JoVE Science Education
Emergency Medicine and Critical Care
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JoVE Science Education Emergency Medicine and Critical Care
Tube Thoracostomy
  • 00:00Overview
  • 00:45Indications
  • 02:00Prepping the Patient
  • 05:27Chest Tube Placement Procedure
  • 09:25Common Complications
  • 10:41Summary

胸腔ドレナージ チューブ挿入

English

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Overview

ソース: レイチェル劉、バオ、MBBCh、救急医学、エール医科大学院、ニューヘブン、コネチカット、米国

胸腔ドレナージ チューブ挿入 (ドレーン留置) は、流体やエアコンの排水のため胸腔内に中空チューブを挿入中に手順です。緊張性気胸や外傷性血胸、大量胸水、穿の決定的な治療のため、緊急の胸腔ドレーンを挿入が実行されます。

空気と胸膜腔に液体貯留の原因に関係なく排水軽減肺圧縮を使用することができ、肺の再膨張。気胸で胸腔内にエア溜まり分離胸膜層、呼吸時に肺の拡張を防止します。異常な体液貯留、膿胸、血胸の場合と同様にこのような分離の原因臓側胸膜の壁側胸膜から肺組織に付着した胸部キャビティのライニングを形成します。呼吸困難を引き起こす肺の動きから胸部の壁運動の切断につながる胸膜層の連結を解くこと。さらに、過度の圧力の空気や液体の胸膜に圧倒的な量からは、心臓に戻る血液の無力を引き起こす中央の胸から縦隔をプッシュ可能性があります。

トラウマ設定で胸管は可能性がありますだけでなく、胸を扱う、出液速度の監視ができます。内出血または継続的な活発な出血は、出血部位をシールする胸壁の開口部は、外科開胸への進行を必要とします。

胸管は、その長さ、および管の先端に沿ってピンホールに沿って実行している放射線不透過性のストリップとクリアパーツで構成されます。チューブのサイズは 12 から 42 フランス語 (Fr) に小児例に使用される小さいサイズで変わる。 サイズ 36 Fr 血胸、膿胸ドレナージに使用する標準的なサイズが大きいか。

Procedure

1. 物理的な検査所見 一般的な検査で、呼吸促迫、浅い呼吸、または影響を受ける側、首の静脈またはチアノーゼの膨満感から気管の偏差と同様、完全な文章を話すことができない患者を観察します。 モニターで患者を置き、頻脈と呼吸数の増加と同様、低酸素血症や低血圧のための観察します。 患者さんの橈骨頚動脈パルスを触診します。弱い、弱々しいパルスは?…

Applications and Summary

Emergent tube thoracostomy is performed in patients in extremis, or when a possibility for the rapid deterioration in the patient's condition is indicated by the size of the pneumothorax or fluid in the chest cavity, worsening symptoms, and the patient's vital signs.

Once a chest tube has been placed, the patient requires constant monitoring to assess for improvement in respiratory effort, resolution of tachypnea and hypoxia, and improving vital signs. Deterioration or plateau of the patient's condition may necessitate a second chest tube placement or surgical intervention. In addition to tube placement, staff need to understand the mechanics of suction or water seal drainage systems for troubleshooting purposes and evaluation of when a chest tube may be safely removed.

The most common complications of tube placement include local infection at the insertion site, subcutaneous emphysema due to air leaking from excessive openings, and injuries to underlying solid organs (lung, spleen, liver, diaphragm, stomach, colon) or vascular structures. The latter may necessitate surgical opening of the chest wall for ligation. Tubes may be placed in the incorrect position, either subcutaneously or intra-abdominally, especially in obese patients in whom anatomical positioning may be less clear. Tubes may also dislodge or become blocked by clotted fluid.

Transcript

Emergency chest tube insertion, or tube thoracostomy, is performed as a definitive treatment for releasing the abnormally increased pressure inside the thoracic cavity. It is a procedure during which a hollow tube is inserted into the thoracic cavity for drainage of accumulated fluid or air. Irrespective of the cause, the drainage relieves lung compression and enables lung re-expansion.

This video will briefly outline the indications and then explain how to conduct the tube thoracostomy procedure in detail.

The indications for emergency chest tube insertion include conditions like tension pneumothorax…traumatic hemothorax…large volume pleural effusion…and empyema.

In case of a pneumothorax, air accumulation in the pleural cavity separates pleural layers, which prevents lung expansion during the respiration. Abnormal fluid accumulation, such as in case of hemothorax, pleural effusion or empyema, causes separation of the visceral pleura that adheres to lung tissue from the parietal pleura that forms the lining of the chest cavity. This uncoupling of the pleural layers leads to disconnection of chest wall movement from the lung movement causing respiratory distress. In addition, an excessive pressure from overwhelming amounts of air or fluid in the pleura may push the mediastinum away from the central chest, causing reduced cardiac filling and therefore decreased cardiac output.

Now that we’ve discussed the indications, let’s review the prepping steps to be performed before performing tube thoracostomy.

First, obtain a chest tube kit, which should include: antiseptic solution, sterile drapes, a local anesthetic, a 20 milliliter syringe, needles, scalpel with a number 10 blade, Kelly clamps, needle holder, silk suture, forceps, straight scissors, large curved scissors, a drainage system with water seal and sterile tubing, petroleum gauze, cloth gauze squares, adhesive tape and chest tubes.

