Thoracic Drainage Thoracic Drainage ProceduresProcedures

Thoracic CavityThoracic Cavity

Thorax is a part of trunk that lies between Thorax is a part of trunk that lies between neck and abdominal cavityneck and abdominal cavity

BoundariesBoundaries

Superior thoracicSuperior thoracic ApertureAperture

Inferior thoracic ApertureInferior thoracic Aperture

Contents Of Thoracic CavityContents Of Thoracic Cavity

cardiovascular systemcardiovascular system heart heart and great vesselsand great vessels

respiratory systemrespiratory system trachea, bronchi and lungs trachea, bronchi and lungs

digestive systemdigestive system esophagus esophagus

endocrine glandsendocrine glands the thymus gland the thymus gland

nervous systemnervous system paired vagus nerves and the paired vagus nerves and the paired sympathetic chainspaired sympathetic chains

LymphaticsLymphatics thoracic duct thoracic duct

Thoracic Drainage Thoracic Drainage ProceduresProcedures Thoracostomy Thoracostomy

1.1. Needle thoracostomyNeedle thoracostomy

2.2. Tube Thoracostomy Tube Thoracostomy

ThoracentesisThoracentesis

PericardiocentesisPericardiocentesis

Tube ThoracostomyTube Thoracostomy ThoracostomyThoracostomy: : surgical formation of an surgical formation of an

opening into the chest cavity for purpose opening into the chest cavity for purpose of Drainageof Drainage

Tube thoracostomy is the insertion of Tube thoracostomy is the insertion of a tube (chest tube) into the pleural a tube (chest tube) into the pleural cavity to drain air or fluids cavity to drain air or fluids

IndicationsIndications

PneumothoraxPneumothorax

1.1. Open or closedOpen or closed

2.2. Simple or tensionSimple or tension Pleural effusion (Pleural effusion (Hydrothorax,Chylothorax, Hydrothorax,Chylothorax,

Empyema Empyema )) Hemothorax Hemothorax HemopneumothoraxHemopneumothorax

ContraindicationsContraindications

– CoagulopathyCoagulopathy– Pulmonary bullaePulmonary bullae– Pulmonary, pleural or thoracic adhesionsPulmonary, pleural or thoracic adhesions– Skin infection over the chest tube Skin infection over the chest tube

insertion siteinsertion site

Identify the patientIdentify the patient

Informed ConsentInformed Consent

Positioning Of PatientPositioning Of Patient

Triangle of safety

• Anterior border of the latissimus dorsi

• lateral border of pectoralis major muscle

• A line superior to the horizontal level of

the nipple

• An apex below the axilla

Injecting Local Anesthetic:•Locally In Skin•Perpendicular in chest wall•Pleural Space

Site of Insertion Of Drain

Incision Along Upper Border Of Rib

Drain sutured in place

Drain insertion

Digital exploration

Blunt Dissection With Clamp

Drainage SystemDrainage SystemChest tube is attached to a Chest tube is attached to a

drainage systemdrainage system thatthat Allows Allows air and fluid to leave the air and fluid to leave the chestchest

Underwater sealUnderwater seal with one- with one-way valve to prevent air & way valve to prevent air & fluid returning to the chestfluid returning to the chest

Expiratory positive pressureExpiratory positive pressure from the patient helps push from the patient helps push air and fluid out of the chest air and fluid out of the chest (cough, Valsalva)(cough, Valsalva)

GravityGravity helps fluid drainage helps fluid drainage as long as the chest as long as the chest drainage system is below drainage system is below the level of the chestthe level of the chest

SuctionSuction can improve the can improve the speed at which air and fluid speed at which air and fluid are pulled from the chestare pulled from the chest

Drainage SystemDrainage System

Tube open to atmosphere vents air

Tube from patient

Tube from patient

Tube open to atmosphere vents air

Fluid drainage2cm fluid

Straw under 20 cmH2O

Tube open to

atmosphere vents airTube to vacuum source

Complications Of Chest Complications Of Chest DrainDrainAcute complicationsAcute complications (technique) (technique)

Haemothorax, usually from laceration of intercostal vessel Haemothorax, usually from laceration of intercostal vessel (may require thoracotomy) (may require thoracotomy)

Lung laceration (pleural adhesions not broken down) Lung laceration (pleural adhesions not broken down) Diaphragm / Abdominal cavity penetration (placed too low) Diaphragm / Abdominal cavity penetration (placed too low) Stomach / colon injury (diaphragmatic hernia not Stomach / colon injury (diaphragmatic hernia not

recognised) recognised) Tube placed subcutaneously (not in thoracic cavity) Tube placed subcutaneously (not in thoracic cavity) Tube placed too far (pain) Tube placed too far (pain) Tube falls out (not secured) Tube falls out (not secured) Late complicationsLate complications

Blocked tube (clot, lung) Blocked tube (clot, lung) Retained haemothoraxRetained haemothorax Empyema Empyema Pneumothorax after removing drainPneumothorax after removing drain

Removal criteriaRemoval criteria

1.1. Absence of an air leak into the chest drain bottle, usually noted Absence of an air leak into the chest drain bottle, usually noted when the patient exhales forcibly or coughs. when the patient exhales forcibly or coughs.

