"Chest Tube Placement" by Chris Weldon for OPENPediatrics

Summary

Dr. Christopher Weldon, a surgeon at Children's Hospital Boston, demonstrates the process of placing a chest tube, or thoracostomy tube. The video covers patient preparation, the step-by-step procedure of inserting the chest tube, connecting it to a suction device, and addressing potential complications. Key points include ensuring patient safety, proper use of equipment, and documenting the procedure. The video emphasizes the importance of anatomical landmarks and careful technique to avoid complications, making it a comprehensive guide for medical professionals.

Takeaways

• 🔹 Dr. Christopher Weldon, a surgeon and intensivist at Children's Hospital Boston, provides a demonstration on thoracostomy tube placement, commonly known as chest tube placement.
• 🔹 The demonstration covers preparation, placement, and connection to a suction device to remove air and fluid from the chest.
• 🔹 Indications for the procedure include compression of the lung and mediastinal structures due to the accumulation of air, fluid, or blood in the pleural space.
• 🔹 There are no true contraindications, but caution is advised for patients with skin infections, coagulopathy, or adhesions in the chest area.
• 🔹 Necessary equipment includes a surgical chest tube, antimicrobial scrub, scalpel, forceps, clamps, sutures, needle driver, suction source, collection device, and monitoring equipment.
• 🔹 Preparation involves scrubbing hands, using universal precautions, confirming procedure details with the team, and prepping the chest with antimicrobial agents before draping with sterile towels.
• 🔹 Placement requires identifying anatomical landmarks such as the nipple and anterior axillary line, making an incision, bluntly dissecting into the pleural space, and securing the tube with sutures.
• 🔹 The chest tube is connected to a collection device to manage air and fluid drainage, ensuring no leakage and proper negative pressure.
• 🔹 The chest tube can be removed when there is no further leakage of fluid or air, confirmed by chest x-ray, and no reaccumulation is observed.
• 🔹 Complications may include injury to organs, bleeding, pneumothorax, infection, and it's essential to monitor the patient's vital signs, oxygen saturation, and comfort level throughout the procedure.

Q & A

What is the main purpose of a chest tube (thoracostomy tube)?

The main purpose of a chest tube is to remove air, fluid, or blood from the pleural space to relieve compression of the lung and mediastinal structures.

What are the indications for performing a chest tube placement?

Indications for chest tube placement include the accumulation of air, fluid, or blood in the pleural space causing compression of the lung and mediastinal structures.

Are there any contraindications to chest tube placement?

There are no true contraindications to chest tube placement, but caution should be exercised in patients with skin infections over the insertion site, coagulopathy, a platelet count less than 50,000 per microliter, pulmonary bullae, pleural adhesions, or diaphragmatic adhesions.

What equipment is needed for chest tube placement?

The equipment needed includes a surgical chest tube, antimicrobial scrub, scalpel, forceps, Kelly clamp, sutures, needle driver, suction source, chest tube collection device, male-to-male connector, shoulder roll, and monitoring equipment.

What are the steps involved in preparing a patient for chest tube placement?

Preparation steps include scrubbing hands with an antimicrobial agent, using universal precautions, confirming the procedure and side with the surgical team, performing a surgical time-out, applying antimicrobial prep to the chest, ensuring the patient is anesthetized and properly prepped, and draping the field with sterile towels.

What is the key anatomical landmark for chest tube placement?

The key anatomical landmark for chest tube placement is the nipple, which signifies roughly the fourth intercostal space, where the chest tube is placed in the anterior axillary line just lateral to the nipple.

How is the chest tube secured after placement?

The chest tube is secured in place with sutures, often using a single Roman stitch technique to tie it down to the skin and around the tube. An occlusive dressing is then placed over the insertion site.

What is the procedure for connecting the chest tube to the collection device?

A male-to-male connector is used to connect the chest tube output to the collection device. The connection is ensured to be secure with no evidence of leakage of air or fluid around the tube.

When can a chest tube be removed?

