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

Pleural cavity

In human anatomy, the pleural cavity is the potential space between the two pleura of the lungs. The pleura is a serous membrane which folds back onto itself to form a two-layered, membrane structure. The thin space between the two pleural layers is known as the pleural cavity; it normally...

. It is used to remove air (pneumothorax

Pneumothorax

Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...

) or fluid (pleural effusion

Pleural effusion

Pleural effusion is excess fluid that accumulates between the two pleural layers, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during ventilation.-Pathophysiology:...

, blood

Hemothorax

A hemothorax is a condition that results from blood accumulating in the pleural cavity.-Cause and presentation:Its cause is usually traumatic, from a blunt or penetrating injury to the thorax, resulting in a rupture of the serous membrane either lining the thorax or covering the lungs...

, chyle

Chyle

Chyle is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids . It is formed in the small intestine during digestion of fatty foods, and taken up by lymph vessels specifically known as lacteals...

), or pus (empyema

Empyema

Pleural empyema is an accumulation of pus in the pleural cavity. Most pleural empyemas arise from an infection within the lung , often associated with parapneumonic effusions. There are three stages: exudative, fibrinopurulent and organizing. In the exudative stage, the pus accumulates...

) from the intrathoracic space. It is also known as a Bülau drain

Drain (surgery)

A surgical drain is a tube used to remove pus, blood or other fluids from a wound. Drains inserted after surgery do not result in faster wound healing or prevent infection but are sometimes necessary to drain body fluid which may accumulate and in itself become a focus of infection...

 or an intercostal catheter.

Indications

• Pneumothorax
  Pneumothorax
  Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
  
  : accumulation of air in the pleural space
• Pleural effusion
  Pleural effusion
  Pleural effusion is excess fluid that accumulates between the two pleural layers, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during ventilation.-Pathophysiology:...
  
  : accumulation of fluid in the pleural space
  • Chylothorax
    Chylothorax
    A chylothorax is a type of pleural effusion. It results from lymphatic fluid accumulating in the pleural cavity.-Causes:...
    
    : a collection of lymphatic
    Lymphatic system
    The lymphoid system is the part of the immune system comprising a network of conduits called lymphatic vessels that carry a clear fluid called lymph unidirectionally toward the heart. Lymphoid tissue is found in many organs, particularly the lymph nodes, and in the lymphoid follicles associated...
    
     fluid in the pleural space
  • Empyema
    Empyema
    Pleural empyema is an accumulation of pus in the pleural cavity. Most pleural empyemas arise from an infection within the lung , often associated with parapneumonic effusions. There are three stages: exudative, fibrinopurulent and organizing. In the exudative stage, the pus accumulates...
    
    : a pyogenic infection
    Infection
    An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
    
     of the pleural space
  • Hemothorax
    Hemothorax
    A hemothorax is a condition that results from blood accumulating in the pleural cavity.-Cause and presentation:Its cause is usually traumatic, from a blunt or penetrating injury to the thorax, resulting in a rupture of the serous membrane either lining the thorax or covering the lungs...
    
    : accumulation of blood in the pleural space
  • Hydrothorax
    Hydrothorax
    A hydrothorax is a condition that results from serous fluid accumulating in the pleural cavity. This specific condition can be related to cirrhosis with ascites in which ascitic fluid leaks into the pleural cavity...
    
    : accumulation of serous fluid in the pleural space

Contraindications

Contraindications to chest tube placement include refractory coagulopathy

Coagulopathy

Coagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...

, lack of cooperation by the patient, and diaphragmatic hernia. Additional contraindications include scarring in the pleural space (adhesions)

Technique

The insertion technique is described in detail in an article of the NEJM. The free end of the tube is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest. Alternatively, the tube can be attached to a flutter valve

Flutter valve

A flutter valve is a one-way valve used in respiratory medicine to prevent air from travelling back along a chest tube. It is most commonly used to help remove air from a pneumothorax...

. This allows patients with pneumothorax

Pneumothorax

Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...

 to remain more mobile.

British Thoracic Society recommends the tube is inserted 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 . More specifically, the tube is inserted into the 5th intercostal space slightly anterior to the mid axillary line.

Chest tubes are usually inserted under local anesthesia

Anesthesia

Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...

