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| == Chest tube ==
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| {{Infobox interventions | | {{Infobox interventions |
| | Name = Chest tube | | | Name = Chest tube |
| | Image = Cross-section Blake Drain.jpg | | | Image = Cross-section Blake Drain.jpg |
| | Caption = The free end of the Chest Drainage Device is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest. | | | Caption = The free end of the Chest Drainage Device is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space and prevents anything from returning to the chest. |
| | ICD10 = | | | ICD10 = |
| | ICD9 = {{ICD9proc|34.04}} | | | ICD9 = {{ICD9proc|34.04}} |
| | MeshID = D013907 | | | MeshID = D013907 |
| | OPS301 = | | | OPS301 = |
| | OtherCodes = | | | OtherCodes = |
| | HCPCSlevel2 = | | | HCPCSlevel2 = |
| }} | | }} |
| | [[File:Dreno torácico tubular multiperfurado.JPG|thumb|right|Size of chest tube:<br> |
| | Adult male = 28–32 [[French catheter scale|Fr]] |
| | [[File:P4053296 logo.jpg|thumb|Portable electronic system]] |
| | [[File:Labelled chest tube drainage system.png|thumb|Chest tube drainage system diagram, with parts labeled in]] |
| | A '''chest tube''' (also known as a '''chest drain''', '''thoracic catheter''', '''tube thoracostomy''', or '''intercostal drain''') is a flexible plastic tube inserted through the chest wall into the pleural space or mediastinum. Its primary function is to remove air, fluid, or pus from the thoracic cavity. Common indications include pneumothorax, pleural effusion, hemothorax, chylothorax, and empyema. |
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| A '''chest tube''' ('''chest drain''', '''thoracic catheter''', '''tube thoracostomy''', or '''intercostal drain''') is a flexible plastic tube that is inserted through the chest wall and into the [[pleural cavity|pleural space]] or [[mediastinum]]. It is used to remove air ([[pneumothorax]]),<ref name="Noppen2002">{{cite journal | vauthors = Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraeten A | title = Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study | journal = American Journal of Respiratory and Critical Care Medicine | volume = 165 | issue = 9 | pages = 1240–4 | date = May 2002 | pmid = 11991872 | doi = 10.1164/rccm.200111-078OC }}</ref> fluid ([[pleural effusion]], [[hemothorax|blood]], [[chyle]]), or pus ([[empyema]]) from the intrathoracic space. It is also known as a Bülau [[Drain (surgery)|drain]] or an intercostal catheter.
| | Chest tubes play a crucial role in managing patients with thoracic trauma, postoperative thoracic procedures, and conditions leading to pleural fluid accumulation. |
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| The concept of [[Chest drainage management|chest drainage]] was first advocated by [[Hippocrates]] when he described the treatment of [[empyema]] by means of incision, cautery, and insertion of metal tubes.<ref>{{cite book|last=Hippocrates|title=Genuine Works of Hippocrates|year=1847|publisher=Sydenham Society}}</ref> However, the technique was not widely used until the influenza epidemic of 1917 to drain post-pneumonic empyema, which was first documented by Dr. C. Pope, on "Joel", a 22-month-old infant.<ref>{{cite journal| vauthors = Graham ME, Bell CR |title=Open Pneumothorax: Its relation to the treatment of empyema|journal=J Med Sci|year=1918|volume=156|issue=6|pages=839–871|doi=10.1097/00000441-191812000-00007|url=https://zenodo.org/record/1431947}}</ref> The use of chest tubes in postoperative thoracic care was reported in 1922,<ref>{{cite journal | vauthors = Lilienthal H | title = Resection of the lung for supportive infections with a report based on 31 consecutive operative cases in which resection was done or intended | journal = Annals of Surgery | volume = 75 | issue = 3 | pages = 257–320 | date = March 1922 | pmid = 17864604 | pmc = 1399898 | doi = 10.1097/00000658-192203000-00001 }}</ref> and they were regularly used post-thoracotomy in [[World War II]], though they were not routinely used for emergency tube thoracostomy following acute trauma until the [[Korean War]].<ref name=Miller>{{cite journal | vauthors = Miller KS, Sahn SA | title = Chest tubes. Indications, technique, management and complications | journal = Chest | volume = 91 | issue = 2 | pages = 258–64 | date = February 1987 | pmid = 3542404 | doi = 10.1378/chest.91.2.258 }}</ref> | | The practice of chest drainage dates back to Hippocrates, who used incision, cautery, and metal tubes for treating empyema. However, widespread use did not occur until the 1917 influenza epidemic, with further advancements in World War II and the Korean War. |