A chest tube can be removed when there is no further leakage of fluid or air into the pleural space, confirmed by a chest x-ray and absence of reaccumulation of air or fluid in the collection device.

What complications can arise from chest tube placement?

Possible complications include injury to the lungs, heart, liver, other organs, and soft tissues, bleeding, pneumothorax, and infection.

What should be documented after chest tube placement?

Documentation should include the indication for the procedure, date and time, size and site of chest tube placement, amount and type of drainage removed, confirmation of placement on chest x-ray, and any adverse outcomes.

Outlines

00:00

👨‍⚕️ Introduction and Overview

Dr. Christopher Weldon, a surgeon and intensivist at Children's Hospital Boston, introduces the demonstration on chest tube placement. He outlines the procedure's steps: preparing the patient, physically placing the chest tube, connecting it to a suction device, and discussing possible complications. He emphasizes the importance of patient safety and pain relief. The procedure is performed to relieve lung compression due to air, fluid, or blood accumulation. There are no true contraindications, but caution is advised for patients with certain conditions. Required equipment includes surgical tools, antimicrobial scrub, and monitoring devices.

05:00

🔧 Equipment and Preparation

Details on the necessary equipment for the chest tube placement are provided, including surgical chest tubes, scrubs, scalpels, clamps, and sutures. The preparation involves scrubbing hands, using universal precautions, and confirming the procedure with the surgical team. A surgical time-out is essential. The chest area is prepped with isopropyl alcohol and chlorhexidine, and the patient must be anesthetized properly. The field is then draped with sterile towels.

10:01

🩺 Procedure: Chest Tube Placement

The procedure begins with identifying anatomical landmarks, specifically the nipple, to locate the correct rib space for the chest tube insertion. The incision is made, and the tube is placed into the pleural space. The importance of confirming the procedure site and the patient's side is reiterated. The incision must be large enough for both the tube and the clamp. After securing the tube with sutures, an occlusive dressing is applied. The tube is connected to a collection device to manage air and fluid drainage.

🔍 Final Steps and Complications

Once the chest tube is in place, it is connected to a collection device using a male-to-male connector. The setup ensures no air or fluid leaks around the tube. The specific collection device used is described, along with its components and functions. The tube can be removed when there is no further leakage, confirmed by chest x-ray. Potential complications include injury to internal organs, bleeding, pneumothorax, and infection. Patient monitoring for vital signs and comfort is crucial before, during, and after the procedure.

📝 Documentation and Conclusion

Documentation after chest tube placement should include the procedure indication, date and time, size and site of the chest tube, amount and type of drainage, x-ray confirmation, and any adverse outcomes. Dr. Weldon concludes the demonstration and requests feedback to improve the content. He asks viewers to comment on the video's complexity and length and invites additional feedback via email.

Keywords

💡Thoracostomy tube

A thoracostomy tube, also known as a chest tube, is a flexible plastic tube that is inserted through the chest wall and into the pleural space. It is used to remove air, fluid, or pus from the intrathoracic space, which can help re-expand the lungs and relieve respiratory distress. In the video, Dr. Weldon explains the placement of the thoracostomy tube and its importance in managing conditions like pneumothorax and pleural effusion.

💡Pleurovac device

The Pleurovac device is a chest drainage system used to collect air and fluid from the pleural space after a chest tube is placed. It helps maintain negative pressure in the pleural cavity, which is essential for lung expansion. Dr. Weldon discusses connecting the chest tube to the Pleurovac device to ensure proper drainage and lung function.

💡Indications

Indications refer to the specific medical conditions or situations that warrant the use of a particular procedure or treatment. In the context of the video, the indications for chest tube placement include the accumulation of air, fluid, or blood in the pleural space that compresses the lung and mediastinal structures. Dr. Weldon outlines these indications as a critical part of patient assessment before performing the procedure.

💡Contraindications

Contraindications are conditions or factors that serve as reasons to withhold a certain medical treatment due to the harm that it would cause the patient. Although there are no true contraindications for chest tube placement, Dr. Weldon notes the need for caution in patients with skin infections at the insertion site, coagulopathy, pulmonary bullae, pleural adhesions, or diaphragmatic adhesions.