. The skin over the area of insertion is first cleansed with antiseptic

Antiseptic

Antiseptics are antimicrobial substances that are applied to living tissue/skin to reduce the possibility of infection, sepsis, or putrefaction...

 solution, such as iodine, before sterile

Sterilization (microbiology)

Sterilization is a term referring to any process that eliminates or kills all forms of microbial life, including transmissible agents present on a surface, contained in a fluid, in medication, or in a compound such as biological culture media...

 drapes are placed around the area. The local anesthetic is injected into the skin and down to the muscle, and after the area is numb a small incision is made in the skin and a passage made through the skin and muscle into the chest. The tube is placed through this passage. If necessary, patients may be given additional analgesics for the procedure. Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied to the area. Once the drain is in place, a chest radiograph will be taken to check 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 tubes can also be placed using a trocar, which is a pointed metallic bar used to guide the tube through the chest wall. This method is less popular due to an increased risk of iatrogenic lung injury. Placement using the Seldinger technique

Seldinger technique

The Seldinger technique is a medical procedure to obtain safe access to blood vessels and other hollow organs. It is named after Dr. Sven-Ivar Seldinger , a Swedish radiologist from Mora, Dalarna County, who introduced the procedure in 1953....

, in which a blunt guidewire is passed through a needle (over which the chest tube is then inserted) has been described.

Chest Drainage Canister

A chest drainage canister device is typically used to drain chest tube contents (air, blood, effusions). There are generally three chambers. The first chamber is a collecting chamber. 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. 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. Newer systems are designed not to need the water seal chamber, so there is not a column of water that can spill and mix with blood, mandating the replacement of the canister. Even newer systems are smaller and more ambulatory so the patient can be sent home for drainage if indicated.

Complications

Major complications are hemorrhage, infection, and reexpansion pulmonary edema

Pulmonary edema

Pulmonary edema , or oedema , is fluid accumulation in the air spaces and parenchyma of the lungs. It leads to impaired gas exchange and may cause respiratory failure...

. 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. 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.

In recent years surgeons have advocated using softer, silicone Blake drains rather than more traditional PVC conventional chest tubes to address the pain issues. Clogging and chest tube occlusion issues have been a problem, including reports of life threatening unrecognized bleeding that occurs in the chest due to an occluded or clogged drain. Thus when a chest tube is inserted for whatever reason, maintaining patency is critical to avoid complications.

Injury to the liver

Liver

The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...

, spleen

Spleen

The spleen is an organ found in virtually all vertebrate animals with important roles in regard to red blood cells and the immune system. In humans, it is located in the left upper quadrant of the abdomen. It removes old red blood cells and holds a reserve of blood in case of hemorrhagic shock...

 or diaphragm

Thoracic diaphragm

In the anatomy of mammals, the thoracic diaphragm, or simply the diaphragm , is a sheet of internal skeletal muscle that extends across the bottom of the rib cage. The diaphragm separates the thoracic cavity from the abdominal cavity and performs an important function in respiration...

 is possible if the tube is placed inferior to the pleural cavity. Injuries to the thoracic aorta

Aorta

The aorta is the largest artery in the body, originating from the left ventricle of the heart and extending down to the abdomen, where it branches off into two smaller arteries...

 and heart

Heart

The heart is a myogenic muscular organ found in all animals with a circulatory system , that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions...

 have also been described.

Minor complications include a subcutaneous hematoma

Hematoma

A hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...

 or seroma

Seroma

A seroma is a pocket of clear serous fluid that sometimes develops in the body after surgery. When small blood vessels are ruptured, blood plasma can seep out; inflammation caused by dying injured cells also contributes to the fluid....

, anxiety, shortness of breath (dyspnea

Dyspnea

Dyspnea , shortness of breath , or air hunger, is the subjective symptom of breathlessness.It is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations...

), and cough (after removing large volume of fluid).

Subcutaneous emphysema

Subcutaneous emphysema

Subcutaneous emphysema, sometimes abbreviated SCE or SE and also called tissue emphysema, or Sub Q air, occurs when gas or air is present in the subcutaneous layer of the skin. Subcutaneous refers to the tissue beneath the cutis of the skin, and emphysema refers to trapped air...

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

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