The Journal of Cardiothoracic Trauma

SURGICAL TECHNIQUES AND VIDEOS
Year
: 2020  |  Volume : 5  |  Issue : 1  |  Page : 33--34

Chest tube removal: Safety and rationality


Moheb A Rashid 
 Department of Surgery, Norwegian Northern Hospital, Gravdal, Lofoten Islands, Norway; Scandinavian Cardiovascular Surgery Center, Gothenburg, Sweden

Correspondence Address:
Moheb A Rashid
Editor-In-Chief, The Journal of Cardiothoracic Trauma




How to cite this article:
Rashid MA. Chest tube removal: Safety and rationality.J Cardiothorac Trauma 2020;5:33-34


How to cite this URL:
Rashid MA. Chest tube removal: Safety and rationality. J Cardiothorac Trauma [serial online] 2020 [cited 2021 May 14 ];5:33-34
Available from: https://www.jctt.org/text.asp?2020/5/1/33/304864


Full Text



Removal of chest tube thoracostomy (CTT) is a simple procedure, but it is one of the most critical processes in caring of cardiothoracic surgical patients. Removal of CTT is usually indicated when it's function has been fulfilled after cardiothoracic surgery, trauma, or pleural effusions of any reason. The techniques of CTT removal are different, and the optimal technique is yet to be established. Some techniques were slightly touched in the guidelines of the British Thoracic Society[1] and others,[2],[3],[4] but it was not touched at all in the just-in-time video of the chest tube presented by the American Association for the Surgery of Trauma - Advanced Trauma Life Support.[5] Securing the chest tube in place during its insertion has been previously described in details.[6],[7] This is to keep the drain in the desired position and to prevent the excessive movement of the drain in and out, and to prevent any spontaneous removal. The current technique of CTT removal after its insertion according to Rashid's technique[6],[7] has several advantages over the conventional methods,[1],[2],[3],[4],[5] as seen in the video and described below;

It helps to have safe and simple control over the wound by pulling up the previously placed mattress suture with the dominant hand while removing the tube with the nondominant handIt does not need placing a new suture to close the wound once the tube is removedIt avoids the use of petroleum gauze that could be a risk for delayed healingIt avoids moisturizing the wound and keeps it dry with a lesser risk of infectionIt allows direct inspection of the wound site through the semi-transparent duoderm (hydrocolloid extrathin film) for any signs of infectionIt avoids the bulky padding with large amount of dressings and tapes of the wound resulting in unnecessary restriction of chest wall movements that is already jeopardized particularly in trauma patientsIt provides perfect wound closure and yields a cosmetic scarOnly one person is enough to perform the procedure safely, thus minimizing the numbers of exposed personnel in case of suspected or confirmed COVID-19.

 Clamping a Chest Tube



I never recommend clamping a chest tube except for;

If the tube is accidentally inserted into a liver vein, vena cava, aorta or the heart. This is to stop the patient's exsanguination as a damage control maneuver[8]During testing the drainage system for air leaksDuring changing the bottles of the drainage systemWhen it is necessary to control the drainage amount as in case of chronic and huge pleural effusionsTemporary clamping in case of autotransfusions if applicablePrior to insertion in a suspected or confirmed Covid-19 patients.

 Chest X-ray



The author usually takes a chest X-ray after chest tube insertion, before and after its removal as well.

 Time to Remove a Chest Tube



When the detected (visually or digitally) air leaks are ceased and the lung is fully expanded with no residual pneumothorax (radiologically confirmed)When satisfactory 24-h fluid output is obtained. It differs slightly among institutions. However, <200 ml for non-infectious fluids,[8] and <50 ml in empyema during the last 24 h could be used as safe guidelinesNo scientific evidence to justify using suction while removing CTT.

 COVID-19 Pandemic Impact



We are well aware that CTT is an aerosol-generating procedure with a tube placed into the pleural cavity directly communicating with an injured lung which in turn is the best place housing the coronavirus, so this is an easy way of transmission of the coronavirus to the personnel. Therefore, we strictly follow precautions and guidelines for personal hygiene and correct using personal protection equipment. Furthermore, the following may be necessary;

A viral filter is recommended to be connected to the drainage system when suction is appliedBleach may be added if indicated to the water seal chamber of the drainage systemFor the removal process, only one person is enough to safely perform it with this technique compared to others.[3]

Acknowledgment

The author acknowledges the assistance of Dr. Mohammad Abdelhay Mahdi Rashid, MD for editing and reviewing the video.[MULTIMEDIA:1]

References

11. Laws D, Neville E, Duffy J, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the insertion of a chest drain. Thorax 2003;58 Suppl 2:ii53-9.
22. Dev SP, Nascimiento Jr. B, Simone C, Chien V. Videos in medicine. Chest-tube insertion. N Engl J Med 2007;357:15.
33. Tang AT, Velissaris TJ, Weeded DF. An evidence-based approach to drainage of the pleural cavity: Evaluation of best practice. J Eval Clin Pract 2002;8:333-40.
44. Younes RN, Gross JL, Aguiar S, Haddad FJ, Deheinzelin D. When to remove a chest tube? A randomized study with subsequent prospective consecutive validation. J Am Coll Surg 2002;195:658-62.
55. Advanced Trauma Life Support (ATLS) Companion. Just-in-time Videos. Chest Tube. 10th ed.. Version 2.5;2018.
66. Rashid MA, Wikström T, Örtenwall P. A simple technique for anchoring chest tube. Eur Respir J 1998;12:958-959.
77. Rashid MA. Chest tube insertion: A safe and simple technique. J Cardiothorac Trauma 2016;1:12.
88. Rashid MA. Intracardiac chest tube placement. The author's reply-Letters to the Editor. J Trauma 1999;46:529-30.