💡Surgical time-out

A surgical time-out is a safety protocol performed before any invasive procedure to verify the patient's identity, the correct procedure, and the correct surgical site. This step is crucial to prevent errors and ensure patient safety. Dr. Weldon emphasizes the importance of performing a surgical time-out with the entire surgical team before proceeding with chest tube placement.

💡Antimicrobial scrub

An antimicrobial scrub is a cleaning solution used to disinfect the skin before surgical procedures to reduce the risk of infection. In the video, Dr. Weldon mentions using a combination of isopropyl alcohol and chlorhexidine to prep the patient's chest before making an incision for the chest tube.

💡Anterior axillary line

The anterior axillary line is an imaginary vertical line on the anterior chest wall that runs along the front edge of the axilla (armpit). It is a critical anatomical landmark for placing a chest tube, as Dr. Weldon points out that the tube should be inserted at the level of the nipple and lateral to this line to avoid injuring internal organs.

💡Blunt dissection

Blunt dissection is a surgical technique that involves separating tissues along natural lines of cleavage without cutting, using an instrument like a clamp. This method reduces the risk of damaging structures beneath the surface. Dr. Weldon describes using blunt dissection to carefully create a pathway for the chest tube into the pleural space.

💡Roman stitch

A Roman stitch is a suturing technique used to secure a chest tube in place after insertion. It involves tying the suture to the skin first, then looping it around the chest tube to hold it securely. Dr. Weldon explains this method as a way to prevent the tube from moving or becoming dislodged.

💡Occlusive dressing

An occlusive dressing is a type of bandage that seals a wound completely to prevent air and contaminants from entering. After securing the chest tube, Dr. Weldon mentions placing an occlusive dressing over the insertion site to maintain a sterile environment and support proper healing.

💡Complications

Complications are unexpected problems that can occur during or after a medical procedure. Dr. Weldon lists potential complications of chest tube placement, including injury to internal organs, bleeding, pneumothorax, and infection. He emphasizes the importance of monitoring for these complications and addressing them promptly.

💡Vital signs

Vital signs are clinical measurements that indicate the state of a patient's essential body functions, such as heart rate, blood pressure, respiratory rate, and oxygen saturation. Dr. Weldon underscores the need to monitor vital signs before, during, and after chest tube placement to ensure patient stability and detect any adverse effects early.

💡Documentation

Documentation involves recording detailed information about a medical procedure in the patient's medical record. This includes the indication for the procedure, date and time, size and site of chest tube placement, amount and type of drainage, confirmation of placement on chest x-ray, and any adverse outcomes. Dr. Weldon highlights the importance of thorough documentation for continuity of care and legal purposes.

Highlights

Introduction to the demonstration on chest tube placement by Dr. Christopher Weldon, a surgeon and intensivist at Children's Hospital Boston.

Explanation of the steps involved in preparing the patient for chest tube placement, including patient safety and pain relief as paramount concerns.

Description of the thoracostomy tube placement procedure, including the use of a pleurovac device or suction device for air and fluid removal.

Indications for chest tube placement when there is lung and mediastinal compression due to air, fluid, or blood accumulation in the pleural space.

Contraindications and precautions for chest tube placement, including considerations for patients with skin infections, coagulopathies, or pulmonary bullae.

List of equipment needed for chest tube placement, including surgical chest tube, antimicrobial scrub, scalpel, forceps, and other essential tools.

Procedure preparation steps, emphasizing the importance of surgical time-out, patient confirmation, and antimicrobial prepping of the chest.

Identification of anatomical landmarks, such as the nipple, for proper chest tube placement to avoid diaphragm violation.

Technique for making an incision, tunneling above the rib, and blunt dissection into the pleural space with a Kelly clamp.

Process of securing the chest tube in place with sutures and an occlusive dressing to prevent leakage.

