Chest tube insertion

General remarks

• Adequate training for the insertion of chest drains in a trauma setting reduces the occurrence of procedure-related complications.
• Prophylactic antibiotics reduces the risks of infectious complications and empyema.
• For drainage of a traumatic pneumo- or hemothorax a large drain (28-36 French) is advised. The preferential insertion site is the 5th intercostal space in the midaxillary line ('Safe Triangle').
• Ideally the chest tube should be aimed apically for a pneumothorax or basally for fluid. However, an effectively functioning drain should not be repositioned only because of its radiographic position.
• Drainage systems consist of a collection bottle, water seal and a suction control. Suction applied at 15-20 cm H2O is recommended for adequate drainage.
• Detection of occult air leaks before removal of the drain can be performed by temporary water seal or clamping of the drain followed by a chest x-ray.
• Removal of a chest drain at end-inspiration is as secure as end-exspiration.

Literature

1. American College of Surgeons. Advanced Trauma Life Support Program for Doctors. 7th ed. Chicago: American College of Surgeons; 2004
2. Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax. 2003;58:ii53-59
3. Baumann MH. What size chest tube? What drainage system is ideal? And other chest tube management questions. Curr Opin Pulm Med. 2003;9:276-281
4. Gonzalez RP, Holevar MR. Role of prophylactic antibiotics for tube thoracostomy in chest trauma. Am Surg. 1998;64:617-621
5. Evans JT, Green JD, Carlin PE, Barrett LO. Meta-analysis of antibiotics in tube thoracostomy. Am Surg. 1995;61:215-219.
6. Bell RL, Ovadia P, Abdullah F, Spector S, Rabinovici R. Chest tube removal: end-inspiration or end-expiration? J Trauma. 2001;50:674-677