Chest

 Tube  Inser-on  

Suprayitno  Wardoyo,  Dr.,  SpBTKV  

•  Basic  Science  
•  Condi-on  requiring  chest  drain  
•  Tools  
•  Technique  
BASIC  SCIENCE  
 History  
•  Go9hard  Bulau  
(1836-­‐1900)  –  Original  
creator  of  water  sealed  
drainage  
•  Playfair  1875,  Hewe9  
1876  
•  19th  century  data  From  
US  army  reconfirm  the  
effec-ve  use  of  closed  
drainage  system  
 Pleural  anatomy  
  Visceral  Pleura  
Parietal  Pleura  
•   Normally,  the  two   Lung  
membranes  are  
separated  only  by  the  
lubrica-ng  pleural  
fluid  
  Intercostal  
muscles  
Ribs  

•   Fluid  reduces  
fric-on,  allowing  the  
pleura  to  slide  easily   Normal  Pleural  Fluid  Quan-ty:  
during  breathing   ±  25mL  /  lung  
CONDITIONS  REQUIRING  CHEST  
DRAINAGE  
Pneumotoraks  
•  Divided  into  closed  and  
open  pneumotoraks  
•  Open  pneumotoraks,  
“sucking  chest  wound”  
•  Closed  pneumotoraks  
can  convert  into  tension  
pneumotoraks  
Hemotoraks  
•  Blood  inside  the  pleural  
space.  
•  When  there  are  air  as  
well  it  is  called  
hematopneumotoraks  
Pleural  Effusion  
•  When  there  are  fluid  
collec-on  in  the  pleural  
space  
–  Exudate  
–  Transudate  
Other  Condi-ons  

•  Empyema  –  pus  inside  the  pleural  cavity  

•  Chylotoraks  –  Lympha-c  drainage  inside  the  pleural  
cavity  
•  Postopera-ve  chest  drain  
–  Thoracic  surgery  
–  Cardiac  surgery  
TOOLS  
Tubes  

•  Size  and  diameter  of  tube  

–  Pa-ent  size  
–  Purpose  
 
•  Straight  tube  vs  “bent”  
tube  
–  Bent  tube  are  used  to  
evacuate  small  amount  of  
effusion  or  blood  near  the  
costrophrenicus  angle  
Trocar  

•  To  help  inser-on  
some  tubes  come  
with  trocar  
 
•  Remember  to  pull  
the  Trocar  slightly  
once  the  tube  is  
introduced  
1  Bo9le  System  
•  The  original  water  seal  
drainage  
 
•  Problem:  When  there  
are  fluid  from  the  
pa-ent  the  bo9le  
becomes  full  
•  Resistance  increases  
and  makes  chest  
drainage  ineffec-ve  
2  Bo9le  System  
•  2  bo9le  system  separates  
the  fluid  drainage  from  
the  pa-ent  with  the  seal  
•  Fluid  collec-on  does  not  
impair  the  seal  drainage  
 
•  Problem:  added  length  
increases  dead  space,  
adding  significant  
resistance  
3  tube  system  
•  Provides  ac-ve  suc-on  
to  the  system  
•  Maintain  pressure  and  
decreases  extra  tubing  
dead  space  resistance  
•  Currently  most  
commercial  
technologies  uses  this  
system  as  their  
blueprint  
Commercial  drainage  
System  
TECHNIQUE  
Chest  Drain  Inser-on  
•  Chest  drain  should  be  
introduced  with  two  
main  considera-ons:  
–  Op-mal  posi-oning  
–  Pa-ent  comfort  

•  Hemodinamic  
monitoring  should  be  
done  at  all  -mes  during  
the  procedure  
 
 1.  Choosing    
inser-on  site    
•  Re-­‐Confirma-on  with  
clinical  examina-on  and  
Chest  Xray  the  
hemitoraks  that  needed  
drainage  
 
•  Height  and  placement  
using  the  triangle  of  
safety  
Triangle  Of  Safety  

•  The  part  of  the  chest  

with  the  thinnest  
muscle  

•  Normally,  a  safe  height  

from  introduc-on  of  
chest  tube  
 2.  Disec-ng  the  
Intercostal  Muscle  
•  Ager  giving  local  
anastesia,  a  small  
incision  is  done.  
•  Con-nued  with  blunt  
dissec-on  un-l  the  
pleural  space.  
•  The  neurovascular  
bundle  is  located  below  
the  costa,  disect  above  
the  ribs.  
 Dissec-ng  the  
Intercostal  muscles  
3.  Introducing  the  drain  
•  The  required  length  of  
the  drain  should  be  
measured  before  
introduc-on  
•  Do  not  Panic  as  air  can  
be  drained  out  later  
using  the  water  sealed  
system  
•  Ini-al  bubble  and  
produc-on  should  be  
measured  
4.  Suture  placement  
•  Place  suture  to  ensure  
chest  drain  does  not  get  
pulled  away  
•  Becareful  of  Re-­‐
expansion  Lung  Edema,  
by  not  draining  too  
much  fluid  at  a  given  
period  of  -me.  
•  Connect  the  Tube  
towards  the  Bo9led  
system.  
Types  of  Suture  
Pictures  courtesy  of  trauma.org  
Thank  You