Chest Tubes-د.عبد الله القضاة

محاضرة Chest Tubes
د.عبد الله القضاة

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Chest Tubes:

Chest Tubes are large, non toxic, non thrombogenic, long and soft or semi-stiff catheters. Also, they are clear plastic tubes that are usually used to drain the pleura. The tubes are soft to avoid laceration of the lung and necrosis of soft tissues
Small tubes are used for pneumothorax and large ones for hemothorax

* Type of Chest Tubes:
1. Small : inserted with needle stylet
2. Intermediate inserted with stylet
3. Large
Only tubes 20 F or larger are rigid enough to be pushed through a tract without internal support

* Another classification for the types is:

- Open Chest Tubes and Closed Chest Tubes
- Active and Passive Drains (Active drains are maintained under suction and could be high or low pressure. Passive drains have no suction and function by differential pressure between body cavities and the exterior).

The mostly used in JUH is the closed system that drains air and different types of fluids (serous, serosanguinous and blood) from the thoracic cavity into a closed chamber that contains a small amount of sterile water; 100ml (Under water seal chamber). This chamber or the transparent closed bottle should be about 40 cm below the patient level to allow all fluids and air by the action of both the gravity and the chest pressure that is more than the atmospheric pressure to enter the bottle through the one-way flutter valve.

Of course we should notice the presence of fluctuations or the oscillations in the draining tubes that indicate their patency.

*Some tubes called Redivag tubes depend on negative pressure suction.

* Site of Insertion:

For hemothorax we insert the tube between 4th and 5th intercostals space at midaxillary line superficial to the lower rib to prevent injury to the intercostal VAN and towards the area of collection up and infront or up and in the back.

* Safe Zone:

Lateral border of pectoralis major
Inferior horizontal line to axilla
Anterior border of lattismus dorsi
Horizontal line above the nipple


For pneumothorax the tube is inserted between 2nd and 3rd intercostals spaces as the air collects high up in the pleura.


* Of course we insert the tubes under local anaesthesia in the skin and up to the muscles. Perpendicular skin injection of 10-20cc of lidocaine till the costal periosteum with IV administration if 10-20mg of morphine are used.

Also, use iodine before inserting any tube in the safe zone area and do CXR at the end of the procedure to check for pneumothorax.

* Absolute Indications of Insertion:

- Pneumothorax due to central line insertion, chest syrgery, trauma, traumatic airway intubation…etc. The size used in cases of pneumothorax is less than or equal to 14Fr or (16-22 Fr.)
- Hemothorax due to any cause as trauma and post surgery
- Hemo-pneumo thorax (blood and air)
- Tension pneumothorax
- Pleural effusion
- Empyema
- Chylothorax

* Relative Indications :

- Positive pressure ventilation and rib fracture
- Hypotension and penetrating chest injury/hypoxia
- Profound hypoxia with unilateral signs of hemithorax













* Some important points after inserting the chest tube:

- Maintain air-tight system connection
- Prevent infection; change dressing and maintain asepsis
- Do not pull the tubes, prevent dependent loops, kinking or lying on the tubes
- The tubes must not hang over the side of the bed nor on the floor
- Monitor drainage
- Use petroleum gauges and occlusive petroleum dressing.

* Major Complications:

- Pneumothorax
- Empyema (chyle, blood effusion)
- Air may leak and bubbles can be seen in the bottle. If the bubbling is continuous for long period of time and is huge then we suspect disconnection of the tube or the tube.
- Usually absence of bubbling indicate that all the air has escaped or maybe there is problem in placing the tube or in the external device.
- Water in the bottles may evaporate and so fluctuations may stop. But, on the other hand, clotting, kinking or even clamping in the tubes may cause fluctuations to stop too. To prevent clotting we can do milking and stripping every couple of hours. But, stripping is very dangerous after CABG surgeries and may lead to lung damage.
- Accidental disconnection or clamping before re-expansion of lungs may lead to mediastinal shift.
- The more the time the tube is connected the more the chance for infection
- Subcutaneous emphysema due to air leakage.
- Haemorrhage
- Pulmonary edema
- Injury to the liver, spleen or even diaphragm during insertion (perforations) and fistulas sometimes occur.
- Injury to the thoracic aorta and heart when the tube is placed in inferior site to the pleural cavity. Injury may also occur to the stomach and colon.
- Tube inserted subcutaneously or inserted too far causing pain.
- Injury to the intercostal nerve, artery and vein if not inserted superficial to the lower rib
- Tube may fall due to the bad technique

* Minor Complications:

