Tube Thoracostomy Management

Overview

The mechanics of ventilation relate to the negative intrathoracic pressure that draws air into the lungs during spontaneous respiration. This negative pressure is best maintained in the pleural space, which is the potential space between the parietal and visceral layers of the pleura. Collections of air, fluid, or blood in the pleural space not only compress the lung tissue but also cause the pleural pressures to become positive, causing inappropriate ventilation.

(See the video below, showing chest tube insertion.)

Insertion of chest tube. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.

Chest drains are inserted to remove pathological collections of air or fluid in the pleural space, to allow the re-creation of the essential negative pressures in the chest, and to permit complete expansion of the lung, thereby restoring normal ventilation. Chest drains are very simple and effective tools in the management of thoracic and pleural pathology. They need proper safe insertion and correct management. Chest drains are lifesaving in critical care.

Chest drainage systems work by combining the following 3 efforts:

Expiratory positive pressure from the patient helps push air and fluid out of the chest (eg, cough, Valsalva maneuver).Gravity helps fluid drainage as long as the chest drainage system is placed below the level of the patient’s chest.Suction can improve the speed at which air and fluid are pulled from the chest.

Any catheter inserted through the chest wall to remove air or fluid from the pleural space may be called a chest tube or chest drain. Crosswell Hewitt is credited as being the first to use a chest drain, in 1876, when he used a red rubber catheter to drain an empyema thoracis.[1] Ideally, the chest tubes (also called thoracic catheters) must be nontoxic, nonthrombogenic, and soft but with thick resilient walls. The traditional red rubber tubes have most of these features but, being opaque, tend to be quickly occluded by encrustation and fibrinous secretions.

Today, chest tubes are made of clear plastic (vinyl or silastic). They are available in varying diameters, sized in multiples of 4 on the French scale (eg, 12F, 16F, 20F, up to 36F). They have multiple side holes to allow effective drainage and have length markers to help note the distance of the lowest hole from the skin surface. A radiopaque strip lines the tube to help easy visualization on chest radiography.[2] Some tubes are mounted on stylets or trocars that act as guides to help insertion and proper placement of tubes.

The standard of care with chest tubes has evolved with experience gained with their use for chest trauma during the Korean War of the 1950s and the Vietnam War thereafter.[3] Improper management of inserted chest tubes results in premature removal or delayed removal, both of which lead to increased hospital stay and costs.

When caring for and maintaining a patient with a chest tube, the following steps are important: Keep chest tubes patent, note the presence of drainage and fluctuations, and observe the patient's vital signs and levels of comfort. The chest dressing status and type of suction must be noted.

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