Thoracostomy tube placement

Question 1

When would you place a chest drain?

Answer 1

• Frequent or repeated drainage of air or fluid from the pleural space
• Medical management of pyothorax
• Removal of air and fluid from the thorax after thoracic surgery

Question 2

What are contraindications to placing a chest drain?

Answer 2

• Severe respiratory compromise - Stabilise first with thoracocentesis
• Severe coagulopathy

Question 3

How would you prepare the patient for a thoracostomy tube?

Answer 3

• Place thoracostomy without draining chest if patient stable - May reduce risk of visceral injury
• Perform thoracocentesis if patient unstable
• Clip and aseptically prepare skin around placement site
• 15cm square area
• Site depends on site of disease and type of drain
• Sedate or anaesthetise patient
• Pre-oxygenate
• Sedate for wire-guided drain placement
• Anaesthetise for trocar drain placement
• Local anaesthesia
  -Skin
• S/C, intercostals and pleura for wire-guided
  drains
• Intercostal nerve block for trocar drains

Question 4

How do you drain the chest?

Answer 4

• Using syringe - every 4hrs
• drain until no fluid + no more than 5ml -ve pressure
• For continuous drainage - consider referral - requires constant supervision

Question 5

What should be done when doing tracheostomy tube placement?

Answer 5

• Aseptic technique when handling drain
• Elizabethan collar at ALL times
• Close monitoring
• Change dressing on drain exit daily
• After removal - cover drain exit with sterile dressing - second intention healing / suture closure

Question 6

What are complications of tracheostomy tubes?

Answer 6

• Visceral or intercostal vessel trauma during placement
• Iatrogenic pneumothorax
• Re-expansion pulmonary oedema
• Accidental removal
• Tube collapse during drainage
• Tube blockage
• Ascending infection