Thoracentesis
Core Course
July 2012
Chest Tubes
Indications
Pneumothorax
Tension
Spontaneous
Iatrogenic
consider while on mechanical ventilation
Hemothorax
Empyema
Chylothorax
Pleurodesis
Bronchopleural fistulas
Pneumothorax
Technique
Things to consider before starting!
Type of tube
Insertion site
(Straight or angled)
Lateral or anterior
(standard or Seldinger)
Specific Considerations
How to choose a chest tube size?
Hemothorax 32 to 40 Fr chest
Insertion site
alternate site
Insertion techniques:
Standard vs.Seldinger
Standard technique The following steps are the most common method employed to
place a chest tube:
The Kelly clamp is then opened to spread the parietal pleura and intercostal muscles.
A finger is inserted through the tract into the pleural space to confirm proper position and lack of
adhesions between the lung and the pleural surface.
Only easily disrupted adhesions should by lysed with the operator's finger, as significant bleeding can occur
if more organized adhesions are disrupted.
The chest tube is clamped at the proximal end with the Kelly clamp.
With the aid of the clamp, the chest tube is inserted through the tract into the pleural space
Directed either apically for a pneumothorax or inferiorly and posteriorly for a pleural effusion.
The skin incision is closed with one or more sutures, and one of the sutures is tied
to the chest tube to anchor it.
The site is covered with sterile gauze and surgical tape.
Some clinicians prefer to cover the site with petroleum-gauze.
The chest tube is connected to the pleural drainage system.
Connections between the chest tube and pleural drainage system should be tight and
taped securely.
Chest radiograph should be obtained to confirm tube position and assess lung
expansion.
The gap in the radiopaque marker in the chest tube, marking the most proximal
drainage hole, must be within the pleural space.
Seldinger technique
An alternative approach to chest tube placement
Chest radiograph should be carefully inspected for adequate separation of the lung and parietal pleura
due to pleural air or fluid.
The patient is placed supine with the arm of the involved side placed behind the head.
The area of insertion is prepped with chlorhexidine and draped with sterile towels.
Using one percent lidocaine, a 2 to 3 cm area of skin and subcutaneous tissue is anesthetized along the
intercostal space that will be penetrated.
Thoracentesis at the intended insertion site is performed with aspiration of air or fluid confirming an
appropriate site for chest tube insertion.
A 2 cm skin incision is made parallel to the intercostal space, and should be performed immediately
above the rib in order to reduce the risk of neurovascular injury should the incision extend more deeply
than intended.
An introducer needle is inserted into the pleural space with aspiration of air or fluid.
A guidewire is placed through the introducer needle into the pleural space.
The guidewire may be directed apically for a pneumothorax or inferiorly for a fluid collection.
Graduated size dilators are serially passed over the guidewire to dilate a tract for the chest tube.
The chest tube itself with its dilator is passed into the pleural space.
The guidewire and dilator are removed, leaving the chest tube in place.
The chest tube is sutured into place and dressed with sterile gauze.
Disadvantages:
Remove when:
Once these criteria are met, the chest tube can be placed on water seal.
CXR on water seal after 6 hours
Some will clamp the chest tube for four to six hours, then confirm the
absence of pneumothorax prior to removing the chest tube.
Mechanical ventilation does not prevent removal of CT if no air leak is
present.
Following inspiration, the patient performs a Valsalva maneuver and the
tube is removed with simultaneous covering of the insertion site with the
gauze dressing
COMPLICATIONS
Thoracentesis
INTRODUCTION
Diagnostic thoracentesis
Bedside procedure
Percutaneous introduction of needle into chest
cavity to remove pleural
Laboratory assessment of pleural fluid can
provide valuable diagnostic and prognostic
information
INDICATIONS for
Diagnostic
thoracentesis
Establish the cause of a pleural effusion.
Confirm by radiographic
Small amount of pleural fluid
And a secure clinical diagnosis (eg, with viral pleurisy)
CONTRAINDICATIONS
There are no absolute contraindications to diagnostic thoracentesis
<1 cm distance from the pleural fluid line to the chest wall on a decubitus radiograph
Mechanical ventilation
does not increase the risk for developing a pneumothorax compared with nonventilated
patients.
however, mechanically ventilated patients are at increased risk of developing tension
physiology or persistent air leak (bronchopleural fistula) if a pneumothorax does occur.
TECHNIQUE
Diagnostic Thoracentesis
COMPLICATIONS
Pneumothorax (12-30%)
Empyema
Soft tissue infection
Spleen or liver puncture
Hematoma
Hemothorax
Hemoperitoneum
Vasovagal events
Seeding the needle tract with tumor
Retained intrapleural catheter fragments have been reported.
The End
Any Questions?