see: [Dunn management of pneumothorax](x-devonthink-item://6A784754-6907-461A-9FFB-C9910E7355D3), [Robert hedges tube thoracostomy](x-devonthink-item://31ACDC98-D2CC-48C5-BE69-E9B37E53FA8C?page=260), [Tintinalli - tube thoracostomy](x-devonthink-item://1ADC8D20-7826-44D0-9DEE-31D41057C9A3?page=72) > [!key points] > 1. [[Scalpel sizes|scalpel]] to SKIN; use kelly/robert clamps for *blunt dissection* and then pointing down over top rim of rib with finger a few cm from tip to puncture pleura > 1. \#10 is easier to cut with quickly; \#11 bit more precision of cut > 2. it can be REALLY hard to get through the pleura! This is an intimidating aspect of the procedure. may need more local in this area > 3. avoid the temptation to use a scalpel for this to avoid incision of a lung or intercostal vessel > 2. make the skin incision 3-4 cm > 3. insert 24 fr chest tube until *all the holes are inside the pleura* > 1. markings on chest tube are from last drain hole, NOT end of tube > 2. tube **8-10cm** in for average person; **12cm** larger chest > 3. paeds: see [[Paeds#Chest tube size|paeds chest tube size]] > 4. probably safer to double glove > 5. ==avert the disaster of the tube coming out of the chest before you secure it== > 1. I clamp the drape around the tube to secure it (similar to how you secure the ETT tubing to the pillow with a clamp), and clamp the tube itself with a second clamp to prevent haemothorax from leaking > 6. chart some cefazolin afterwards (controversial) > > **✱** in the context of a [[Traumatic arrest]] just do [[#4. Pleural decompression|finger thoracostomy]] (aka pleural decompression) > > > ***In a spontaneously breathing patient:*** > > Finger thoracostomy followed *immediately* with ICC + underwater seal because patient is generating negative pressure while breathing → sucking chest wound/open pneumothorax where patient breathing in pulls more air into the pleural space > > > > ***In intubated patient:*** > > ICC can be delayed IF other resus priorities need to be attended to because positive pressure ventilation will not cause air to be drawn into chest on inspiration, but it is better to "formalise" the chest tubes sooner if there is no contraindication to doing so. > > **Aeshan's hot tip:** > recommend scalpel cut is ~4 cm. index finger generally around this size, so if cut is shorter than index finger, it is probably not long enough. ![[Pasted image 20240226003732.png]] ![[Pasted image 20241127091641.png]] ![[Pasted image 20241127071943.png]] # Overview ## Indication - tension [[Trauma/pneumothorax]] - [[Traumatic arrest]] - primary spontaneous pneumothorax in unstable patient un failed aspiration, very large PTx (complete lung collapse - all secondary spontaneous pneumothoraces - pleural lavage in management of severe [[Hypothermia]] - [[Haemothorax]] ## Contraindications (relative) > there are no absolute contraindications to pleural decompression in the emergency setting, but there are several situations for caution and relative contraindications: - spont ventilation (for finger thoracostomy) - may create a sucking chest wound - tx occlusive dressing and formalisation to tube thoracostomy - significant [[Coagulopathy]] - may consider seldinger - presence of pulmonary bullae - CT can help guide management - presence of traumatic diaphragmatic hernia - Alert patient declines consent ## Alternatives - needle thoracostomy - small intercostal cathether with seldinger technique - large intercostal cathether (blunt dissection 24-32 Fr) ## Consent - no consent in emergency - Explain below complications otherwise ## Complications *immediate* - failure to decompress - pain - malposition (extrapleural, intrafissural, intrapulmonary, trans-diaphragmatic) - solid organ injury (lung, liver, spleen, colon) - trauma to [[Procedures#procedures and specific anatomical considerations|intercostal neurovascular bundle]] (long thoracic nerve, intercostal vessel injury) - tube impingement or kinking leading to failure to drain - haemorrhage - [[pupil exam#Horner Syndrome|Horner's syndrome]] *late* - infection (empyema) - pneumothorax re-accumulation - bronchopleural fistula - re-expansion pulmonary oedema - malpositioning (leading to damage to chest or subdiphragmatic organs) - kinking or obstruction with blood/clot, leading to failure to drain chest and risks of tension - dislodgement or migration out of chest leading to open pneumothorax - infection > [!pearl] structure for complications of x procedure > - **procedural complications** - eg damage to intercostal, lung contusion, liver injury > - **equipment complication** - tube kinking, malposition into fissure leading > - **post-procedure complication** - dislodgement, migration > - **late complications** - infection and empyema **underwater seal -- ?suction** - suction only if pt significantly compromised and lung not expanding -- no evidence of routine suction in spont ptx (some say after 48 hours) - suction starts at -10 to -20 cm H2O (normal intrapleural pressures are -8 to -3.4 cm H2O **indications for removal** - lung has re-expanded on CXR - no evidence of air leak - no suction in prev 6 hours - do not clamp at time of removal - remove preferably during expiration or when performing a valsalva - immediate closure and occlusion of the insertion site - repeat CXZR in 2-6 hours following tube removal and discharge if PTX completely resolved # Procedure ## 1. Position - below axillary hairline, between anterior and mid-axillary lines - lateral to pectoralis major and breast tissue - medial to latisimus dorsi in "triangle of safety" - 4th-5th intercostal space ![[Pasted image 20241127072018.png]] can also identify mid-humeral point btwn acromion and olecranon ## 2. analgesia and sedation generous lignocaine/adrenaline suspension ## 3. equipment - 24 Fr ICC - skin prep - [[Scalpel sizes|scalpel]] (#10 or #11, usually easier with a #10) - curved roberts or kelly forceps - 2x large tegaderms - size 0 silk suture x 2 - PPE including eye protection and double glove ![[Pasted image 20250307174137.png]] ![[Pasted image 20250307174222.png]] ## 4. Pleural decompression > when using kelly clamp to puncture pleura, a considerable amount of pressure may be needed. hold finger a few cm from tip of clamp and angle down over border of top rib ![[Pasted image 20241127074952.png]] ![[Pasted image 20241127075051.png]] - apply skin prep - infiltrate local anaesthetic to skin and then down to pleural space (may aspirate air to see you are in the right space; can then infiltrate local into pleura as well) - skin incision 3-5cm long over 5th rib - blunt dissect in oblique plane through intercostal muscles over superior rib margin using curved roberts forceps - the oblique direction helps close the tract after removal to prevent re-accumulation pneumothorax - open forceps in AP direction then rotate to enlarge pleural breach - finger sweep of cavity to ensure no adhesions - ==if you feel the lung you get to shout "Lung is up!" triumphantly to the resus room== - if you do **NOT** feel the lung up, communicate this as well, as ongoing tension pneumothorax may be cause of patient shock, and indication for early chest tube on suction. ## 5. ICC insertion ![[Pasted image 20241127082552.png]] - insert ICC through lowest point of intercostal space - run along surface of finger to prevent intrapulmonary insertion - orient *apical-posterior* for pneumothorax - *basilar-posterior* for haemothorax/haemo-pneumothorax - 3-4 cm beyond last drainage hole in pleura - usual insertion length ==8-12 cm== (more in obese patients) - once inserted, rotate 360 deg to reduce risk of kinking ![[Pasted image 20250307174417.png|inserted 10cm into chest in this non-obese adult]] ## 6. Secure the ICC - use 0 silk and place vertical mattress on superior side of drain, tying a locked knot. use remaining suture to wrap around tube close to skin and secure with another locked knot that bites the tube - repeat for inferior side of tube - do **NOT** "roman sandal" tie; make the ties proximal to the skin and give a tug after finishing to ensure it is actually secure - cut a gauze to pad over entry site of tube - place two large tegaderms using a sandwich - after attaching underwater seal drain, secure drain on a mesentery to abdominal wall using sleek tape - Wrap sleek vertically around connection between drain and ICC , leaving a window to ensure no blood clots occluding drain ## 7. underwater seal drain ![[Pasted image 20241127090237.png|The "atrium"]] The atrium has 3 chambers: - D - collects fluid or blood drained from pleural cavity - C - underwater seal drain. prevents air from being pulled into pleural cavity. ==this chamber always has 2cm of water in it== - A - suction control chamber. allows suction to be applied and is used when a greater negative intrapleural pressure is needed to drain a large volume or persistent pneumothorax - generally in the acute setting of trauma leave this off Air leaks can be measured by looking at the markings in the underwater seal chamber (c) ![[Pasted image 20241127091608.png]] **Set up** - fill water seal with 45mL water to 2cm line - fill suction control chamber to desired level (460mL for -25cm H2O pressure; 315 mL for -20 cm) - connect patient catheter - +/- connect to suction source - clamp tube then cut blue nipple cover on outer end of tube - ensure drain is bubbling and swinging can use **heimlich valve** in interim eg transport ![[Pasted image 20241127091449.png|Heimlich valve. ICC connects to the top end of the valve; a drainage bag or connector can be attached to the bottom]] # Troubleshooting see also: [[Peri-intubation collapse#troubleshooting post-intubation hypoxia or hypotension|post-intubation troubleshooting]] **Drain stopped swinging** - has the lung re-expanded - is the tube kinked or blocked? - is lung tissue blocking tube during expiration? check tube placement on CXR **patient deteriorates** eg hard to ventilate, EtCO2 going down, hypotensive - blocked tube, circuit, or kinking -- can cause tension pneumothorax in presence of ongoing air leak - is suction tubing attached to suction limb? if the suction tubing is not switched on this can create a closed circuit and causes tension in presence of air - is there worsening s/c emphysema? check if drainage holes have migrated outside pleural space or if the drain is blocked - check for tube displacement > when in doubt, re-sweep the chest. # Interesting research | Study | Year | Relevance | | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ---- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | [Pleural decompression prorocedural safety for traumatic pneumothorax and haemothorax: kelly clamps vs fine artery forceps](https://onlinelibrary.wiley.com/doi/10.1111/1742-6723.14019) | 2022 | - ↑ force to puncture simulated parietal pleura with kellys than artery forceps<br>- Pulm injury risk may be reduced using fine artery forceps rather than kelly clamps for pleural decompression |