1.1. The volume of fluid draining into the chest drain is minimal (10-The volume of fluid draining into the chest drain is minimal (10-20ml)20ml)

2.2. There is no evidence of respiratory compromise or failureThere is no evidence of respiratory compromise or failure

3.3. There is no coagulation deficit or increased risk of bleedingThere is no coagulation deficit or increased risk of bleeding

Preventing air re-entryPreventing air re-entry

Remove the drain at the height of inspirationRemove the drain at the height of inspiration

Tie The sutures ImmediatelyTie The sutures Immediately

Observe Site Observe Site

A repeat X-ray will be required following removal to detect any new A repeat X-ray will be required following removal to detect any new fluid or air collection.fluid or air collection.

Needle ThoracostomyNeedle Thoracostomy

INTRODUCTION

Its Needle Decompression Of Chest done when sign and symptoms are suggestive of tension pneumothorax

INDICATIONS

Rapidly deteriorating patient with severe respiratory distress who has signs and symptoms of life– threatening tension pneumothorax, such as:

– Progressively worsening dyspnoea. – Hypotension. – Shock. – Decreased or diminished breath sounds on the affected side. – Distended neck veins. – Tracheal deviation away from the affected side.

Needle Thoracostomy : ProcedureNeedle Thoracostomy : Procedure Preparation Of area

Needle Insertion

perpendicular to the chest wall level of the superior border of the third rib until needle is in

contact with the rib. Maintain negative pressure on the syringe

– a "popping" sound or "giving way" sensation – a sudden rush of air – ability to aspirate free air into the syringe

• Remove needle; leave cannula in place and secure it

• If there is no improvement, this procedure may be repeated.

ThoracocentesisThoracocentesis It is an invasive procedure to remove fluid from pleural It is an invasive procedure to remove fluid from pleural

spacespace

Indications:Indications:1.1. DiagnosticDiagnostic2.2. TherapeuticTherapeutic

Contraindications:Contraindications:1.1. CoagulopathyCoagulopathy2.2. Localized infectionLocalized infection3.3. Severe hemodynamic orSevere hemodynamic or respiratory compromiserespiratory compromise

Pre-requisite:Pre-requisite: Lateral decubiti and Erect XrayLateral decubiti and Erect Xray

Thoracocentesis ProcedureThoracocentesis Procedure

Obtain consentObtain consent

Position Of PatientPosition Of Patient

Percuss fluid level and go 1-2 spaces belowPercuss fluid level and go 1-2 spaces below

Preparation Of Skin SitePreparation Of Skin Site Local AnesthesiaLocal Anesthesia

SiteSite

– Enter thorax PosteriorlyEnter thorax Posteriorly– Stay 5-10cm lateral to spineStay 5-10cm lateral to spine– Ideally should stay above 9Ideally should stay above 9thth rib rib and below 7and below 7thth

– Maintain Negative Pressure In Syringe Enter Maintain Negative Pressure In Syringe Enter – At level of rib below the intercostal space.At level of rib below the intercostal space.– Advanced till fluid returnsAdvanced till fluid returns– 20-30ml fluid for diagnostic purposes20-30ml fluid for diagnostic purposes– 1-1.5litre for therapeutic purposes.1-1.5litre for therapeutic purposes.

ComplicationsComplications1.1. PneumothoraxPneumothorax2.2. Re-epansion edemaRe-epansion edema3.3. HemothoraxHemothorax4.4. InfectionInfection5.5. Subcutaneous hemotomaSubcutaneous hemotoma

PericardiocentesisPericardiocentesis Removal Of Fluid from Pericardial SacRemoval Of Fluid from Pericardial Sac

Indications:Indications:

TherapeuticTherapeutic cardiac tamponade, i.e. haemodynamic compromise due to cardiac tamponade, i.e. haemodynamic compromise due to

large/rapidly developing pericardial effusion.large/rapidly developing pericardial effusion. Management of a large pericardial effusion (>20 mm separation of Management of a large pericardial effusion (>20 mm separation of

pericardial membranes on echocardiogram (ECHO).pericardial membranes on echocardiogram (ECHO). Palliative in cases of metastatic neoplastic disease involving the Palliative in cases of metastatic neoplastic disease involving the

pericardium.pericardium.

