Clinical Pathways
Clinical Pathways
No Concurrent Hemothorax
No Concurrent Hemothorax

No Concurrent Hemothorax

View The Full Pathway

Action

Measure radial distance of largest air pocket from mediastinum/visceral pleura to parietal pleura/chest wall

Decision

Size of Pneumothorax

≥35 mm

  • Place small tube thoracostomy or pigtail catheter in the fourth or fifth anterior axillary line

<35 mm

  • Observe, and perform CXR in 6 hr to monitor for progression of pneumothorax

Background

Chest Tube Insertion

For tension pneumothoraces and larger pneumothoraces in symptomatic patients, TT is the definitive treatment for air evacuation. The chest tube should be placed at the midaxillary line in the fourth or fifth intercostal space with the tube directed anteriorly to allow for drainage of the pneumothorax. Standard chest tube size ranges from 28F to 40F; pigtail chest tube size generally ranges from 8F to 20F.

Positioning and adequate analgesia are central to successful placement of a chest tube. The patient’s arm should be positioned above the head to allow full access to the lateral chest wall. The skin should be anesthetized where the incision will be made, and lidocaine should be administered along the entire tract that the chest tube will traverse, from skin to parietal pleura. The rib periosteum and the parietal pleura are pain-sensitive structures that require a large amount of local anesthetic.

Patients undergoing TT should be counseled on tube-related complications, as well as the possible need for the insertion of additional chest tubes. (See Table 2.) The most common complications associated with chest tube insertion are bleeding and intercostal neuralgia, although there are also more-severe and morbid complications that can occur due to improper positioning or premature tube removal. Risk of damage to surrounding structures can be minimized with proper insertion technique. Although re-expansion pulmonary edema is a rare complication, it carries a high degree of morbidity and mortality.

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Data from Mohammed HM. Chest tube care in critically ill patient: a comprehensive review. Egyptian Journal of Chest Diseases and Tuberculosis. 2015;64(4):849-855.

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References
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