Connection of the chest tube to a collection device using a male-to-male connector for air and fluid collection.

Use of an Atrium Single system collection device for negative pressure and water seal chamber to collect fluid.

Criteria for chest tube removal, including no further leakage of fluid or air and confirmation via chest radiogram.

Potential complications of chest tube placement, such as injury to organs, bleeding, pneumothorax, and infection.

Importance of patient monitoring, including vital signs and amount of drainage removed during the procedure.

Documentation requirements following chest tube placement, detailing procedure information, drainage, and outcomes.

Conclusion of the chest tube placement demonstration and a call for feedback to improve content.

Transcripts

Chest Tube Placement by Dr. Christopher Weldon.

Hello.

My name is Christopher Weldon.

I'm a surgeon and intensivist at Children's Hospital Boston in Boston, Massachusetts in

the United States.

Today, I will be giving a demonstration on the placement of a thoracostomy tube, or better

known as a chest tube.

During this demonstration, I will show you the steps that you take to prepare the patient

for a thoracostomy tube or a chest tube, the steps involved with physically placing the

chest tube, and then hooking it up to the pleurovac device or the suction device to

remove both air and fluid from the chest once the tube is placed.

And finally, we'll go over the possible complications with not only placement of the tube, but also,

a malfunctioning or non-functioning tube.

The steps that we will use will simply be those that we perform on a daily basis in

this hospital, which may be slightly different than your home institution.

Furthermore, the use of sedatives or other agents to assist you in the placement of the

tube is beyond the scope of this video.

But we must remember first and foremost that patient safety and the relief of pain and

discomfort are of paramount importance.

Indications.

This procedure may be performed when there is compression of the lung and mediastinal

structures secondary to the accumulation of air, fluid, or blood in the plural space.

Contraindications.

There are no true contraindications to this procedure, but you may need to choose an alternative

site in patients with a skin infection over the chest tube insertion site.

You will need to exercise caution in patients with coagulopathy or a platelet count less

than 50,000 per microliter, pulmonary bullae, pleural adhesions, or diaphragmatic adhesions.

Equipment.

You will need the following equipment to perform the procedure: surgical chest tube, antimicrobial

scrub, scalpel, forceps, Kelly clamp, sutures, needle driver, suction source, chest tube

collection device, male-to-male connector, shoulder roll, monitoring equipment.

Procedure: Preparation.

After appropriately prepping myself by scrubbing my hands with a antimicrobial agent and then

using universal precautions to make sure that I protect myself from the patient and the

patient from me, I then take the time to confirm both the laterality and the procedure that

will be performed with the remainder of the surgical team.

A surgical time-out must be performed prior to any invasive procedure and should include

confirmation of patient, procedure site, and potential complications.

After confirmation of that, I will then take any number of antimicrobial agents of which

to prep the chest, which includes, in this case, a combination of isopropyl alcohol and

chlorhexidine.

We will then prep out our chest, using wide arcs starting at the middle, extending outwards,

and prep much more of the chest wall into the field than actually is needed just in

case there's any problems during the procedure itself.

Care is taken to make sure that the patient is appropriately anesthetized again, that

appropriate sedatives are on board, the patient has been appropriately prepped for the procedure,

and that the prepping solution is in place.

After the prepping solution has been utilized, it's taken off the field, after which point

the entire field is then draped using sterile towels.

Procedure: Placement.

Once the patient has been appropriately prepped with the proper antimicrobial agents and draped

in a sterile fashion, the most important thing to remember is that our landmarks must still

be into view.

In placing a chest tube for air, fluid, or both, the most important landmark in the patient

is the nipple.

The nipple signifies roughly the fourth inner thoracic space at which point the chest tube

is then placed in the anterior axillary line, just lateral to the nipple but at the same

level to ensure that the chest tube is not placed too low on the patient, thereby violating

the diaphragm and placing the chest tube inadvertently into the peritoneal cavity.

Again, we appropriately identify the nipple, come across to the anterior axillary line

laterally on the affected side, after which point then we'll place a chest tube through

that rib space and into the pleural space.