DiagnosticDiagnostic Obtaining pericardial fluid for analysis.Obtaining pericardial fluid for analysis.

Contraindications:Contraindications: Bleeding Diathesis Bleeding Diathesis Aortic dissection as a cause of pericardial effusionAortic dissection as a cause of pericardial effusion Small and posteriorly located effusionSmall and posteriorly located effusion

ProcedureProcedure Pre-requisites:Pre-requisites:

Sterile procedure.Sterile procedure.

ECG monitoring equipment .ECG monitoring equipment .

Resuscitation facilities, i.e. defibrillator and emergency medications.Resuscitation facilities, i.e. defibrillator and emergency medications. Nowadays it is commonplace to perform the procedure under Nowadays it is commonplace to perform the procedure under

echocardiographic (ECHO) guidance. echocardiographic (ECHO) guidance.

Sit the patient at a 30-45º angle (this allows the pericardial fluid to Sit the patient at a 30-45º angle (this allows the pericardial fluid to pool inferiorly).pool inferiorly).

Selection Of Entry SiteSelection Of Entry Site

Local AnesthesiaLocal Anesthesia Incise the skin over the entry site (about 0.5 cm long) Incise the skin over the entry site (about 0.5 cm long)

The procedureThe procedure

Introduce the needle towards the Introduce the needle towards the pericardial space using ECHO guidance pericardial space using ECHO guidance

use the left sub sternal approach and use the left sub sternal approach and advance the needle towards the left advance the needle towards the left shoulder at a 15-20º angle from the shoulder at a 15-20º angle from the abdominal wall.abdominal wall.

Confirm via use of ECHO Confirm via use of ECHO

Mostly pericardial space is determined Mostly pericardial space is determined by a 'give' when the parietal pleura is by a 'give' when the parietal pleura is pierced and by obtaining flashback of pierced and by obtaining flashback of pericardial fluid.pericardial fluid.

Use Of Guide WireUse Of Guide Wire

After this, pass the soft-tipped cannula with After this, pass the soft-tipped cannula with multiple side-holes over the guide wire, i.e. a multiple side-holes over the guide wire, i.e. a pigtail catheter.pigtail catheter. Then remove the guide wire and Then remove the guide wire and

connect to drainage tubing and connect to drainage tubing and secure (sutures are usually secure (sutures are usually needed).needed).

Cannula may be left in situ for up Cannula may be left in situ for up to 24 hours to drain large to 24 hours to drain large effusions, with drainage under effusions, with drainage under negative pressure using a vacuum negative pressure using a vacuum container (most effective).container (most effective).

Post-procedure Post-procedure Closely observe and record vital signs and electrocardiographic Closely observe and record vital signs and electrocardiographic

(ECG) monitoring during and after the procedure, looking for (ECG) monitoring during and after the procedure, looking for evidence of complications, as listed below.evidence of complications, as listed below.

Consider post-procedure CXR and echocardiogram (ECHO) to Consider post-procedure CXR and echocardiogram (ECHO) to confirm the position of the cannula and to confirm the position of the cannula and to exclude exclude pneumothorax.pneumothorax.

ComplicationsComplications

1.1. Injury to myocardiumInjury to myocardium2.2. Coronary vessels perforationCoronary vessels perforation3.3. Pneumothorax.Pneumothorax.4.4. Cardiac arrhythmias (particularly bradycardia).Cardiac arrhythmias (particularly bradycardia).5.5. Peritoneal puncture.Peritoneal puncture.6.6. Laceration/puncture of abdominal viscera, particularly the liver.Laceration/puncture of abdominal viscera, particularly the liver.7.7. Internal mammary artery fistula (rare).Internal mammary artery fistula (rare).8.8. Purulent pericarditis (rare).Purulent pericarditis (rare).9.9. Acute cardiac decompensation and Acute cardiac decompensation and pulmonary oedema pulmonary oedema (rare).(rare).

Outcome Outcome Use of echocardiographic (ECHO) guidance has reduced Use of echocardiographic (ECHO) guidance has reduced morbidity from ~ 50% to <1% with mortality reduced from ~ 10% morbidity from ~ 50% to <1% with mortality reduced from ~ 10% to zeroto zero

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