Chest Tube Hero

Don't worry Mark, I did this back on "ER"!

Placing a tube thoracostomy, like an intubation or emergent cricothyrotomy, is one of several critical interventions performed by emergency physicians.  These procedures can quickly change the patient's course away from certain demise offering us a sense of instant gratification. That, and it's pretty darn sexy.

However, like proper endotracheal tube positioning and strict adherence to the cricothyroid membrane, placing a chest tube involves more than just incising the tissue and blindly pushing a tube until the last hole goes in. In this post we review select pearls for optimal passage of the thoracostomy tube to achieve proper posterior-apical placement, as well as a solid approach to securing the tube once you're in.

As a means of crediting my fellow Shock Trauma teammate/thoracic surgery-enthusiast Dr. Brian "Mitz", who first showed me the technique, we shall henceforth refer to this approach as the Mitz method of tube thoracostomy.

Step 1: Know your landmarks before you cut

If you don't cut through the muscle (borders), your patient will thank you

In the above schematic of the axilla (done to the best of my abilities on Microsoft Paint) you'll notice the optimal site for your incision--which should be no longer than 2 cm, just large enough to accommodate your finger--located in the 4th (depicted here) or 5th intercostal space. The trick to never missing your mark, especially with those patients whose habitus does not lend itself to Netter's, is palpating out your borders:

• follow the lateral fold of the pectoralis major superiorly (patient supine)
• follow the border of the the lattissimus dorsi inferiorly (supine)
• find the apex where these two landmarks converge cephalad
• feel (if possible) the inferior angle of the scapula
• in large females, find the inferior mammary fold

Step 2: A "rightful" passage

The trick to getting your tube positioned posterior-apically with beautiful surgical precision is to guide the tube toward the posterior (concave) surface of your corresponding rib (that's rib 4 in the 4th IC space and 5 if entering through the 5th IC space) with the clamp. Getting your tips to the back end of the rib may require some pivoting caudally-inferiorly against the patient's skin surface (see images below). Once you feel the clamp's tips touching the rib surface, unlatch while continuing to hold in place and carefully advance the tube.

Note: incision NOT to scale! (Tube not shown)

The following image depicts guiding the clamp (with tube) toward the posterior rib surface. Always make sure your clamps track along the top of the rib so as to avoid lacerating the neurovascular bundle in the inferior angle.

Black is air (pneumothorax), pink is lung (partially collapsed)

Step 3: Securing the tube (like a boss):

Once you've passed the tube posteriorly (and apically) and the final perforation is within the pleural cavity, it's time to lock it down (suture it down, that is). In the Mitz method, securing the tube involves a series of "figure-4" ties. 

"Did someone say figure 4?? Woooooo!"

• Start with a simple interrupted on one side of the tube
• Form a "figure-4" with one tail over the tube (cut the needle off first, it's no longer needed)
• Repeat with your other tail--the two ends should remain on opposite sides after
• Tie these down using a surgeon's knot (double throw) and cinch down the tube. This will be your most important knot. 
• Wrap each tail around the tube
• Tie down again, no surgeon's knot needed here

See figure below for an illustration

Now apply your favorite dressing, connect to a vac system, and get your chest x-ray champ.

Stay tuned for a video representation of the technique....