DateCreated:: [[20230204]] DateLastModified:: 20230406 FileFolder:: Textbook # Chest Tube Thoracostomy vs. Pigtail Catheters [[100 Welcome to Outlines of Technique in Cardiac Surgery]] ## Target Audience Anyone who deals with the thorax, and with thoracic disease that may result in collections of any fluid (including air) into the pleural space. This therefore includes (but is not limited to) the following health care practitioners: - Surgical personnel taking care of trauma patients. 80% of penetrating trauma can be handled by draining the pleural space. - Medical personnel taking care of mechanically ventilated patients, including Intensivists of all types, Anesthesiology staff, all those who care for patients who may be ventilated for procedures including Obstetricians/Gynecologists - Personnel whose recreational activities expose them to changes in atmospheric pressure, including air travel, scuba diving. As can be seen, this is a subject of broad interest. Moreover, these pathologic entities can present suddenly, and dramatically, so familiarity with procedures to treat them should be almost as ubiquitous as BLS/ACLS training. ## Broad Comparison of Pigtail Catheters and Chest Tube Thoracostomy | Pigtails | Chest Tube | |:---------------------------------------------------------------------:|:---------------------------------------------------------------------:| | Smaller size ranges | Larger size ranges | | More prone to kink | Less prone to kink | | Slicker surface, trickier to secure to skin with suture/tape | Easier to secure with suture/Tape | | Less painful in most studies | More painful in most studies | | Traditional: equally effective for PTX and Thin, Non-coagulable fluid | Traditional: equally effective for PTX and Thin, Non-coagulable fluid | | Traditional: less effective for thick and/or coagulable fluid | Traditional: more effective for thick and/or coagulable fluid | | Modern: RCT's show equally effective for hemothorax drainage | Modern: RCT's show equally effective for hemothorax drainage | | Insertion uses Seldinger Technique, less tactile information | Insertion more tactile, actual finger sweep of thoracic interior | The understanding of the differences between these two methods of access to the pleural cavity is in evolution, as can be seen from the table above. The discussion below focuses on the relative merits of these two techniques from the perspective of the spectrum of the acuity of the clinical situation. Pigtail insertion kits often come in a convenient, fully assembled tray, complete with sterile prep solutions, drapes, masks, gowns, local anesthetic, etc. Instructional materials are often available on the internet for your kit, and should be reviewed prior to insertion.[^a] Chest tubes are often separate from autoclaved sets of reusable instruments, and require the practitioner to forage for local anesthetic, stitches, pleural drainage canisters, etc. Fundamentally, the difference comes down to the method of insertion. The Seldinger technique relies on the safe insertion of a a flexible guidewire into the desired space through a needle. A relatively stiff dilator is usually inserted over the wire to create a channel for the catheter, before removing the dilator to insert the catheter over the guidewire into the space. Some larger pigtails use a system where the dilator is temporarily inserted into the catheter, and this assembly is slid dow the guidewire into the pleural space. The guidewire and the dilator are then withdrawn, leaving the catheter in the intended space. Whatever the method, the safety of this system depends on a few principles. 1. The needle must enter into the safe space, following a safe course that does not injure any other structure. Because the needle is necessarily sharp, and the surface low friction, very little tactile feedback is available to prevent entry into all but the most rigid structures (e.g, bones). 2. The guidewire, traveling through the needle, hopefully into the desired space, provides some, but not much more tactile feedback. If it has inadvertently entered the wrong structure or space, it will guide the dilator and catheter into the wrong structure or space, enlarging and exacerbating the resulting injury. 3. The flexibility of the wire is partially intended to preclude the chance of poking it unintentionally into a vital structure. The dilator is necessarily more rigid than the guidewire, and if the disparity of the rigidity is great, and/or the length of guidewire in the safe space insufficient, the dilator may "flip" the wire out of position, and the safe "rail" for insertion will be lost. The traditional chest tube thoracostomy involves the creation of a skin incision and subcutaneous tract at least large enough to allow a finger to palpate rigid structures like ribs as an anatomic guide to insertion. The creation of the subcutaneous tract is continued on top of the rib and just into the pleural space. This pleurotomy allows egress of at least some of the pleural contents immediately, but more importantly, it allows the operator to insert a finger into the pleural cavity, and