Intercostal Chest Tube Insertion
While breathing, our lungs expand. What will happen if lung volume decreases? Our breathing will be difficult. From another point of view: our life will be in danger if; the expansion of the lung decreases. Chest drains or intercostal tube insertion; are used for saving lives in critical care.
The procedure of intercostal tube insertion is known as closed tube thoracostomy. What are the conditions in which this procedure is applicable? Can this life-saving procedure have any complications? Let’s find the answers to these questions in this article.
Indications
The lung expansion can be reduced: due to any pus collection, abnormal blood collection in the thoracic cavity. What will we do if we get any pus collection or fluid collection in other parts of the body? We will use aspiration techniques to cure those conditions. An intercostal chest tube is also used; to eliminate the abnormal collections in the thoracic space.
- Pneumothorax
- hydrothorax, chylothorax
- Haemothorax
- Haemo pneumothorax
- Empyema
- Pleural lavage
We use chest drains in all these conditions to remove the pathological collections, and it ensures complete expansion of the lung and restores normal ventilation.
Contraindications
- Traumatic diaphragmatic hernia
- Refractory coagulopathy
- Pleural adhesions
- Emphysematous bullae
- Infection over the insertion site
If the patient is diagnosed to have any of these, close tube thoracostomy: is contraindicated in such cases.
Types of Intercostal Drainage
Mainly it is three types; single bottle water seal system, two bottle systems, and three bottle systems. A typical drainage system contains three bottles. Underwater; seal bottle, trap bottle, and suction regulator bottle.
Principles And Procedure
The intercostal chest tube is working based on,
- Gravity: we always keep the drainage bottle below the patient’s chest level, as the fluid and air flows from higher to lower level.
- Pressure: the abnormal collections in the thoracic cavity create a positive or a higher pressure gradient. This expiratory, positive pressure also helps to push out the abnormal collections from the chest cavity.
- Suction: it will help to; increase the speed at which the air, pus, and fluid are removed: from the chest.
We will explain the procedure to the patient. After getting the consent, the patient is kept: in the supine position with the head elevated to 45°, and local anesthesia is given just above the rib to avoid injury to the neurovascular bundle. Give a horizontal skin incision about 4 cm in length; the skin, fascia, intercostal muscles are opened and separated. The adequacy of opening to insert the drainage tube is confirmed using inserting a fingertip. A suitable intercostal tube is inserted: into the parietal pleura; the outer end of the tube is clamped first, which will, later on, connect to the underwater seal apparatus. After that, the intercostal chest tube is sutured: to the skin.
| CHEST TUBE SIZE |
| Adult:Pneumothorax: 20-24 FHaemothorax, haemo pneumothorax, empyema: 28-36 FChild: 18-24 FInfant: 14-20 FNeonate: 8-12 F |
Triangle of Safety
We usually consider the ‘triangle of safety’ as a region for the safest site for insertion of the chest drain.
- Anterior border: lateral end of pectoralis major muscle
- Lateral border: anterior border of latissimus dorsi muscle
- Inferior border: horizontal line at the level of nipple/ line of 5th intercostal space.
- Superior portion of the apex of the triangle is the base of the axilla.
This area is: more preferred because, at this site, the muscle bulk is less, i.e., it is easy to administer ICT, and it allows the side-to-side movement of the tube and avoids kinking of the chest tube.
Postoperative Care
To avoid complications: proper post-operative care is crucial in this procedure. We should observe the ICT for kinks, clots; if found, it should be removed, to maintain proper drainage. Observe water seal fluctuations based on the patient's breathing pattern: if it is properly functioning, the fluid will rise on inspiration and fall with expiration. Lung expansion is checked at regular intervals.
ICT Removal
ICT removal is equally important; as chest tube insertion. After the chest x-ray shows proper lung expansion, the pleural fluid drain will convert to the serous collection, and if it is less than 25 ml/day for 3 consecutive days, and the water column movement becomes less than 1 cm, we will remove the ICT.
We will apply the double clamp; to the chest tube near the patient’s chest; to prevent the entry of air into the pleural cavity while removing the tube. After that, we will remove the bottle attached to the chest tube. The sutures are removed; the patient is asked to take a deep inspiration, and the tube; is pulled out. The wound is then cleaned quickly and sealed using plaster dressing. This procedure will avoid the re-entry of air into the pleural cavity.
Complications
The lifesaving procedure also can put our life in danger if proper care; is not given. The complications of ICT are tube Malposition, blocked drain, chest drain dislodgement, Re-expansion Pulmonary Edema, Subcutaneous Emphysema, Nerve Injuries, Cardiac and Vascular Injuries, Residual/Postextubation Pneumothorax, esophageal Perforation, Herniation through Insertion Site, fistula formation, infection through suture site and Cardiac Dysrhythmia.
Even though we may consider it; as a simple aspiration/ drainage process, thorough knowledge about the anatomy: of the thoracic cavity is necessary to perform a successful intercostal chest tube insertion. Proper care should give in operative, post-operative, and while doing ICT removal to avoid complications.
References
- Bailey & Loves Short Practice of Surgery 27th edition; Page no: 920
- SRB Manual of Surgery 5th Ed; Page no: 1121 - 1123
Author’s Footnote
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