With the patient appropriately prepped and draped prior to doing the procedure, we confirm

one last time the reason why the procedure is being done and confirm the side that the

procedure needs to be done on, in this case his left chest.

We then confirm our anatomical landmarks, which is the nipple and the anterior axillary

line, which should represent either the fourth or the fifth interspace where the chest tube

will be placed.

We palpate the ribs in that area.

We will then make the incision, tunnel in above that incision, just above the rib.

We will then bluntly dissect into the pleural space, holding the position with the clamp,

after which point the tube will then be placed through the clamp into the pleural space.

Ideally, once the patient has been appropriately, again, prepped, draped, and anesthetized,

confirm placement.

We then document the placement of the nipple at the junction of the anterior axillary line

on the affected side.

We then make an incision below the affected rib space.

The incision needs to be large enough not only to accept the chest tube but also to

accept the clamp for the dissection into the chest cavity itself.

The incision is made with any sharp knife that is then placed off the field so as not

to inadvertently injure the operator or the assistants.

You then take the blunt instrument.

You then find your affected rib space.

You then gently dissect in directly over the rib cephalad to where you are, thereby confirming

the location.

You then dissect into the pleural space.

Once you have adequate entrance into the pleural space, the clamp is left in as a bookmark,

if you would, to guide the passage of the chest tube, which is in place through the

clamp itself and then into the patient.

Sometimes the chest tube will be assisted by placing the clamp around the tube to help

guide it through the ribs and into the pleural space.

Once the chest tube has been adequately placed, it then needs to be secured in a proper position

with the placement of a suture in and around the chest tube itself.

The chest tube may be secured in many different ways.

We attempt to perform a single Roman stitch whereby we tie it down to the skin first,

locking it in place on the skin, and then having the suture go in around the tube itself

to then secure it to the skin stitch.

Sometimes more than one suture is needed to perform this technique.

An occlusive dressing is then placed over the site of chest tube insertion.

Once the tube has been placed in the proper location and secured in place, we then take

a male-to-male connector so that we can connect the chest tube output to our collection device

to collect both air and blood.

Once the tubes have been placed via the connector, the tube is ensured to be in adequate position

with no evidence of leakage of air or fluid around the tube and secured in place.

We use an Atrium Single system collection device whereby our negative pressure is conducted

through this compartment.

We generally raise to a level of 20 centimeters of water.

This is our water seal chamber, which we then raise to 2 centimeters of water pressure,

after which point this serves as our collection apparatus to collect fluid.

Fluid will then collect sequentially starting in the rightmost chamber, going towards the

middle, and then finally to the leftmost, after which point any evidence of leakage

of air from the pleural surface or from within the pleural space is dribbled out through

a water seal chamber, after which point our negative pressure is delivered through here.

Your actual collection device may vary dramatically depending on your precise location and your

equipment at hand.

Removal of Chest Tube.

The chest tube can be removed when there is no further leakage of fluid or air into the

pleural space.

When there is no ongoing leakage of fluid or air in the pleural space while on suction,

the chest tube is placed to atmospheric pressure or waterseal and a chest radiogram is obtained.

If there is no reaccumulation of air or fluid in the pleural space on chest x-ray or in

the collection device, the chest tube can be removed.

Complications.

The complications that you may observe include injury to lungs, heart, liver, other organs

and soft tissues, bleeding, pneumothorax, infection.

Assessment and Monitoring.

First of all, it is important to monitor the patient's vital signs including oxygen saturation.

You will also want to monitor how much, if any, air, fluid, or blood was removed during

the procedure.

Lastly, you will want to assess the patient's comfort before, during, and after the procedure.

Documentation.

Following chest tube placement, you should document the following information in the

patient's medical record: indication for procedure, date and time, size and site of chest tube

placement, amount and type of drainage removed, confirmation of placement on chest x-ray,

adverse outcomes.

Thank you very much.

This concludes the demonstration of placement of a chest tube or tube thoracostomy.

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