Chest tubes vary in size from 6 to 40 French. For patient comfort and to avoid complications, the smallest tube that will drain the pleural space should be chosen.
When available bedside ultrasound should be used for pleural diagnosis and to guide chest tube insertion.
For a hemothorax, continued drainage of more than 250 mL of blood per hour warrants a surgical consult.
The most common complications of chest tube insertion include malposition, blockage, infection, dislodgement, re-expansion pulmonary edema, subcutaneous emphysema, nerve injuries, intrathoracic organ injuries, and residual pneumothorax.
Chest tube systems should be examined daily for the amount of drainage, the presence of an air leak and the presence of respiratory variation of the fluid column.
Tube thoracostomy is the procedure of insertion of a sterile tube or catheter into the pleural space. It is used to remove air and/or fluid to restore negative pressure to the pleural space. The various indications, diagnostic techniques, procedural approaches, and complications will be discussed in this chapter.
ANATOMY AND PHYSIOLOGY
The pleural cavity is a closed space that exists between the visceral and the parietal pleura. The visceral and parietal pleura contain a single layer of mesothelial cells with multiple layers of connective tissue.1 The parietal pleura is innervated by the intercostal nerves while the visceral pleura is not innervated. In a healthy individual, the mesothelial cells on the visceral pleura create a thin film of fluid that allows the pleura to glide smoothy during respiration. See Table 94–1 below for the characteristics of normal pleural fluid versus transudate and exudate.
++ Table Graphic Jump Location Table 94–1Characteristics of normal pleural fluid versus transudate and exudate. ||Download (.pdf) Table 94–1 Characteristics of normal pleural fluid versus transudate and exudate.
| ||Normal Pleural Fluid ||Transudate ||Exudate |
|pH ||7.60-7.64 ||> 7.20 ||< 7.20 |
|Glucose ||Similar to plasma ||> 60 mg/L ||< 60 mg/L |
|Protein ||1-2 g/dL ||Pleural fluid/serum |
| || ||< 0.5 ||> 0.5 |
|LDH ||< 0.5 ||Pleural fluid/serum |
| || ||< 0.6 ||> 0.6 |
|Microbiology ||< 1000 WBC/mm3, mostly macrophages, no organisms ||No organisms present ||Organisms possibly found |
|Appearance ||Clear ||Clear, free-flowing fluid ||Turbid, septations, and loculations may be present |
Chest tube sizes are based on the external diameter, ranging from 6 to 40 French (Fr). Adult small bore chest tubes (SBCT) are tubes ≤ 14Fr. Chest tubes also come in a variety of shapes; the majority of chest tubes used in common practice are either straight, right angle, or pigtailed. Each tube has length markers to guide insertion and fenestrations for pleural drainage. Chest tubes can be “tunnelled” to decrease the rate of dislodgement and infection and to allow for long-term, outpatient management of pleural effusions. See Table 94–2 for a summary of choice of tubes based on indication.