Thoracotomy tube placement Flashcards
For what reasons do we drain the thorax?
- Diagnostic and therapeutic removal of clinically significant volumes of air or fluid accumulated within the pleural space when frequent drainage is expected or required
- Air
- Effusions
- Following thoracic surgery (removal of haemorrhage, fluid and air, delivery of intrapleural local anaesthetic)
Air in the thorax is termed?
Pneumothorax
Name the 5 effusion types that can be found in the thorax
- Pyothorax
- Chylothorax
- Haemothorax
- Serosanguinous effusions
- Neoplastic effusions
When in drainage of the thorax contraindicated?
- If patient is not appropriately stable
- Ongoing haemothorax (trauma or coagulopathy)
- Clinically insignificant volumes (no effect on respiratory function)
Describe the pathophysiology of the normal pleural cavity
- Potential space within the thoracic cavity that sits around the heart and lungs
- Mesothelial cell lining
- Small volume of pleural fluid: lubricates lungs & pleural surfaces to facilitate ventilation
Describe the pathophysiology of a penumothorax
- Uncouples the coordinated movement of the thoracic wall & the lungs during ventilation
- Lung collapse -> atelectasis
- Ventilation/perfusion (V/Q) mismatch
Describe the pathophysiology of pleural effusions
- Decreases space for lung expansion during inhalation which decreases tidal volume
- Fluid accommodation -> diaphragmatic expansion -> decreases diaphragmatic movement -> decreases ventilation
What are the clinical signs of a pneumothorax/pleural effusion?
- Increasing severity of signs with rapid progression and/or larger volumes
- Restrictive or paradoxical breathing pattern
- Tachypnoea/dyspnoea/cyanosis
- Orthopnoic posture
- Diminished cardiac auscultation
Compare lung sounds and thoracic percussion in a pneumothorax vs pleural effusion
Pneumothorax: reduced
Pleural effusion: Increased lung sounds & hyper-resonant percussion DORSALLY, decreased ventrally due to “fluid line”
How would you drain the thorax for patient stabilisation/’one off’ drainage/sampling?
Needle Thoracocentesis
How would you drain the thorax for repeated draining/anticipated drainage?
- Trocar thoractostomy tube
- Wire guided small bore multi-fenestrated thoracostomy tubes (e.g. MILA)
How is a patient prepped for needle thoracocentesis, describe where the prep site is?
- Pre-oxygenate +/- sedation
- IV catheter in place
- Sternal recumbency
- Aseptic preparation of lateral thoracic procedure site (15cm2): 7th-9th intercostal space (dorsal 1/3 if air, ventral 1/3 if fluid, middle 1/3 if both)
- Consider local anaesthesia: SC (lidocaine) or EMLA cream
- 3 way tap OFF before insertion
Once prepped describe the needle thoracocentesis procedure
- Butterfly needle inserted on CRANIAL aspect of rib, BEVEL UP
- Flatten needle parallel to chest wall, slowly advance through intercostal muscles
- OPEN 3 way tap & aspirate pleural fluid contents
- Must turn 3 way tap “OFF” before detaching syringe or removing needle from thorax
- Post-procedure thoracic radiographs
List 4 complications that can occur during needle thoracocentesis?
Lung laceration
Pneumothorax
Haemorrhage
Iatrogenic infection
During needle thoracocentesis why do you want the needle inserted parallel to the chest rather than 90 degrees to the chest?
Decreases lung laceration risk
When is thoracostomy tube placement indicated?
- Repeated thoracocentesis required
- Following thoracic surgery
- Medical management of pyothorax
How is a patient prepped for thoracostomy tube placement, describe where the prep site is?
- Preoxygenate
- Sedation or general anaesthesia?
- Lateral or sternal recumbency?
- Clip and prep from caudal border of scapula to caudal to last rib
Describe the thoracostomy tube placement procedure
- Insertion into the chest through the 7th or 8th intercostal space regardless of tube type
- CRANIAL border of the rib (intercostal AVN on the caudal aspect of the rib)
- Side of the chest: Based on clinical or imaging findings - Bilateral is preferred if massive effusion or pyothorax
Describe how you would select an appropriate tube size for a thoracostomy tube placement?
Internal diameter= 50% width of intercostal space
External diameter=mainstem bronchus diameter
Length=2nd to 7th/8th/9th ribs
List the equipment needed for a thoracostomy tube placement
- Sterile gloves!
- Intercostal nerve block / local anaesthetic / lidocaine
- Scalpel handle / blade
- haemostat
- Thumb forceps
- Needle holders
- Scissors
- Tube clamps
- 3-way stopcock
- Tube equipment
Describe the local anaesthesia used in a thoracostomy tube placement
Local anaesthesia/analgesia
Intercostal nerve block > intercostal nerves run caudal to ribs
Infiltrate puncture site/tunnel
Describe the procedure for inserting a trocar-type chest drain
- Skin incision over 10th or 11th intercostal space and drain tunnelled cranioventrally under skin
- Tube held vertical at 7th or 8th intercostal space in one fist – small portion of sharp end between surgeon’s hand and thoracic wall
- Tube inserted into the chest – forced into IC space with pressure on stylet
- Tube placed parallel to thoracic wall and advanced off the stylet
How is a thoracostomy tube secured?
Fingertrap suture pattern
What should be carried out one a thoracostomy tube has been placed?
Drain pleural cavity
Radiograph thorax to check positioning
Describe post-placement care following thoracostomy tube placement
- Close monitoring for dislodgement or tube disconnection > pneumothorax
- HARD Elizabethan collar, body vest at ALL TIMES
- Multi-modal analgesia: Opioids/NSAIDS/local anaesthetic into pleural cavity via tube (post thoracotomy)
- Monitor respiratory rate and effort
- Monitor insertion site: subcutaneous emphysema, inflammation, discharge
Compare continuous vs intermittent post-placement drainage
C = commercial systems / 3-chambered suction apparatus
I = manual aspiration (q4hrs or as necessary)
Must record volumes of AIR and FLUID retrieved
Calculate: ml/kg/hr over each 12 hr period to monitor trends
List some possible post-thoracostomy tube placement problems?
- Discharge around the tube site
- Accidental tube damage/removal -> pneumothorax
- Tube blocking/kinking
- Subcutaneous emphysema
- Damage to intra-thoracic structures
- Pain
How are post-thoracostomy tube placement problems prevented?
- Asepsis
- Elizabethan collar
- Appropriately secure tube
- Analgesia
When can a thoracostomy tube be removed?
- Volume of fluid drained <2ml/kg/day (fluid production due to presence of the chest drain)
- Volume of air drained: none
- Patient status, disease progress, diagnostics