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| ==Medical uses== | | == '''Indications''' == |
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| [[File:Pneumothorax CT.jpg|thumb|Left-sided pneumothorax (right side of image) on CT scan of the chest with chest tube in place.]] | | [[File:Pneumothorax CT.jpg|thumb|Left-sided pneumothorax (right side of image) on CT scan of the chest with chest tube in place.]] |
| *[[Pneumothorax]]: accumulation of air or gas in the pleural space
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| *[[Pleural effusion]]: accumulation of fluid in the pleural space
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| **[[Chylothorax]]: a collection of [[lymphatic system|lymphatic]] fluid in the pleural space
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| **[[Empyema]]: a [[pyogenic]] [[infection]] of the pleural space
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| **[[Hemothorax]]: accumulation of blood in the pleural space
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| **[[Hydrothorax]]: accumulation of serous fluid in the pleural space
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| ==Contraindications==
| | A chest tube is indicated in the following conditions: |
| Contraindications to chest tube placement include refractory [[coagulopathy]] and presence of a diaphragmatic hernia, as well as hepatic hydrothorax.<ref name="pmid3717119">{{cite journal | vauthors = Runyon BA, Greenblatt M, Ming RH | title = Hepatic hydrothorax is a relative contraindication to chest tube insertion | journal = The American Journal of Gastroenterology | volume = 81 | issue = 7 | pages = 566–7 | date = July 1986 | pmid = 3717119 | doi = }}<!--|access-date=2012-09-05--></ref> Additional contraindications include scarring in the pleural space (adhesions).
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| | * '''[[Pneumothorax]]''' – Accumulation of air or gas in the pleural space. |
| | * '''[[Pleural effusion]]''' – Excess fluid accumulation in the pleural cavity. |
| | '''[[Chylothorax]]''' – Accumulation of lymphatic fluid. |
| | '''[[Empyema]]''' – Collection of pus due to infection. |
| | '''[[Hemothorax]]''' – Presence of blood in the pleural space. |
| | '''[[Hydrothorax]]''' – Presence of serous fluid in the pleural space. |
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| | == '''Contraindications''' == |
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| | Chest tube placement is generally safe, but some conditions may contraindicate its use: |
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| ==Complications==
| | * Severe coagulopathy – Increased bleeding risk. |
| The most common complication of a chest tube is chest tube clogging. Chest tube clogging is widely recognized in published surveys of surgeons and nurses. In one study, 100% had seen chest tube clogging, and a majority had seen adverse patient outcomes from chest tube clogging.<ref>{{cite journal | vauthors = Shalli S, Saeed D, Fukamachi K, Gillinov AM, Cohn WE, Perrault LP, Boyle EM | title = Chest tube selection in cardiac and thoracic surgery: a survey of chest tube-related complications and their management | journal = Journal of Cardiac Surgery | volume = 24 | issue = 5 | pages = 503–9 | year = 2009 | pmid = 19740284 | doi = 10.1111/j.1540-8191.2009.00905.x }}</ref> In a prospective observational study, over 36% of patients had chest tube clogging after heart surgery.<ref>{{cite journal | vauthors = Karimov JH, Gillinov AM, Schenck L, Cook M, Kosty Sweeney D, Boyle EM, Fukamachi K | title = Incidence of chest tube clogging after cardiac surgery: a single-centre prospective observational study | journal = European Journal of Cardio-Thoracic Surgery | volume = 44 | issue = 6 | pages = 1029–36 | date = December 2013 | pmid = 23520232 | doi = 10.1093/ejcts/ezt140 }}</ref> Chest tube clogging can lead to retained blood around the heart and lungs that can contribute to complications and increase mortality.<ref>{{cite journal | vauthors = Balzer F, von Heymann C, Boyle EM, Wernecke KD, Grubitzsch H, Sander M | title = Impact of retained blood requiring reintervention on outcomes after cardiac surgery | journal = The Journal of Thoracic and Cardiovascular Surgery | volume = 152 | issue = 2 | pages = 595–601.e4 | date = August 2016 | pmid = 27210474 | doi = 10.1016/j.jtcvs.2016.03.086 }}</ref>