sweep the bent finger 360 degrees in the space to identify dangerous anatomy, including potential pleural adhesions. ![[Finger Sweep.jpg]] ## Tension Pneumothorax Chief among the maladies that require this discussion is the Tension Pneumothorax. The key features of this condition and its treatment are: - Fluid, usually air, has entered the pleural cavity under sufficient pressure that it exceeds central venous pressure. This limits venous return to the heart precipitating arrest. It should always be considered during Pulseless Electrical Activity cardiac arrest. - This is a CLINICAL DIAGNOSIS, suggested by a typical scenario (e.g. penetrating trauma, positive pressure ventilation, etc) with increasing hypotension - There is no time to seek IMAGING, and the diagnosis should not rely therefore on imaging, though often imaging has already been obtained - It should be addressed by the quickest available method, by the nearest prepared pracitioner. All other concerns, including potential damage to lung parenchyma are of distant secondary concern in this situation. This includes - Large bore angiocaths in the second intercostal space on the midclavicular line - Pigtail catheters - Chest Tube Thoracostomy ## Inviolable Anatomical Principles for All Practitioners Two inviolable anatomical principles, no matter the acuity, that all practitioners must follow are: 1. Stay away from the heart in the left chest 1. Stay high and anterior (as in the angiocaths in the second intercostal space on the midclavicular line) 2. Stay high (4th interspace, which is roughly at the height of the left nipple in a male) and lateral/posterior to the midclavicular line 2. Insert the catheter into the chest on top of rib to avoid neurovascular bundle under the rib and potential for bleeding 1. For Seldinger Technique/Angiocaths. Broad infiltration with local anesthetic, If clinical situation allows. Then identify a rib below intended interspace by palpation or ultrasound, and intentionally aim the needle at the rib once the tip has passed through the skin. Once it hits the rib, pull it back, but not out of the skin, and angle it slightly upwards. Alternatively, withdraw the needle from the skin completely, and re-insert at the same angle a few millimeters above. In either case, repeat these steps, "bouncing" the needle off of the rib until it slides into the chest just on top of the rib. Then proceed with the steps required for your particular kit (i.e. pull back on the syringe upon which the needle is mounted, when fluid/air is withdrawn, advance guidewire into pleural space, etc.) 2. For Chest Tube Thoracostomy. Broad infiltration with local anesthetic, if clinical situation allows. Then identify a rib below intended interspace by palpation. Cut towards the rib with scissors, or probe and spread tissues down to the rib with Kelly clamp as per personal preference. Hit the rib with these instruments, then continue the tract into the pleural space by following the surface of the rib to the tissue immediately on top. In the extremely obese patient, the incision through the skin can be made first and through some of the fat, as long and as deep as is necessary to palpate the rib through the incision. ![[Needle Bouncing.jpg]] ## All Other Conditions Requiring Pleural Drainage OTHER THAN Tension Pneumothorax Is there time in your scenario to stop and consider? - Is the patient hemodynamically stable? - No hypotension Imaging can be consulted if it is available in time allowed by the scenario. Does the clinical situation suggest the possibility of loculation/adhesion that may complicate pleural drainage? - Is there a history of previous thoracic surgery? - Is there a history of previous chest tubes? - Is there a history of previous inflammatory disease of the lung or pleura, such as pneumonia, empyema, pleuritis, pulmonary fibrosis, etc.? Does the imaging suggest the presence of adhesions? - Ultrasound: Are there areas where lung is apposed to the pleura, but the lung does not slide with respiration at this point of the pleura? - X-Ray/CT: Is there evidence of loculation on these studies? Are air or fluid pockets in continuity? Unloculated fluid layers usually align according to gravity, and shift with changes in position. The more adhesions there are, the less likely that a tension pneumothorax can develop, as the adhesions resist the accumulation of air under pressure. The more adhesions there are, the more complex pleural drainage will be, and as it is less likely to be emergent, the better option may be image guided drainage. In the rare circumstance that evidence of threatening tension pneumothorax develops in a patient with evidence of adhesions, traditional chest tube thoracostomy is considered safer. The finger sweep maneuver will identify empty space, or identify and possibly clear light adhesions, permitting safe passage of a tube. If adhesions are identified, but cannot be cleared, the incision should be abandoned, and another should be created immediately at an alternate site. ![[Final Chest Tube Algorithm.jpg]] [^a]: https://www.cookmedical.com/products/cc_utpt_webds/#videos