In the world of trauma, tube thoracostomy, or chest tubes, are common place. A variety of indications exist for their placement: pneumo-, hemo-, pneumohemothorax to mention the highlights. It doesn't need to be reiterated that proper technique is required for the thoracostomy tube to function as intended. Misplaced tubes are the bane of the chief surgical resident's existence at our program. Whether placed subcutaneously, intraparenchymal, or in the wrong location, a misplaced tube is a set up for increased hospital stay, further procedures and, in the extreme setting, a trip to the operating room for a thoractomy. So much emphasis is placed on placement that it often seems the proper technique for removal is overlooked. Interns are left to pull tubes having only seen this done or been taught how to once or twice with no real oversight. The result is the dreaded post-pull pneumothorax. So how do we best prevent this and what should our algorithm be with the occasional post-pull pneumothorax.
Does technique matter?
The major principles of removing a chest tube are fairly constant. These are discussed in detail in the following section. There does exist one matter of debate when pulling chest tubes. That is should the tube be pulled at end-inspiration or end-expiration. A study from the Journal of Trauma in 2001 out of Yale looked at this very matter. They did a prospective trial, randomizing patient's into pull at end-expiration vs pull at end-inspiration. They found that the rates of post pull pneumothoraces were similar and not statistically significant (8% for end-inspiration and 6% for end-expiration). The conclusion was both techniques were equally safe. A more recent study from the division of CT surgery at UAB also looked at this question. In a study published in the Journal of Thoracic and Cardiovascular Surgery, they also randomized patients to pull at end-inspiration vs end-expiration. Of note, these were not trauma patients, but rather patients post pulmonary resection. They found that 32% had a larger or new pneumothorax in the end-inspiration group vs 19% in the end-expiration group (P=0.007). However, of those with post pull pneumothoraces, only 3% required intervention or delayed discharge in the end-inspiration group vs 1% in the end-expiration group (P=0.78). In the end, the majority of the literature states that either method is acceptable.
My personal technique.
We all have been taught some way to pull tube thoracostomies. Chances are we all do it a little differently. As with most learned procedures, it comes down to sticking with the basic, required principles and finding a technique that is reproducible in terms of outcome for you as an individual. To this day I do my central lines the same way, every time, down to every last detail. There is almost no thought, just muscle memory. It is my opinion that pulling chest tubes should be the same. The main principles will apply to whichever technique you prefer. These are: ensuring the tube is off suction, removing the skin suture or whatever fixation to the skin was placed originally, and placing an occlusive dressing with simultaneous removal of the tube at a quick pace. Sounds easy enough right? Then why so many post pull pneumos? I believe it is all in your preparation and the details. So here is my personal offering, take it or leave it. I learned this from a thoracic surgeon at our community hospital. He was well into his 70's and literally sat me down as a second year resident and spent a good 45 minutes teaching me his philosophy on pulling tube thoracostomies. Initially I thought this was a waste of time. However, looking back, I now can appreciate how taking your time during the initial learning process is valuable. Especially since every time I pull a chest tube, I use the same technique he taught me, with his voice echoing in the back of my head.
How to. It's all in the preparation. Get everything you will need for removal and have it in the patient's room. No running off halfway through because you forgot tape. Here is the supply list I use: 2 boxes of 4 by 4's, one Vaseline dressing, one chuck, a roll of 3 inch silk tape, a suture removal kit, and a scalpel as a backup. The first thing I do is begin to fashion my dressing. On a sidetable, take three pieces of silk tape and fashion them into a square that is ~ 7 inches by 7 inches, with the sticky side facing up. Next, place two 4 by 4's flat in the middle of this dressing. Place this to the side. Next open the vaseline dressing and fold it so that it is about ½ inch larger than the size of the opening in the skin you will be covering. You then need to take about five 4 by 4's and separately fold them into fourths, stacking them on top of each other. Place the folded vaseline guaze at the base of this “bump” of folded 4 by 4's. Your “bump” should be a good two inches high once it is made. This is what you will use to directly cover the chest tube site as you are removing the tube. Next, turn your attention to the patient. Ensure the chest tube is off suction. Take down your chest tube site dressing and throw it away, leaving the site exposed. Place a chuck beneath the chest tube on the bed, about at the location of the connector. This will ensure a clean bed and thus, a happy nurse. Examine how the chest tube is sutured in. Use your scissors from the suture removal kit to cut the suture tethering the tube to the skin. If it is too tight, use the scalpel. While doing this ensure that one of your hands is firmly holding the tube so it doesn't change position. With the other hand grab your “bump,” which consists of the folded 4 by 4's and vaseline dressing. Place this directly over the site of the chest tube incision, pressing down firmly. The goal is to simultaneously press down the occlusive “bump” dressing as you quickly pull the tube out and into the chuck. I personally have the patient take a deep breath and hold it, and then do the pull (end inspiration). As noted above, the data out there could support the pull at end inspiration or end expiration. Pick one and stick with it. Now the tube is in the chuck, leave it there. Your other hand is pressing the occlusive “bump” dressing over the prior tube site. The patient should have some slight discomfort with the amount of pressure you are applying. With your now free hand, grab the 7 by 7 inch dressing you originally fashioned and carefully place it over your “bump” occlusive dressing, thus creating a nice tight, final dressing. If you have done it properly, the dressing will not be flat, but will be elevated in the middle at the site of your “bump,” creating a pseudo pressure dressing over the occlusive portion. Toss the chuck with the chest tube into an appropriate trash can and order your post-pull chest x-ray.
Post-pull Management Algorithm.
In the event of a post-pull pneumothorax, it is important to have an algorithm of how to treat this occurrence. The literature doesn't directly address this but a good rule of thumb is as follows: treat the patient, not the x-ray. Depending on the size of the pneumo, watching the patient clinically is acceptable. Generally, at our institution, the patient is watched clinically for an established period of time (6-8 hours) and the x-ray is repeated to evaluate for progression. If the pneumothorax is increasing in size, action may need to be taken depending on the overall clinical picture. If the pneumothorax is stable on repeat, then no further imaging is required unless clinically indicated.
References
Bell RL, et al. Chest tube removal: end-inspiration or end-expiration? J Trauma. 2001 Apr;50(4):674-7.
Cerfolio RJ et al. Optimal technique for the removal of chest tubes after pulmonary resection. J Thorac Cardiovasc Surg. 2013 Mar 15. pii: S0022-5223(13)00157-8. doi: 10.1016/j.jtcvs.2013.02.007. [Epub ahead of print]
this post submitted by Dr. Ben Veenstra
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