| | * Diaphragmatic hernia – Risk of injury to abdominal organs. |
| | * Pleural adhesions – Risk of trauma to surrounding structures. |
| | * Hepatic hydrothorax – Risk of fluid imbalance and recurrence. |
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| A common complication after thoracic surgery that arises within 30–50% of patients are air leaks.<ref name=":0">{{cite journal | vauthors = Brunelli A, Cassivi SD, Salati M, Fibla J, Pompili C, Halgren LA, Wigle DA, Di Nunzio L | title = Digital measurements of air leak flow and intrapleural pressures in the immediate postoperative period predict risk of prolonged air leak after pulmonary lobectomy | journal = European Journal of Cardio-Thoracic Surgery | volume = 39 | issue = 4 | pages = 584–8 | date = April 2011 | pmid = 20801054 | doi = 10.1016/j.ejcts.2010.07.025 }}</ref> Here, digital [[Chest drainage management|chest drainage systems]] can provide a remedy as they monitor [[Intrapleural pressure|intra-pleural]] pressure and air leak flow, constantly.<ref name=":1">{{cite web |title=Compact Digital Thoracic Drain Systems for the Management of Thoracic Surgical Patients: A Review of the Clinical Effectiveness, Safety, and Cost-Effectiveness |url=https://www.cadth.ca/compact-digital-thoracic-drain-systems-management-thoracic-surgical-patients-review-clinical |website=Canadian Agency for Drugs and Technologies in Health |date=October 1, 2014 }}</ref>
| | == '''Complications''' == |
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| Major insertion complications include [[hemorrhage]], [[infection]], and reexpansion [[pulmonary edema]]. Injury to the [[liver]], [[spleen]] or [[Thoracic diaphragm|diaphragm]] is possible if the tube is placed inferior to the pleural cavity. Injuries to the thoracic [[aorta]] and [[heart]] can also occur.<ref name=Miller />
| | == Common Complications == |
| | * Chest tube clogging – The most frequent complication, leading to fluid accumulation. |
| | * Infection – Introduction of bacteria into the pleural space. |
| | * Persistent air leaks – May require prolonged drainage. |
| | * Pain and discomfort – Common during insertion and while in place. |
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| Minor complications include a subcutaneous [[hematoma]] or [[seroma]], anxiety, shortness of breath ([[dyspnea]]), and cough (after removing large volume of fluid). In most cases, the chest tube related pain goes away after the chest tube is removed, however, chronic pain related to chest tube induced scarring of the intercostal space is not uncommon.{{Cit|date=October 2018}}
| | == Serious Complications == |
| | * Hemorrhage – Injury to blood vessels during insertion. |
| | * Lung injury – Including reexpansion pulmonary edema. |
| | * Diaphragm, liver, or spleen injury – If placed incorrectly. |
| | * Thoracic aorta or heart injury – Rare but life-threatening. |
| | * Subcutaneous emphysema – Air accumulation under the skin due to a blocked drain. |
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| [[Subcutaneous emphysema]] indicates backpressure created by undrained air, often caused by a clogged drain or insufficient negative pressure.{{Cit|date=October 2018}}
| | == '''Types of Chest Tubes''' == |
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| ==Device== | | == Traditional Chest Tubes == |
| | [[File:Dreno torácico tubular multiperfurado.JPG|thumb|right|Size of chest tubes:]] |
| | '''Sizing Guidelines:''' |
| | * Adult males: 28–32 [[French catheter scale|Fr]] |
| | * Adult females: 28 Fr |
| | * Children: 18 Fr |
| | * Newborns: 12–14 Fr |
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| ===Characteristics===
| | Traditional chest tubes are clear plastic with multiple drainage holes, distance markers, and a radiopaque stripe for visibility on X-ray. |
| [[File:Dreno torácico tubular multiperfurado.JPG|thumb|right|Size of chest tube:<br>
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| Adult male = 28–32 [[French catheter scale|Fr]]<br>Pp
| | == Channel-Style Drains (Blake Drains) == |
| Adult female = 28 Fr<br>
| | Channel-style drains (e.g., Blake drains) use capillary action rather than active suction to remove fluids, and they may cause less pain compared to rigid tubes. |
| Child = 18 Fr<br>
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| Newborn = 12–14 Fr<br>
| | == '''Chest Drainage Systems''' == |
