wire is used to change a central line. A good match for size is important. The flange should be cut off of the chest tube and the inspired oxygen should be increased. Positive pressure ventilation can be performed through the chest tube by the addition of an endotracheal tube adaptor at the cut off end.
Chest tube insertion is generally considered a safe procedure. We describe a patient who developed winging of the scapula following chest tube insertion. This complication has not been documented before.
BACKGROUND: The traditional treatment for pneumothorax is tube thoracostomy. Chest tube placement often involves complications, particularly in newborns. The aim of this study is to introduce the method of air drainage with venous catheter and to compare two different methods, chest tube placement and venous catheter insertion, in the treatment of pneumothorax in newborns. METHODS: We treated 72 newborn patients with pneumothorax over a 4-year period in neonatal intensive care units at two different medical centers. We randomly divided the patients into two groups. In group I, we treated the patients with chest tube placement technique. We used 18-gauge venous catheter connected to an underwater system to drain air in group II patients. The duration of the procedure, the period of time that the chest tube or catheter was left in place, and the complications associated with the two different procedures were statistically compared. RESULTS: The time required to perform the venous catheter procedure was significantly shorter than that for chest tube placement (P < 0.05). The duration of the device in place was also significantly shorter in group II than group I (P < 0.05). Only two minor complications were recorded in patients who underwent venous catheter placement, and this group's complication rate was significantly lower than the rate in the chest tube group (P < 0.05). CONCLUSION: Insertion of a venous catheter is a safe alternative to chest tube placement as a method of draining air from newborn patients with pneumothorax. This is an easy and quick bedside procedure and is particularly useful for newborn patients that require immediate air drainage.
OBJECTIVE: Recent literature suggests that patients who undergo emergent tube thoracostomy in the field are at increased risks for complications. This study evaluates indications, complications, and effectiveness of field placement of chest tubes by an aeromedical service. METHODS: In a prospective study, 624 consecutive patients with chest injuries (Abbreviated Injury Scale score 1-6) were included. All patients were treated at the scene by a physician-staffed aeromedical service and transported by air to a Level I trauma center. Indications, clinical findings before and after chest tube insertion, and subsequent radiologic diagnosis by chest roentgenography were documented prospectively. RESULTS: Seventy-six chest tubes (50 unilateral, 13 bilateral) were inserted laterally in 63 patients (10%) by blunt dissection. Clinical findings included pneumothorax in 30 patients and hemothorax in 18 patients. In 15 patients receiving field chest tubes, neither pneumothorax nor hemothorax was confirmed. Six patients (<1%) arrived at the trauma center with unsuspected pneumothoraces and required chest tube insertion. No tension pneumothoraces escaped field detection and treatment. Four chest tubes placed in the field required repositioning in the hospital because of malfunction or malpositioning. Radiologic findings excluded intraparenchymal tube placements in all patients. No pleural infections were observed in these 63 patients during their hospital stay. No antibiotics were administered as a result of prehospital chest tube placement. CONCLUSION: Prehospital chest tube thoracostomy is safe, effective, and associated with low morbidity. Nontherapeutic chest tube placements occurred in 15 of 624 patients (2.4%); missed pneumothoraces occurred in 6 of 624 patients (<1%). Aggressive prehospital physician management of blunt chest trauma leads to an earlier treatment of potentially life-threatening injuries. Significant morbidity can be avoided by prompt pleural decompression using proper techniques.
Chest tube tracks may simulate normal structures or pathology. This article will help the radiologist to understand their formation and to recognize them as iatrogenic shadows.
Competent chest tube management represents the mainstay of postoperative care for the cardiothoracic patient. Patency and integrity of mediastinal and pleural catheters is crucial to preservation of cardiopulmonary performance. Despite the relatively brief period of time these catheters dwell, knowledge of their placement, function, and current research findings relevant to their care is essential for appropriate nursing interventions. This article addresses application and management of chest tubes, autotransfusion techniques, and areas for future nursing research.
OBJECTIVE: The aim of this study was to compare the accuracy between computed tomography (CT) and frontal chest radiography in the diagnosis of malpositioned chest tubes (MCT). MATERIALS AND METHODS: CT scans positive for MCT between March 2000 and March 2004 were reviewed. Two radiologists assessed for intra- and extrathoracic locations of MCT in CT studies. Two physicians who were blinded to the results of CT scans assessed the frontal chest radiographs for location of chest tubes, within the pleural space or outside pleural space. The results of CT were then compared with the results of frontal chest radiographs. Medical records were also reviewed for function of the chest tubes and any complications induced by MCT. RESULTS: CT revealed 28 MCT among the 76 chest tubes that were placed in 54 patients. Among the 28 MCT detected by CT, 23 tubes were in the intrathoracic location (20 intraparenchymal; 3 intrafissural) and 5 tubes were in the extrathoracic location (4 in mediastinum; 1 in chest wall). Frontal chest radiographs only revealed six MCT. Among 28 MCT, 16 sufficient, 8 insufficient, and 4 indeterminate functions of the chest tubes were noted from medical charts. One patient complicated with lung abscess, four patients had suffered pleural empyema, and one patient suffered active lung parenchymal bleeding, resulting from MCT. CONCLUSIONS: CT is more accurate than chest radiograph for the diagnosis of MCT. For selected patients with inadequacy drainage of the tubes and when chest radiograph is noncontributory, CT scan is recommended to clarify the exact location of chest tubes.
