CURRENT Essentials of Critical Care.pdf

Chapter 7 Pulmonary Disease 85■■Chest Tube ThoracostomyEssential Concepts• Bedside procedure performed to remove fluid or air from pleuralspace or to instill agents to ablate pleural space• May require ultrasound or CT imaging to guide tube placementif loculated fluid or air collection• No absolute contraindication exists but care should be taken inpatients with coagulopathies, bullae, large effusions due to mainairway occlusion, previous thoracotomy, pleurodesisEssentials of Management• Chest tube size depends on type of material to be aspirated:smaller caliber tubes (12 to 28 Fr) for air and larger tubes forfluid (32 to 36 Fr for effusion, 36 to 42 Fr for pus or blood)• Drainage system prepared at bedside before beginning procedure:three “bottle” system consisting of collection compartment,water seal chamber, manometer for suction control• Most chest tubes inserted in fourth or fifth intercostal spacealong anterior axillary line• Positioning of tube depends on indication for insertion: apicallyplaced tubes for pneumothoraces; dependently placed tubes forpleural effusions or fluid drainage• Once tube inserted into pleural space, apply suction (10–20 cmH 2 O) until all air or fluid removed• System should be evaluated to assure proper function: fluctuationof fluid column with respiration suggests tube is withinpleural space and subjected to intrapleural pressures• Once lung fully expanded, air leak resolved, or drainage 150mL per day, system can be switched to water seal and monitored;if lung remains expanded and no significant reaccumulationof fluid or air, tube can be removed• If persistent air leak, evaluate entire system to locate source asit may come from within apparatus and not patient• If drainage ceases, “milking” tubing may help reestablish flow• Complications: improper positioning, subcutaneous emphysema,bleeding, intercostal nerve damage, diaphragm or abdominalorgan injury, pain, re-expansion pulmonary edema■ PearlA tension pneumothorax may develop if a chest tube is clamped duringtransportation or movement of the patient.ReferenceGilbert TB et al: Chest tubes: indications, placement, management, and complications.J Intensive Care Med 1993;8:73. [PMID: 10148363]