CTT

Question 1

Things to know in CTT insertion

Answer 1

A. Preparation of materials
B. Preparation of the patient
C. Placement of chest tube
D. Hooking to drainage system
E. Monitoring
F. Troubleshooting

Question 2

Materials for CTT

Answer 2

1. Sterile gown and gloves
2. Sterile drapes and antiseptic
3. Local anesthetic (e.g., Lidocaine 2%, 20mg/mL)
4. Scalpel, blade 10
5. Large Kelly clamp
6. Chest tube
7. Suture (1-0 silk) and dressing
8. Drainage system

Question 3

How to prepare the patient

Answer 3

1. Position
   - 30-60 degrees head elevation (to lower diaphragm and decrease the risk for injury to the diaphragm, spleen and liver)
   - raise arm with hands behind the head
2. Monitoring
3. Site identification
   Inframammary crease in women - 5th ICS

Question 4

10 steps in chest tube insertion

Answer 4

1. Don PPE
2. Disinfect and drape
3. Anesthesize
4. Incise
5. Blunt dissection
6. Puncture of parietal pleura
7. Verification of parietal pleura penetration
8. Chest tube insertion
9. Verification of chest tube insertion
10. Suture, dress, and secure

Question 5

How to anesthesize

Answer 5

Anesthesia is the 3rd step
Use general local anesthesia, such as up to 4 mg/kg of locally injecteed 1% lidocaine with or without epinphrine
(max of 5 mg/kg of lidocaine)

Question 6

What to do while waiting for anesthesia to take effect?

Answer 6

1. Premeasure the estimated depth of chset tube by placing the tip near the clavicle with a gentle curve of chest tube toward the incision
2. Place a clamp on the tube to mark the maximum length that the tube should be inserted
3. Load blade

Question 7

How to perform skin incision

Answer 7

Skin incision is the 4th step
1. Make a 2-3 cm (ATLS) or 3-5 cm (Roberts and Hedges) oblique incision following the orientation of the ribs
2. Make the incision 1-2 cm below the interspace through which the tube will be placed (Tintinalli)
3. Use a No. 10 blade

3-5 cm is 2-3 fingerbreadths

Question 8

What is the 5th step in chest tube insertion?

Answer 8

Blunt dissection

Question 9

Remarks in puncturing the parietal pleura

Answer 9

Puncture of the parietal pleura is the 6th step
1. This is the most painful part, so an additional injection of local anesthetic may be done
2. Hold the kelly clamp near the tip to prevent sudden deep insertion and injury to underlying structure
3. Considerable force may be needed.
4. A pop will be heard, with gush of air or pleural fluid
5. Enlarge the hole to at least 2 cm, but avoid a large opening to reduce the risk of air leak

Question 10

Remarks on verification of pleural space penetration

Answer 10

1. Slide a sterile gloved finger over the clamp and into the pleura before withdrawing the clamp
2. Leave the finger in the pleural space to ensure that the hole is not lost
3. Make a 360-degree sweep to verify the correct space, to feel for adhesions, to clear clots

Question 11

Remarks on the actual insertion of chest tube

Answer 11

Chest tube insertion is the 8th step
1. direction:
- pneumothorax: toward the apex, away from the hilum and mediastinum
- hemothorax - toward the posterior and lateral

2. The tube should pass with little resistance, otherwise it may be passing subcutaneously, is in a fissure, or is abutting against the mediastinum
3. Rotate the tube 360 degrees to reduce the likelihood of kinking
4. Advance tube at least until the last side hole is 2.5 to 5.0 cm inside the chest wall, or until the previously placed clamp from the premeasure has reached in the insertion site

Question 12

How to verify chest tube insertion into the pleural space?

Answer 12

Fogging
Listen for breath sounds

Question 13

Remarks on suturing the tube

Answer 13

1. Use 0 or 1-0 silk or nylon sutures
   (Nylon sutures are acceptable but must be tied tightly or they will slip on the surface of the tube)
2. Tie the sutures tightly enough to indent the chest tube slightly and avoid slippage

Question 14

Methods of suturing

Answer 14

Stay suture
Horizontal mattress suture

Question 15

How to dress chest tube

Answer 15

Place an occlusive dressing of petrolatum-impregnated gauze.
Place another dressing at 90 degrees to the first

Question 16

Remarks on drainage and suction system

Answer 16

Recent studies have called into question the need for suction as opposed to a water seal without suction in patients with uncomplicated traumatic pneumothoraces and hemothroaces

Question 17

Troubleshooting: if a chest tube becomes blocked and a significant pneumothorax or hemothorax is still present…

Answer 17

1. Replace the tube or place a second chest tube on the affected side
2. Irrigating an occluded chest tube or passing a Fogarty catheter through it in an effort to reestablish its patency is not advised

Question 18

Troubleshooting: if a tube is kinked or dysfunctional or the sterile field has been lost and advancement is required….

Answer 18

Place a new tube in sterile fashion through the same tract

Question 19

Troubleshooting: if the tube has been advanced too far ….

Answer 19

Simply withdraw it to the correct depth

Question 20

Chest tube monitoring

Answer 20

1. Leave chest tubes in place on suction for at least 24 hours after all air leaks have stopped (if placed for a simple pneumothorax) or until drainage is seroius and <200 mL/24 h (if placed for hemothorax
2. However, in intubated patients, maintain chest tube throughout mechanical ventilation to prevent sudden development of a new pneumothorax