Page 497 - Clinical Application of Mechanical Ventilation

Procedures Related to Mechanical Ventilation 463

Indications for Chest Tube

Common indications for chest tube include large pneumothorax (.25%), hemotho-
Common indications rax, and pleural effusion. Causes of pneumothorax include positive pressure ventilation,
for chest tube include large
pneumothorax (.25%), ruptured bleb due to emphysema, bronchopleural fistula, leaking subpleural cyst, and
hemothorax, and pleural chest trauma. Iatrogenic pneumothorax may be caused by invasive procedures such
effusion.
as thoracentesis, central vein/pulmonary artery catheterization, and bronchoscopy/
transbronchial biopsy (Chen et al., 2002). Excessive pleural fluid may be caused by tho-
racic trauma (hemothorax), heart failure (pleural effusion), intra-abdominal infection
Potential complications
of chest tube placement (empyema), and blockage of lymphatic system (chylothorax) (Irwin et al., 2003).
include hemorrhage at
insertion site, hematoma, Contraindications and Complications. There are no absolute contraindications to chest
laceration of lung parenchyma tube placement in patients who are symptomatic from the above indications.
or intra-abdominal organs,
and infection. Relative contraindications include infection over the insertion site, and conditions
that may lead to severe bleeding during chest tube placement (Thomas, 2004).
Potential complications of chest tube placement include hemorrhage at the inser-
tion site, hematoma, and laceration of lung parenchyma or intra-abdominal organs.
The suggested chest tube
size for teens and large adults Infection can be a late complication (Thomas, 2004).
ranges from 28 to 40 Fr.
Chest Tube Selection and Placement

The chest tube may be straight, curved, trocar, or nontrocar. A trocar is a sharply
trocar: A trocar is a sharply
pointed instrument for incision pointed instrument for incision into the chest cavity (Figure 14-1). The suggested
into the chest cavity. chest tube size for large adults ranges from 36 to 40 French (Fr). For small adults

or teens, a range from 28 to 32 Fr is adequate. For children and neonates, the
Since clotting of the appropriate chest tube sizes are 18 and 12 to 14 Fr, respectively.
chest tube with blood or Clotting of blood inside the chest tube is a potential complication following place-
pleural fluid is less likely in
pneumothoraces, 16 to 20 Fr ment. For this reason, larger tubes are selected for treatment of hemothorax or other
may be adequate for adults. thick pleural fluids (e.g., empyema). Since clotting is less likely when the chest tube is
used to treat pneumothoraces, smaller sizes (16 to 20 Fr) may be adequate for adults.

Chest Tube Placement. Chest tubes are inserted under sterile conditions at the bedside
To treat pneumothorax,
the chest tube (16 to 20 Fr) is or in surgery. To treat pneumothorax, the chest tube (16 to 20 Fr) is usually placed
placed at the second or third at the second or third intercostal space anteriorly along the midclavicular line or
intercostal space anteriorly
along the midclavicular line or midaxillary line. For drainage of blood or other pleural fluids, a size 36 Fr (ranging
midaxillary line. from 28 to 40 Fr) chest tube is recommended to reduce clotting. The insertion point
is from the fourth to sixth intercostal space at the midaxillary line (usually a line
lateral to the nipple) for optimal drainage of pleural fluid (Figure 14-2).
To drain fluid, the chest
tube is placed from the fourth
to sixth intercostal space at
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the midaxillary line.

Figure 14-1 A chest tube with trocar (lower solid piece). The trocar is placed inside the chest tube
for insertion through the incision on the chest wall.

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