- Hematoma
- Seroma
- Anxiety
- SOB
- Cough

* Late Complications:

- Blocked tube (clot,lung)
- Retained hemothorax
- Empyema
- Pneumothorax after removal(poor technique)

* Removing the Tube:

1. Do percussion and ascultate the lungs to confirm re-expansion. You can also do CXR
2. Check that no more air and fluid are getting out (you can ask the patient to cough and by taking deep breath and look for bubbling and oscillations to make sure no more air/fluid is till found)

So the Indications to remove the tube:

- Effusion: <30cc/day,Persistence of the fluid:2ed chest tube
- Pneumothorax: Bubbling ceases for 12 hours and no pneumothorax on CXR
- Never clamp a tube with air leak

* Contraindications:

- Refractory coagulopathy
- No cooperation of the patient
- In cases of diaphragmatic hernia

* Type of water seal systems:

a. One Bottle Water-Seal System:

Initially it contains 100ml sterile water with an airtight cap and two ventilation tubes. Tthe air ventilation is shorter to give chance for air entering from the chest to escape and must always remain patent in order for pressure not to build up within the bottle.
Usually the long tube sinks to 2cm below the water.






b. Two Bottle Water-Seal System:

The first bottle collects drainage and air while the second is water seal. Here the first bottle has 2 short ventilation tubes. One of the tubes is connected to the chest to bring air and fluid but the other is connected to the second bottle that has also 2 ventilation tubes. One of them is 2cm under the 100ml sterile water while the other is short allowing air to escape.


c. Three Bottle System:

The 1st bottle to collecte drainage, the 2nd to be the water seal, the 3rd is the suction control. The level of the middle tube in the bottle #3 below the water level determines the amount of suction in the system.
















* Notes For OSCE Exam:

- Materials Used: several pairs of sterile gloves, sterile drape, betadine solution, vial of 1% lidocaine, alcohol sponge, 10cc syringe, 22G 1 inch and 22G 5/8th inch needles, sterile forceps and scalpel, one rubber tipped clamp for each chest tube inserted, sterile gauze pads, sterile 4x4s, sturdy elastic tape and scissors, the chest tube, a trocar, suture kit, and the thoracic drainage system with its collection tubes.

- Oscillations are normally seen with any pressure created as sneezing, coughing…etc and you may even see bubbles in the water in the bottle.

- Procedure to insert a chest tube:
Site of insertion
The area is prepped and draped appropriately
An incision is made along the upper border of the rib below the intercostal space to be used.
The drain track will be directed over the top of the lower rib to avoid the intercostal vessels lying below each rib.
The incision should easily accommodate the operator's finger.
Using a curved clamp the track is developed by blunt dissection only.The clamp is inserted into muscle tissue and spread to split the fibres. The track is developed with the operator's finger.
Once the track comes onto the rib, the clamp is angled just over the rib anddissec tion continued until the pleural is entered.
A finger is inserted into the pleural cavity and the area explored for pleural adhesions.
At this time the lung, diaphragm and heart may be felt, depending on position of the track.
A large-bore (32 or 36F) chest tube is mounted on the clamp and passed along the track into the pleural cavity.
The tube is connected to an underwater seal and sutured / secured in place.
If desired, a U-stitch is placed for subsequent drain removal.The chest is re-examined to confirm effect.
A chest X-ray is taken to confirm placement & position.

- If there is a bottle or picture of a bottle as the one below then comment on the content of the bottle (Yellow: Serous, Brown: Blood, Red: Serosanguinous)

- Comment on signs of infection at the site of insertion and if there is any obstruction in the tube

- Confirm functioning by asking the patient to take a deep breath or to cough and look for oscillations and bubbles.

- Examine subcutaneous emphysema by palpation for crackles

- Auscultate the chest

- Removal:
Chest drains may be removed when they are no longer draining any fluid and any air leak has resolved. Removal is ideally performed with two people; one to remove the tube and one to occlude the drain site. The tube should be removed either at the end of expiration or at peak inspiration, to avoid further air being entrained into the pleural cavity.
The area is cleaned and sterilised. An occlusive dressing is prepared and held ready. Any stay sutures are removed. With the patient holding his breath (out or in), the tube removed rapidly and the occlusive dressing applied.
Some surgeons prefer to use a purse-string or U-suture to close the wound. This may be placed at the time of drain insertion. While there is no detriment in using a closing suture, they probably serve little purpose and the purse-string especially may produce an ugly scar.

Best Wishes


Done By Fadi Riad Sunna’
4th Year Medical Student
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