| <ref>{{cite web | title = Chest Tube and Fuhrman Catheter Insertion | work = University of Bullfalo, The State University of New York |url=http://apps.med.buffalo.edu/procedures/chesttube.asp?p%3D7 |access-date=2009-07-19 |url-status=dead |archive-url=https://web.archive.org/web/20100408000045/http://apps.med.buffalo.edu/procedures/chesttube.asp?p=7 |archive-date=2010-04-08 }}</ref>]]
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| [[File:Chest Tube Drainage Holes.jpg|thumb|Chest tube drainage holes]] | | [[File:Labelled chest tube drainage system.png|thumb|Chest tube drainage system diagram, showing labeled parts.]] |
| Chest tubes are commonly made from clear plastics like [[PVC]] and soft [[silicone]]. Chest tubes are made in a range of sizes measured by their external diameter from 6 Fr to 40 Fr. Chest tubes, like most catheters, are measured in [[French catheter scale]]. For adults, 20 Fr to 40 Fr (6.7 to 13.3mm external diameter) are commonly used, and 6 Fr to 26 Fr for children. Conventional chest tubes feature multiple drainage fenestrations in the section of the tube which resides inside the patient, as well as distance markers along the length of the tube, and a radiopaque stripe which outlines the first drainage hole.<ref name=Miller /> Chest tubes are also provided in right angle, trocar, flared, and tapered configurations for different drainage needs. As well, some chest tubes are coated with [[heparin]] to help prevent thrombus formation, though the effect of this is disputed.<ref>{{cite journal | vauthors = Kumar P, McKee D, Grant M, Pepper J | title = Phosphatidylcholine coated chest drains: are they better than conventional drains after open heart surgery? | journal = European Journal of Cardio-Thoracic Surgery | volume = 11 | issue = 4 | pages = 769–73 | date = April 1997 | pmid = 9151051 | doi = 10.1016/s1010-7940(96)01145-1 }}</ref>
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| Chest tube have an end hole (proximal, toward the patient) and a series of side holes. The number of side holes is generally 6 on most chest tubes. The length of tube that has side holes is the effective drainage length (EDL). In chest tubes designed for pediatric heart surgery, the EDL is shorter, generally by only having 4 side holes.<ref>{{Cite web | url=http://www.medgadget.com/2016/08/pleuraflow-pediatric-cardiothoracic-surgery-chest-tubes.html | title=PleuraFlow for Pediatric CT Surgery Clears Chest Tubes of Clots || date=2016-08-02}}</ref>
| | A chest drainage system is used to collect air, blood, or fluid. It consists of: |
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| Channel style chest drains, also called Blake drains, are so-called [[silastic]] drains made of silicone and feature open flutes that reside inside the patient. Drainage is thought to be achieved by capillary action, allowing the fluids to travel through the open grooves into a closed cross section, which contains the fluid and allows it to be suctioned through the tube.<ref name = Obney>{{cite journal | vauthors = Obney JA, Barnes MJ, Lisagor PG, Cohen DJ | title = A method for mediastinal drainage after cardiac procedures using small silastic drains | journal = The Annals of Thoracic Surgery | volume = 70 | issue = 3 | pages = 1109–10 | date = September 2000 | pmid = 11016389 | doi = 10.1016/s0003-4975(00)01800-2 | url = https://zenodo.org/record/1259523 }}</ref> Though these chest tubes are more expensive than conventional ones, they are theoretically less painful.<ref>{{cite journal | vauthors = Frankel TL, Hill PC, Stamou SC, Lowery RC, Pfister AJ, Jain A, Corso PJ | title = Silastic drains vs conventional chest tubes after coronary artery bypass | journal = Chest | volume = 124 | issue = 1 | pages = 108–13 | date = July 2003 | pmid = 12853511 | doi = 10.1378/chest.124.1.108 }}</ref>
| | 1. Collection Chamber – Gathers drained fluids. |
| | 2. Water Seal Chamber – Prevents air from re-entering the pleural space. |
| | 3. Suction Control Chamber – Regulates negative pressure. |
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| ===Chest drainage system===
| | Modern systems may use mechanical check valves or electronic suction for continuous monitoring. |
| [[File:P4053296 logo.jpg|thumb|Portable electronic system]]
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| [[File:Labelled chest tube drainage system.png|thumb|Chest tube drainage system diagram, with parts labeled in]]
