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MANAGEMENT OF CHEST TUBES:
Pneumothorax
Dr. Carmine Simone
Thoracic Surgery Toronto East General Hospital
Chest tube insertion
• Chest tube insertion is an essential skill for the general surgeon in Ontario
Pneumothorax
• Indications for chest tube insertion: – Small, asymptomatic pneumothorax can be treated
expectantly – Moderate size, >25%
• 3 intercostal spaces off apex, off lateral wall, off diaphragm
– Tension pneumothorax – Significant bullous disease in contralateral lung – Persistent symptoms – Progression of pneumothorax
Pneumothorax
Pneumothorax
Pneumothorax
• Before inserting chest tube: – Ensure proper imaging – MAY NEED A CT SCAN – Patient (SDM) aware – Proper equipment and location
• Risks of chest tube insertion: – Bleeding – Lung injury – Pain – Infection
Pneumothorax
When do you need to admit a patient with a chest tube?
Pneumothorax
When do you need suction versus underwater seal?
Pneumothorax
• Tube selection: – Interventional radiology is needed only when image
guidance is required – Small bore chest tubes need not be inserted only by IR – Smallest tube possible to get the job done – Rarely need greater than 28 Fr chest tube for
pneumothorax
Pneumothorax
• Tube management: – Monitoring
• Daily CXR • Nature and volume of drainage and air leak
– Tubes should never be clamped (usually) – Functional status of tube (oscillation) – Maintenace of patency
• Milking and stripping • Irrigation not recommended
– Check dressing daily and daily changes needed – Airtightness of system
Pneumothorax
• Patient management: – Pain management
• Narcotics and stool sofeteners • NSAIDS
– Mobilization – Dressing changes, minimize adhesive tape
Pneumothorax
Bullae
Pneumothorax
Pneumothorax
Pneumothorax
• Contraindications for chest tube insertion: – Giant bulla – Previous thoracic surgery, pleurisy, pleurodesis,
hemothorax – INR > 1.8, PTT > 45, platelets < 100 – Therapeutic doses of heparin, coumadin, not prophylaxis – Therapeutic doses of antiplatelet therapies
Pneumothorax
• Indications for surgery: – Persistent air leak > 7 days – Large BPF
– Bilateral pneumothorax – Failure to re-expand lung with air leak – Significant contralateral bullous disease – Contralateral pneumonectomy – Specialized occupation (airline pilot, scuba diver) – Isolation from medical care – Recurrence
THANK YOU