Tube InsertioN

The Procedure In Gif Format...

• Clean the insertion site with chlorhexidine or iodine.
• Create a sterile field by draping four sterile towels and a large sterile drape to frame the insertion site.
• Maintain sterile field throughout the procedure.
• Prepare the chest tube by cutting the external end to fit onto the atrium tubing and clamp it with Kellys.
• Anesthetize the skin and subcutaneous tissue. Too little anesthesia is the most common mistake.
  • Start with the skin and subcutaneous tissue using lidocaine 1% with epinephrine.
  • Advance the needle until it hits the rib inferior of the selected intercostal space and inject anesthetic over the periosteum. Then inject over the superior rib in a similar manner.
  • While continuously aspirating, advance the needle over the inferior rib and into the pleural space (evidenced by return of air or blood). Withdraw the needle until the return of air ceases and inject onto the parietal pleura.
• Make a superficial skin incision, 1.5-2 cm in length, parallel to and overlying the rib inferior to the selected intercostal space.
• Create a subcutaneous track using Kelly clamps for blunt dissection.
• Keeping the Kellys in the closed position, advance over the inferior rib until the pleura is breached (confirm with “pop”/loss of resistance), then open the Kellys and withdraw them to create a tract.
• Insert one finger into the pleural space to confirm intrapleural location and rotate to identify lung and break up adhesions.
• Advance the chest tube into the pleural space using Kellys to guide it into appropriate position, anterior and superior for pneumothorax and posterior for hemothorax.
• Remove the Kellys and advance the chest tube to the appropriate depth.
• Confirm with chest radiograph before securing. 

Securing the Tube

1. Close half of incision with a single simple suture
2. Place a second suture close to the thoracostomy tube
3. Wrap remaining suture around tube to anchor and, leaving the ends long, tie down to the thoracostomy tube
   • This tie will be cut upon removal of the tube and the long ends can be used to close skin after tube removal
4. Occlusive dressing
   • Cut a Y-cut into stack of 4x4 gauze ~2-3 layers thick
   • Apply bacitracin/petroleum on one side of the gauze
   • Place petroleum impregnated gauze around the thorocostomy tube with the petroleum against to the incision
   • Apply 2-3, 4” by 8” tegaderm pieces over occlusive dressing to hold it in place