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| A [[Chest drainage management|chest drainage]] system is typically used to collect chest drainage (air, blood, effusions). Most commonly, drainage systems use three chambers which are based on the three-bottle system. The first chamber allows fluid that is drained from the chest to be collected. The second chamber functions as a "water seal", which acts as a one way valve allowing gas to escape, but not reenter the chest. Air bubbling through the water seal chamber is usual when the patient coughs or exhales but may indicate, if continual, a pleural or system leak that should be evaluated critically. It can also indicate a leak of air from the lung. The third chamber is the suction control chamber. The height of the water in this chamber regulates the negative pressure applied to the system. A gentle bubbling through the water column minimizes evaporation of the fluid and indicates that the suction is being regulated to the height of the water column. In this way, increased wall suction does not increase the negative pressure of the system. Newer drainage systems eliminate the water seal using a mechanical check-valve, and some also use a mechanical regulator to regulate the suction pressure. Systems which employ both these are dubbed "dry" systems, whereas systems that retain the water seal but use a mechanical regulator are called "wet-dry" systems. Systems which use a water seal and water column regulator are called "wet" systems. Dry systems are advantageous as tip-overs of wet systems can spill and mix with blood, mandating the replacement of the system. Even newer systems are smaller and more ambulatory so the patient can be sent home for drainage if indicated.<ref name=Miller />
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| More recently digital or [[Chest drainage management|electronic chest drainage systems]] have been introduced. An onboard motor is used as vacuum source along with an integrated suction control canister and water seal. These systems monitor the patient and will alert if the measured data are out of range. Due to the digital control of the negative pressure, the system is able to objectively quantify the presence of a pleural or system leak. Digital drainage systems allow clinicians to mobilize patients early, even for those on continuous suction, which is difficult to accomplish with the traditional water-seal system under suction.<ref name=":0" /><ref name=":2">{{cite journal | vauthors = Bertolaccini L, Rizzardi G, Filice MJ, Terzi A | title = 'Six sigma approach' - an objective strategy in digital assessment of postoperative air leaks: a prospective randomised study | journal = European Journal of Cardio-Thoracic Surgery | volume = 39 | issue = 5 | pages = e128-32 | date = May 2011 | pmid = 21316980 | doi = 10.1016/j.ejcts.2010.12.027 }}</ref> Recently published clinical data indicates, that application of such systems can also lead to a reduction in complications.<ref>{{cite journal | vauthors = Leo F, Duranti L, Girelli L, Furia S, Billè A, Garofalo G, Scanagatta P, Giovannetti R, Pastorino U | display-authors = 6 | title = Does external pleural suction reduce prolonged air leak after lung resection? Results from the AirINTrial after 500 randomized cases | journal = The Annals of Thoracic Surgery | volume = 96 | issue = 4 | pages = 1234–1239 | date = October 2013 | pmid = 23866802 | doi = 10.1016/j.athoracsur.2013.04.079 }}</ref><ref>{{cite journal | vauthors = Miller DL, Helms GA, Mayfield WR | title = Digital Drainage System Reduces Hospitalization After Video-Assisted Thoracoscopic Surgery Lung Resection | journal = The Annals of Thoracic Surgery | volume = 102 | issue = 3 | pages = 955–961 | date = September 2016 | pmid = 27234573 | doi = 10.1016/j.athoracsur.2016.03.089 }}</ref>
| | == '''Procedure''' == |
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| ==Technique== | | == Tube Thoracostomy (Insertion Technique) |
| | Chest tube insertion follows these key steps: |
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| ===Tube thoracostomy===
| | 1. Patient Preparation: |
| The insertion technique for emergency pleural drainage is described in detail in an article of the [[NEJM]].<ref>{{cite journal | vauthors = Dev SP, Nascimiento B, Simone C, Chien V | title = Videos in clinical medicine. Chest-tube insertion | journal = The New England Journal of Medicine | volume = 357 | issue = 15 | pages = e15 | date = October 2007 | pmid = 17928590 | doi = 10.1056/NEJMvcm071974 }}</ref> The free end of the tube is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest. Alternatively, the tube can be attached to a [[flutter valve]]. This allows patients with [[pneumothorax]] to remain more mobile.
