Thoracostomy The insertion technique for emergency pleural drainage is described in detail in an article of the NEJM. The free end of the tube is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest. Alternatively, the tube can be attached to a flutter valve. This allows patients with pneumothorax to remain more mobile. British Thoracic Society recommends the tube is inserted in an area described as the "safe zone", a region bordered by: the lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi and a horizontal line superior to the nipple. More specifically, the tube is inserted into the fifth intercostal space slightly anterior to the mid axillary line.<unk> s are usually inserted under local anesthesia. The skin over the area of insertion is first cleansed with antiseptic solution, such as iodine, before sterile drapes are placed around the area. The local anesthetic is injected into the skin and down to the muscle, and after the area is numb a small incision is made in the skin and a passage made through the skin and muscle into the chest. The tube is placed through this passage. If necessary, patients may be given additional analgesics for the procedure. Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied to the area. Once the drain is in place, a chest radiograph will be taken to check the location of the drain. The tube stays in for as long as there is air or fluid to be removed, or risk of air gathering.<unk> s can also be placed using a trocar, which is a pointed metallic bar used to guide the tube through the chest wall. This method is less popular due to an increased risk of iatrogenic lung injury. Placement using the Seldinger technique, in which a blunt guidewire is passed through a needle (over which the<unk>  is then inserted) has been described. Protocols to maintain<unk>  patency by preventing<unk>  clogging are necessary. Postoperative drainage The placement technique for postoperative drainage (e.g. cardiac surgery) differs from the technique used for emergency situations. At the completion of open cardiac procedures,<unk> s are placed through separate stab incisions, typically near the inferior aspect of the sternotomy incision. In some instances multiple drains may be used to evacuate the mediastinal, pericardial, and pleural spaces. The drainage holes are placed inside the patient and the<unk>  is passed out through the incision. Once the tube is in place, it is sutured to the skin to prevent movement. The<unk>  is then connected to the drainage canister using additional tubing and connectors and connected to a suction source, typically regulated to -20 cm of water. Dressings After suturing, dressings are applied for hygienical reasons covering the wound. First, a y-slit compress is used around the tube. Second, a compress (10 x 10 cm) is placed on top and finally an adhesive plaster is added in a way that tension is avoided. A bridle rein is recommended to fix the tube to the skin. This tape bridge will prevent the tube from moving backwards and the possibility to cause clogging. It also prevents pain as it reduces tension on the fixation stitch. Alternatively, a large adhesive plaster that functions like a tape bridge may be used. Management<unk> s should be kept free of dependent loops, kinks, and obstructions which may prevent drainage. In general,<unk> s are not clamped except during insertion, removal, or when diagnosing air leaks.<unk>  clogging with blood clots of fibrinous material is common. When this occurs, it can result in retained blood around the heart or lungs that can lead to complications such as hematoma that needs to be drained, effusions, empyema, or, in the long term, fibrothorax. Thus its critical to maintain<unk>  patency. Manual manipulation, often called milking, stripping, fan folding, or tapping, of<unk> s is commonly performed to clear<unk>  obstructions. However these approaches are controversial. No conclusive evidence has demonstrated that any of these techniques are more effective than the others, and no method has shown to improve<unk>  drainage. Furthermore,<unk>  manipulation has proved to increase negative pressure, which may be detrimental, and painful to the patient. For these reasons, many hospitals do not allow these types of manual tube manipulations. One option is active<unk>  clearance without breaking the sterile field. According to a consensus of multiple experts in cardiac surgery, anesthesia and critical care in 2019 the ERAS Guidelines for Perioperative Care recommends active clearance of<unk> s to prevent retained blood and other complications. This was given an IB-NR rating, meaning, it should routinely be performed. Makeshift efforts such as open<unk>  clearing that involves breaking the sterile environment separating the<unk>  from the drainage canister tubing to suction it out should not be performed (Class III, A). Side of placement In December 2018 the European Respiratory Journal published correspondences that raise the possibility of improving mobility as well as patient outcomes by placing a<unk>  more optimally.
Chest tube
Chest drainage
Tracheal tube
Pulmonary bay
Quinton catheter
Intrapleural pressure
Thoracostomy
Thoracotomy