Chest tubes are composed of clear plastic. They typically have a radiopaque strip running along their sides and fenestrations at the tip. The tube sizes vary from 12 to 42 French. The smaller sizes are typically reserved for pediatric patients, where as 36 French or larger tubes are used in hemothorax treatment and empyema drainage.

Begin by administering supplemental oxygen to the patient via a nasal cannula or a non-rebreather mask. Ensure the patient is connected to a cardiac monitoring device and a pulse oximetry device. Next, move the patient into a semi-recumbent position and elevate the head of the bed to a 30-60 degree angle. Conducting the procedure in this position can reduce the risk of injury to the diaphragm muscle and sub-diaphragmatic organs.

Now place the patient’s ipsilateral arm over their head and stabilize the arm in this position with tape or a strap attached to the stretcher. Next, administer parenteral analgesics such as morphine prior the procedure. Prepare the sterile field by liberally applying antiseptic solution to the entire affected chest wall. Following that, cover the field with sterile drapes so only the insertion site is exposed.

At this point, put on the sterile gown, don sterile gloves and lay equipment or medications on a sterile tray. It can be helpful to have several size chest tubes ready.

Now estimate the size of tube needed to reach the patient’s pleural space. To do so, place the tip of the tube gently against the patient’s clavicle and direct it towards the insertion site on the lateral chest wall. Be sure the tube is long enough to reach the apex of the patient’s lung. Clamp the tube to mark the estimated length and ensure that the most distal drainage fenestration will be located within the pleural space once the tube is inserted. Next, palpate to identify the preferred location for chest tube placement, which is either the fourth or fifth intercostal space located between the anterior axillary and mid-axillary line. Note that the fifth intercostal space is usually found at nipple level. You can mark the insertion site with a sterile surgical marker.

Now you’re ready to start the chest tube placement procedure. Administer local anesthetic by infiltrating the skin over the superior aspect of the 5th or 6th rib. Then slowly inject through the subcutaneous tissue, muscle, rib periosteum and the parietal pleura along the projected pathway of tube passage. Intermittently aspirate the syringe while performing the injection. When air is withdrawn upon aspiration, it indicates that the parietal pleura has been reached. Inject liberally to infiltrate the pleural lining and then withdraw the syringe.

Following anesthesia administration, make a 3 to 5 centimeter transverse incision above and parallel to the 5th or 6th rib. Be sure the incision is made through the patient’s skin and subcutaneous tissue and is large enough to fit the tube, fitting clamps and an index finger. An incision made in this manner protects against damage to neurovascular bundles, which lie at the inferior aspect of each rib. Next, insert the Kelly clamp into the incision and perform blunt dissection of the subcutaneous tissues down to the intercostal muscles until a firm resistance is detected. Firm resistance indicates the parietal pleura has been reached. Blunt dissection may be aided by use an index finger.

Next, close the ends of the Kelly clamp, hold it with the index finger positioned near the clamp tip and push it through the parietal pleura into the pleural space. A popping sensation will be felt and a rush of air or fluid will be audible when the pleural space is reached. Following that, open and spread the clamp to produce an opening. The opening must be large enough to accommodate both a finger and a chest tube, but not excessively large — as that might lead to an air leak. Sweep the space with the gloved index finger to ensure there are no blockages. Leave the finger in the opening while withdrawing the clamp to maintain the incision’s integrity.

Now insert the tube beside the finger into the pleural space. The fingertip can guide the tube into the appropriate direction posteriorly, medially, and superiorly until the last fenestration of the tube is in the thorax. All holes should be within the pleural space and the tube should be able to rotate freely. Premature resistance to passage of the tube could indicate that the tube is not in the pleura and may be passing in subcutaneous tissue or abutting the mediastinum. Observe the tube for condensation and listen for the movement of air. Visible tube condensation and audible airflow are indications the tube is in the correct position.

Attach the tube to the water seal or suction system. Note the flow of fluid, and its rate. Bubbling within the water seal chamber is usually immediately apparent, but you may ask the patient to cough and observe for bubbles in the water seal chamber to ensure system patency.

Next, secure the tube by using a “stay” suture. Start with a simple interrupted suture near the site of the chest tube and leave both ends of the suture long. Then tie the free ends around the tube and secure it in place. Lastly, apply occlusive petroleum gauze dressing over the chest tube site using a Y cut to fit the tube. This will prevent air leaks. And tape the dressing to the skin and to the tube to avoid dislodgment. To confirm tube placement, order a chest X-ray.

“Emergent tube thoracostomy is performed in patients in extremis or when the size of the pneumothorax or fluid in the chest cavity, worsening symptoms and the patient’s vital signs indicate a possibility for the rapid deterioration in the patient’s condition.”

“Once a chest tube has been inserted into a patient, the patient will require constant monitoring. The patient’s vital signs must be assessed along with an improvement in respiratory effort and a resolution of tachypnea and hypoxia. A decline or plateau in the patient’s condition may necessitate the placement of a second chest tube or surgical intervention.”

“The most common complications of tube placement include: local infection at the insertion site, subcutaneous emphysema due to air leaking from excessive openings and injuries to underlying solid organs such as the lung and spleen. Furthermore, tubes may dislodge or become blocked by clotted fluid. Tubes may also be placed in the incorrect position, either subcutaneously or intra-abdominally, especially in obese patients where anatomical positioning may be misleading.”

You have just watched a JoVE video demonstrating the indications and procedure for tube thoracostomy. As always, thanks for watching!

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JoVE Science Education Database. JoVE Science Education. Tube Thoracostomy. JoVE, Cambridge, MA, (2023).