| | * Position: Semi-recumbent or supine. |
| | * Local anesthesia to minimize pain. |
| | * Sterile drapes and antiseptic preparation. |
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| British Thoracic Society recommends the tube is inserted in an area described as the "safe zone", a region bordered by: the lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi and a horizontal line superior to the nipple.<ref>{{cite journal | vauthors = Laws D, Neville E, Duffy J | title = BTS guidelines for the insertion of a chest drain | journal = Thorax | volume = 58 Suppl 2 | issue = 90002 | pages = ii53-9 | date = May 2003 | pmid = 12728150 | pmc = 1766017 | doi = 10.1136/thorax.58.suppl_2.ii53 }}</ref> More specifically, the tube is inserted into the 5th intercostal space slightly anterior to the mid axillary line.<ref>{{cite web | title = Ventilatory management | work = University of Pretoria |url=http://www.up.ac.za/academic/medicine/anatomy/current/ecp/ecpst05e.html |access-date=2009-09-16 |url-status=dead |archive-url=https://web.archive.org/web/20090617011611/http://www.up.ac.za/academic/medicine/anatomy/current/ecp/ecpst05e.html |archive-date=2009-06-17}}</ref>
| | 2. Insertion Site: |
| | * Safe Zone: Between the anterior axillary line and midaxillary line, at the 5th intercostal space. |
| | * Inferior insertions risk injury to the liver, spleen, or diaphragm. |
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| Chest tubes are usually inserted under local [[anesthesia]]. The skin over the area of insertion is first cleansed with [[antiseptic]] solution, such as iodine, before [[sterilization (microbiology)|sterile]] drapes are placed around the area. The local anesthetic is injected into the skin and down to the muscle, and after the area is numb a small incision is made in the skin and a passage made through the skin and muscle into the chest. The tube is placed through this passage. If necessary, patients may be given additional [[analgesics]] for the procedure. Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied to the area. Once the drain is in place, a [[chest radiograph]] will be taken to check the location of the drain. The tube stays in for as long as there is air or fluid to be removed, or risk of air gathering.
| | 3. Placement: |
| | * A small incision is made, and a blunt dissection technique is used. |
| | * The tube is inserted and secured with sutures. |
| | * A chest X-ray confirms placement. |
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| Chest tubes can also be placed using a trocar, which is a pointed metallic bar used to guide the tube through the chest wall. This method is less popular due to an increased risk of iatrogenic lung injury. Placement using the [[Seldinger technique]], in which a blunt guidewire is passed through a needle (over which the chest tube is then inserted) has been described.