Chest tube removal after coronary artery bypass graft is frequently reported by patients as stressful and painful, highlighting the need for effective nonpharmacological interventions. Slow deep breathing relaxation exercises (SDBREs) may serve as a simple nursing strategy to reduce discomfort. In this study, we aimed to evaluate the effect of SDBRE on pain and anxiety during and after chest tube removal following coronary artery bypass grafting in Nablus hospitals. An experimental design was used with 80 patients recruited from 2 hospitals. Participants were randomly assigned to either an intervention group (n = 40) that practiced SDBRE or a control group (n = 40) that received standard care. Data were collected through a self-administered questionnaire, the Numeric Pain Scale, and the Visual Anxiety Scale. Data collection occurred from March to October 2024. The intervention group reported significantly lower pain scores during removal (M: 5.325 vs 7.125, P < .001) and after removal (P < .001). Anxiety scores were significantly lower both during and after removal (P < .001). Pain correlated with duration, with more complex operations and prolonged chest tube insertion linked to higher scores. SDBRE significantly reduced pain and anxiety during and after chest tube removal, supporting its integration into routine postoperative nursing care.
BACKGROUND: Pain during chest tube removal can be moderately to severely intense and distressful to patients. Little evidence-based research has guided clinicians in attempts to alleviate such pain. OBJECTIVE: To test pharmacological and nonpharmacological interventions to alleviate pain during chest tube removal in cardiac surgery patients. METHODS: Four interventions were tested in 74 patients in a randomized, double-blind study: (1) 4 mg intravenous morphine and procedural information; (2) 30 mg intravenous ketorolac and procedural information; (3) 4 mg intravenous morphine plus procedural and sensory information; and (4) 30 mg intravenous ketorolac plus procedural and sensory information. Analgesics were administered to correspond to peak effect, and scripted information was provided. Pain intensity and pain distress were measured before analgesic administration, immediately after chest tube removal, and 20 minutes later Pain quality was measured immediately after chest tube removal. Level of sedation was measured before and 20 minutes after chest tube removal. Repeated-measures analyses of variance were used to test differences among groups over time. RESULTS: Pain intensity, pain distress, and sedation levels did not differ significantly among groups. However, procedural pain intensity (mean 3.26, SD 3.00) and pain distress (mean 2.98, SD 3.18) scores for all were low. Patients remained alert, regardless of which analgesic was administered. CONCLUSIONS: If used correctly, either an opioid (morphine) or a nonsteroidal anti-inflammatory (ketorolac) can substantially reduce pain during chest tube removal without causing adverse sedative effects. Thus, clinicians may choose among several safe and effective analgesic interventions during chest tube removal.
Insertion of a chest tube into the pleural space is standard management for various pleural disorders. Malpositioning of chest tubes in extrathoracic, intraparenchymal and mediastinal locations and in the fissures is common. Malpositioning results not only in inadequate drainage of air and fluid but may also result in increased morbidity and mortality. Diagnosis of a malpositioned tube is sometimes difficult to establish on a chest radiograph. CT, however, has proven to be extremely accurate in evaluating the position of a chest tube and has often provided additional valuable information with significant therapeutic impact.
Blood gas analysis of chest tube drainage following thoracostomy for experimental and clinical penetrating chest injuries was evaluated to determine its usefulness in predicting the etiology of the injury. Twenty dogs were divided into four groups and sustained right chest injury as follows: Group I--closed chest lung laceration; Group II--open chest lung laceration; Group IIII-gunshot wounds; Group IV--thoracotomy and injection of autologous, mixed venous blood. All animals and 14 patients who sustained penetrating chest injury were made simultaneously from chest tube draininage, systemic artery, and central vein in all dogs and patients. Eight patients (Group A) had pneumothorax; six patients (Group B) did not. Mean control canine aortic PO2 and pulmonary arterial PO2 values in Group I did not differ significantly from those in the other three canine groups, nor from the two human groups. Group II dogs exhibited chest tube PO2 which was significantly (p less than 0.01) above aortic PO2. In Group IV, chest tube PO2 was increased significantly above pulmonary arterial blood. Patients without pneumothorax had values for PO2 in chest tube drainage and aorta which were not significantly different, whereas when pneumothorax was present, PO2 of chest tube drainage was significantly higher than that of aortic PO2. Thus blood gas determinations on chest tube drainage may reflect the nature of the injury; however, the presence of air in the pleural space can result in oxygenation of contained blood well above systemic arterial levels.
