Chest Tubes

Contraindications

• Absolute: need for emergent thoracotomy 
• Relative: Coagulopathy (INR Goal < 2-3), large pulmonary bullae, pleural/pulmonary adhesions, skin infection at insertion site, hepatic hydrothorax (associated with increased mortality), malignant effusions (durable drainage devices used in palliative cases)

Placement

• Consult pulmonology – they will delegate to interventional pulmonology or IR 
• Location: Dependent on pathology 
• Pneumothorax – anterioapical at 2nd intercostal space or midaxillary line (triangle of safety) 
• Effusion (water, pus, blood, chyle) – posterobasal; fifth of sixth intercostal space or midaxillary line (triangle of safety) 
• Potential complications: organ damage/perforation (lung, heart, diaphragm, intraabdominal), trauma of the intercostal neurovascular bundle, subcutaneous emphysema, pneumothorax, infection, re-expansion pulmonary edema

Understanding the Atrium

1. Dry suction control - set by the provider. Determines degree of suction (typically -10 to -20 cm H2O). Note, the level of suction is determined by (A), regardless of what the wall suction setting is. If the atrium is disconnected from the wall suction, it is on “water seal” 
2. Water seal chamber - allows for the one-way flow of pleural space contents out of the chest
3. Air leak monitor - air bubbles, seen here, indicate the presence of air in the pleural space. Degree of leak graded by how far along the bubbles are noted 
4. Collection chamber - Enables measurement and visualization of drained pleural fluid 
5. Suction verification window - will be orange when suction is being applied

Troubleshooting

• Always consult pulmonary for chest tube management unless another team (e.g. thoracics) is actively managing. IR does not generally manage chest tubes, even if they place them. 
• Ensure daily CXR in patient with a chest tube

Air Leaks

• Bubbles within the water seal chamber. Indicate air entrapment from the 1. Pleural space or 2. Chest tube/drainage system 
• Patient related: air from the pleural space, i.e. from a PTX. If persistent air leak, consider bronchopleural fistula or alveolar/bronchopleural fistula 
• Bubbling stops if you clamp the chest tube near the patient 
• System related: air originating from the environment. Seen in chest tube dislodgement, faulty dressing seal at insertion site, cracked or damaged drain system 
• Bubbling continues if you clamp the chest tube near the patient

Tidaling

• A normal finding referring to the rise (during inspiration) and fall (during expiration) of fluid in the water seal chamber 
• Indicates communication between pleural space and the drainage system

Lack of tidaling

• When lung has fully re-expanded, the chest tube is blocked (clogged/kinked), suction is turned on, or tube is dislodged/mispositioned

Clogging

• Evidenced by debris in the collection chamber and lack of tidaling 
• Try flushing 10cc of sterile saline toward the pt or “stripping” the chest tube using manual pressure (pressing the chest tubing with your fingers and pulling towards the drainage system)

Removal

• When the underlying condition requiring their insertion has plateaued, improved, or resolved 
• Effusions: output <150 cc in 24 hours 
• PTX: Once air leak resolves, transition from suction to water seal 
  • CXR prior to transitioning 
  • Repeat CXR 2 hours after 
• Pigtail catheters must be “unlocked” prior to removal to release the pigtail 
• Patient should hum during chest tube removal to prevent air being re-introduced into pleural space