| | 4. Connection to Drainage System: |
| | * The tube is attached to a water seal or suction device. |
| | * Continuous monitoring for air leaks or fluid output. |
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| ===Postoperative drainage===
| | == Postoperative Chest Tube Use == |
| The placement technique for postoperative drainage (e.g. [[cardiac surgery]]) differs from the technique used for emergency situations. At the completion of open cardiac procedures, chest tubes are placed through separate stab incisions, typically near the inferior aspect of the sternotomy incision. In some instances multiple drains may be used to evacuate the mediastinal, pericardial, and pleural spaces. The drainage holes are placed inside the patient and the chest tube is passed out through the incision. Once the tube is in place, it is sutured to the skin to prevent movement. The chest tube is then connected to the drainage canister using additional tubing and connectors and connected to a suction source, typically regulated to -20 cm of water.<ref name=Obney />
| | Post-surgical placement differs, typically involving: |
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| ===Dressings===
| | * Multiple drains for different compartments. |
| After suturing, [[Dressing (medical)|dressings]] are applied for hygienical reasons covering the wound. First, a y-slit [[Gauze|compress]] is used around the tube. Second, a compress (10 x 10 cm) is placed on top and finally an [[Adhesive bandage|adhesive plaster]] is added in a way that tension is avoided. A bridle rein is recommended to fix the tube to the skin. This tape bridge will prevent the tube from moving backwards and the possibility to cause clogging. It also prevents pain as it reduces tension on the fixation stitch. Alternatively, a large adhesive plaster that functions like a tape bridge may be used.<ref>{{cite book |title=Chest Drains in Daily Clinical Practice |last=Kiefer |first=Thomas | name-list-format = vanc |publisher=Springer |year=2017 |isbn=9783319323398 |pages=102–103 }}</ref>
| | * Lower suction settings to prevent lung collapse. |
| | * Early mobilization to promote drainage. |
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| ===Chest tube management===
| | == Chest Tube Removal == |
| Chest tubes should be kept free of dependent loops, kinks, and obstructions which may prevent drainage.<ref>{{cite journal | vauthors = Schmelz JO, Johnson D, Norton JM, Andrews M, Gordon PA | title = Effects of position of chest drainage tube on volume drained and pressure | journal = American Journal of Critical Care | volume = 8 | issue = 5 | pages = 319–23 | date = September 1999 | pmid = 10467469 }}</ref> In general, chest tubes are not clamped except during insertion, removal, or when diagnosing air leaks.
| | * The tube is removed once drainage decreases and there is no evidence of air leaks. |
| | * The suture site is dressed and monitored for any fluid accumulation. |
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| Manual manipulation, often called milking, stripping, fan folding, or tapping, of chest tubes is commonly performed to clear chest tube obstructions. No conclusive evidence has demonstrated that any of these techniques are more effective than the others, and no method has shown to improve chest tube drainage.<ref name = Wallen>{{cite journal | vauthors = Wallen M, Morrison A, Gillies D, O'Riordan E, Bridge C, Stoddart F | title = Mediastinal chest drain clearance for cardiac surgery | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD003042 | date = October 2004 | pmid = 15495040 | doi = 10.1002/14651858.CD003042.pub2 }}</ref> Furthermore, chest tube manipulation has proved to increase negative pressure, which may be detrimental, and painful to the patient.<ref name=Wallen /> For these reasons, many hospitals do not allow these types of manual tube manipulations.<ref name=Shalli>{{cite journal | vauthors = Shalli S, Saeed D, Fukamachi K, Gillinov AM, Cohn WE, Perrault LP, Boyle EM | title = Chest tube selection in cardiac and thoracic surgery: a survey of chest tube-related complications and their management | journal = Journal of Cardiac Surgery | volume = 24 | issue = 5 | pages = 503–9 | year = 2009 | pmid = 19740284 | doi = 10.1111/j.1540-8191.2009.00905.x }}</ref>
| | == '''Post-Procedure Management''' == |