A 62-year-old woman developed shock immediately after the insertion of a right-sided chest tube. A chest roentgenogram showed the chest tube to be overlying the heart and possibly compressing the right ventricle. An animal model was developed to replicate this clinical situation. Using a domestic goat model pulmonary artery, peripheral arterial catheters were inserted along with a right sided chest tube placed to suction. A second chest tube guided by a flexible fiberoptic bronchoscope placed within its lumen was positioned between the right ventricle and the sternum of the animals. Thirteen paired measurements in three goats (average of 4.3 measurements per animal) of cardiac output, heart rate, and mean arterial blood pressure were made at baseline and after chest tube placement over the right ventricle. The data were analyzed using a paired t test statistic. Compared with baseline measurements, there was a significant decrease in cardiac output (p less than 0.001) and mean arterial pressure (p less than 0.001) as well as an increase in heart rate (p = 0.0056) after placement of the chest tube across the right ventricle. We conclude that a misplaced chest tube compressing the right ventricle can impede cardiac output and lead to a low cardiac output state. Physicians inserting chest tubes in patients should be aware of this potential complication as it is easily treated by withdrawal of the chest tube.
Nurses prepare patients for chest tube removal, yet little has been written to indicate the sensations to be expected during this routine procedure. The sensations reported by patients and factors that could influence those sensations were examined in this study. The sample consisted of 36 patients after thoracic surgery (24 men and 12 women), all of whom were scheduled to have either a mediastinal or a pleural tube removed. They reported their sensations and the intensity of those sensations (using a 100 mm visual analog scale) within 15 minutes after tube removal. The most frequently reported sensation during chest tube removal was burning, followed by pain and pulling with mean intensities of 64, 62, and 45, respectively. Subjects reported having few sensations after the tube was removed with only five reporting soreness in the chest. The sensations and intensities did not differ for those who did and did not receive analgesia or for those having a pleural tube versus a mediastinal tube removed. The sensations were similar for the old and young subjects with younger subjects reporting higher intensities. Women reported pain more frequently than men, but the intensities of the sensations reported by men and women were not significantly different. The sensations reported during chest tube removal differ from those described in the literature and can be used to prepare patients more appropriately for chest tube removal.
BACKGROUND: The insertion and subsequent removal of chest tubes are frequently performed procedures. We hypothesize that routine chest radiographs obtained after chest tube removal to confirm the absence of any post-procedure complications have little impact on clinical management. MATERIALS AND METHODS: A 5-year retrospective study of 73 patients with tube thoracotomies was performed in a level II trauma center's intensive care unit. Patients were identified from billing records for chest tube placement. Medical records and official chest x-ray film reports, both before and after removal, were reviewed, and demographic data were collected. RESULTS: Of the 73 patients examined, only 8 had postprocedure reports that differed from the preprocedure reports. Two of these 8 patients required reinsertion of a chest tube to treat the recurrence of a significant pneumothorax. However, the decision to reinsert the chest tube was based on the patient's clinical appearance rather than on the x-ray findings. CONCLUSION: Chest radiography following the removal of chest tubes should not be a routinely performed procedure, but should preferably be based on the good clinical judgement and discrimination of the surgeon.
BACKGROUND: The purpose of this study was to determine the appropriate time interval between the removal of a chest tube and the chest radiograph (CXR). We hypothesized that a CXR obtained 1 hour after chest tube removal would exclude the presence of a recurrent pneumothorax. METHODS: Of 214 trauma intensive care unit patients with a chest tube during a 1-year period, 75 met entry criteria and underwent chest tube removal according to an institutional review board-approved prospective study protocol. Patients were undergoing positive-pressure ventilation, with an existing solitary chest tube, and had less than 150 mL of drainage on water seal over the previous day. After chest tube removal, serial CXRs were obtained at approximately 1, 10, and 36 hours. Demographic, chest tube, and ventilator data were collected. RESULTS: None of the patients experienced hemodynamic or respiratory deterioration after chest tube removal. There were nine pneumothoraces (12%). All pneumothoraces were present on the initial CXR after chest tube removal. Two patients (3%) required intervention for pneumothorax. Of the remaining seven small pneumothoraces, three resolved and four were unchanged on the third CXR. CONCLUSION: A CXR obtained within 1 to 3 hours after chest tube removal effectively identifies pneumothorax in mechanically ventilated patients.