Chest Tube Thoracostomy (CTT)

The free end of the tube is usually attached to an underwater seal, below the level of the chest to allow the fluid or air to move from the pleural space, preventing anything returning to the chest.

Sizes of Chest Tube:
Newborn = 12-14 Fr
Child = 18 Fr
Adult or Teen Male = 28-32 Fr
Pp Adult or Teen Female = 28 Fr

A chest tube is a flexible plastic tube that is inserted through the side of the chest into the pleural space.

Indications

Pneumothorax: accumulation of air in the pleural space
Pleural effusion: accumulation of fluid in the pleural space
Chylothorax: a collection of lymphatic fluid in the pleural space
Empyema: a pyogenic infection of the pleural space
Hemothorax: accumulation of blood in the pleural space
Hydrothorax: accumulation of serous fluid in the pleural space

Contraindications

Contraindications to chest tube placement include refractory coagulopathy, lack of cooperation by the patient, and diaphragmatic hernia. Additional contraindications include scarring in the pleural space (adhesions)

Insertion site
- 5th intercostal space slightly anterior to the mid axillary line, or
- in an area described as the "safe zone", a region bordered by: the lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi and a horizontal line superior to the nipple

Procedure

A small incision is made over the "safe zone" after injection of a local anesthesia, and a passage is made through the skin and muscle into the chest. The tube is placed through this passage.

Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied to the area.

A chest radiograph confirms the location of the drain.

The tube stays in for as long as there is air or fluid to be removed, or risk of air gathering.

Chest Drainage Canister

There are generally three chambers.
1. The first chamber is a collecting chamber.
2. The second is the "water seal" chamber which acts as a one way valve. Air bubbling through the water seal chamber is usual when the patient coughs or exhales but may indicate, if continual, a pleural or system leak that should be evaluated critically. It can also indicate a leak of air from the lung.
3. The third chamber is the suction control chamber. The height of the water in this chamber determines the negative pressure of the system. Bubbling should be kept a gentle bubble to limit evaporating the fluid. Increased wall suction does not increase the negative pressure of the system.

Complications

Major complications are hemorrhage, infection, and reexpansion pulmonary edema. Chest tube clogging can also be a major complication if it occurs in the setting of bleeding or the production of significant air or fluid. When chest tube clogging occurs in this setting, a patient can suffer from pericardial tamponade, tension pneumothorax, or in the setting of infection, an empyema. All of these can lead to prolonged hospitilization and even death. To minimize potential for clogging, surgeons often employ larger diameter tubes. These large diameter tubes however, contribute significantly to chest tube related pain. Even larger diameter chest tubes can clog.[4] In most cases, the chest tube related pain goes away after the chest tube is removed, however, chronic pain related to chest tube induced scarring of the intercostal space is not uncommon.

Injury to the liver, spleen or diaphragm is possible if the tube is placed inferior to the pleural cavity. Injuries to the thoracic aorta and heart have also been described.

Minor complications include a subcutaneous hematoma or seroma, anxiety, shortness of breath (dyspnea), and cough (after removing large volume of fluid).

Subcutaneous emphysema indicates backpressure created by a clogged drain or insufficient negative pressure.