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| One option is active chest tube clearance without breaking the sterile field. According to a consensus of multiple experts in cardiac surgery, anesthesia and critical care in 2019 the ERAS Guidelines for Perioperative Care recommends active clearance of chest tubes to prevent retained blood and other complications.<ref name=Engelman>{{cite journal | vauthors = Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman RM, Gregory AJ, Boyle EM | display-authors = 6 | title = Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations | journal = JAMA Surgery | date = May 2019 | pmid = 31054241 | doi = 10.1001/jamasurg.2019.1153 }}</ref> This was given a IB-NR rating, meaning, it should routinely be performed. Makeshift efforts such as open chest tube clearing that involves breaking the sterile environment separating the chest tube from the drainage canister tubing to suction it out should not be performed (Class III, A).<ref name = Halejian>{{cite journal | vauthors = Halejian BA, Badach MJ, Trilles F | title = Maintaining chest tube patency | journal = Surgery, Gynecology & Obstetrics | volume = 167 | issue = 6 | pages = 521 | date = December 1988 | pmid = 3187876 }}</ref>
| | == Dressing and Fixation == |
| | * Dressings should be sterile and secured to prevent infection. |
| | * A bridle rein (tape bridge) is recommended to minimize tension on sutures. |
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| ===Chest tube side of placement=== | | == Monitoring and Maintenance == |
| In December 2018 the [[European Respiratory Journal]] published correspondences that raise the possibility of improving mobility as well as patient outcomes by placing a chest tube more optimally.{{clarify|date=September 2019}}<ref>{{cite journal | vauthors = Kartoun U | title = Improving the management of spontaneous pneumothorax | journal = The European Respiratory Journal | volume = 52 | issue = 6 | pages = 1801857 | date = December 2018 | pmid = 30523206 | doi = 10.1183/13993003.01857-2018 }}</ref><ref>{{cite journal | vauthors = Porcel JM | title = Improving the management of spontaneous pneumothorax | journal = The European Respiratory Journal | volume = 52 | issue = 6 | pages = 1801918 | date = December 2018 | pmid = 30523207 | doi = 10.1183/13993003.01918-2018 }}</ref>
| | * Keep tubes free of kinks and dependent loops to ensure proper drainage. |
| | * Avoid unnecessary clamping, which can cause tension pneumothorax. |
| | * Manual manipulation (milking/stripping) is controversial and may increase negative pressure. |
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| == References == | | == Innovations in Chest Drainage == |
| {{Reflist}}
| | * Digital chest drainage systems provide real-time monitoring of pressure and air leaks. |
| | * Portable ambulatory devices allow for home drainage in select cases. |
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| ==Further reading== | | == '''See Also''' == |
| {{refbegin}}
| | * '''[[Thoracic surgery]]''' |
| *Catheter drainage is used for empyemas after chest-tube failure: {{cite journal | vauthors = vanSonnenberg E, Nakamoto SK, Mueller PR, Casola G, Neff CC, Friedman PJ, Ferrucci JT, Simeone JF | title = CT- and ultrasound-guided catheter drainage of empyemas after chest-tube failure | journal = Radiology | volume = 151 | issue = 2 | pages = 349–53 | date = May 1984 | pmid = 6709904 | doi = 10.1148/radiology.151.2.6709904 }} | | * '''[[Pneumothorax]]''' |
| *Commonly used after Percutaneous CT-Guided Lung Biopsies: {{cite journal | vauthors = Saji H, Nakamura H, Tsuchida T, Tsuboi M, Kawate N, Konaka C, Kato H | title = The incidence and the risk of pneumothorax and chest tube placement after percutaneous CT-guided lung biopsy: the angle of the needle trajectory is a novel predictor | journal = Chest | volume = 121 | issue = 5 | pages = 1521–6 | date = May 2002 | pmid = 12006438 | doi = 10.1378/chest.121.5.1521 }} | | * '''[[Pleural effusion]]''' |
| {{refend}}
| | * '''[[Hemothorax]]''' |
| | * '''[[Thoracotomy]]''' |
| | * '''[[Chest trauma]]''' |
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| ==External links== | | == '''External Links''' == |
| *{{Commonscatinline}} | | * [https://www.thoracic.org/professionals American Thoracic Society] |
| | * [https://www.nejm.org/doi/full/10.1056/NEJMvcm071974 New England Journal of Medicine – Chest Tube Insertion] |
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| | {{Respiratory system procedures}} |
| {{Emergency medicine}} | | {{Emergency medicine}} |
| {{Respiratory system procedures}} | | {{Thoracic surgery}} |
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| {{DEFAULTSORT:Chest Tube}}
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| [[Category:Emergency medical procedures]] | | [[Category:Emergency medical procedures]] |
| [[Category:Intensive care medicine]] | | [[Category:Intensive care medicine]] |
| [[Category:Pulmonology]] | | [[Category:Pulmonology]] |
| [[Category:Thoracic surgical procedures]] | | [[Category:Thoracic surgical procedures]] |
| {{stub}} | | {{Stub}} |
