Keywords

Prior to Procedure

  • Review a------ny chest x-ray and computer tomography prior to initiation of the procedure.

  • Confirm laterality.

Preference Card

  • Large barrier drapes/blue towels.

  • Sterile gloves/gown.

  • Mask, eyewear, hat.

  • Chlorhexidine.

  • Chest tube 28–40 French.

  • Hemostats.

  • #15 blade scalpel.

  • Needle driver.

  • Nylon/silk suture.

  • Local anesthetic 1% lidocaine.

  • Kelly clamps.

  • Collection chamber.

  • Commercially available chest drainage system with water seal and collection chamber.

Patient Positioning/Operating Room Setup (Fig. 8.1)

  • Patient should be supine or slightly lateral decubitus.

  • Place the ipsilateral arm of the affected side up and over the patient’s head.

  • Ensure arm is clear of the surgical field

Fig. 8.1
figure 1

Patient position and landmarks

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Nodal Points

Procedure Starts

  • Identify incision site – palpate the chest wall to identify the fifth intercostal space, anterior to the mid axillary line.

  • Use nipple level as landmark in males to identify the fourth intercostal space.

  • In females stay above the inframammary fold.

  • Using 1% lidocaine and a 23-gauge needle, infiltrate the skin, subcutaneous tissue, to the periosteum of the underlying rib and the pleura just past the rib.

Incision

  • Make a 2–3 cm transverse incision at the predetermined site with a #15 blade scalpel.

  • Bluntly dissect the subcutaneous tissue with a Kelly clamp.

  • Feel for the top border of the rib and gently push through the parietal pleura to the pleural space. A rush of air or fluid will confirm entry.

  • Note: you must enter the pleural space over the top of the rib to avoid damaging the neurovascular bundle that lies along the groove of the inferior border of each rib.

  • Once inside the pleural space, gently spread the Kelly clamp, and withdraw while spreading to create a sufficient opening in the pleura for the chest tube.

  • Place finger into the surgical site, and rotate 360° to ensure correct location and relieve any adhesions or impediments to placing chest tube.

Insertion of Chest Tube (Fig. 8.2)

  • Clamp both the proximal and distal ends of the chest tube, to aid in insertion and contain pleural contents until connected to collection chamber, respectively.

  • Advance chest tube into pleural space posteriorly, and aim superiorly toward the thoracic apex.

  • All drainage holes on chest tube should be within the chest cavity.

Fig. 8.2
figure 2

Chest tube placement

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Fix Chest Tube in Place and Connect to Suction

  • Suture the drain in place with 2-0 silk suture.

  • Place chest tube to suction at 20 cmH2O.

Confirm Chest Tube Position and Assess Treatment Response

  • Obtain anterior-posterior chest x-ray.

  • Assess correct placement of the chest tube; rule out remaining pneumothorax and fluid collections.

  • Place occlusive dressing with Vaseline/Xeroform gauze and 4 × 4 gauze.