|
Chest drains are usually of large diameter
(10 to 32 French depending upon patient size). A large diameter tube is necessary if being
used to remove viscous fluid from the pleural space.
A flexible, rubber feeding tube with
additional fenestrations (arrow) can be used as a chest drain. Fenestrations should be in
the most distal portion of the catheter (~ last 4 -5 cm). When the tube is in place, all
fenestrations should be within the pleural space rather than the subcutaneous space. The
white roller clamp is used to occlude the lumen of the tube when it is not being
aspirated. This clamp should be closed when placing the tube in the pleural space.
Pictured is an argyle styleted
thoracic drain. The stylet is placed inside the flexible plastic catheter. The end of the
flexible catheter is fenestrated for several centimeters. The sharp point is used to drive
the catheter through the chest wall.
 |
Pictured is a Jackson-Pratt drain which is
generally used for abdominal drainage. It also functions well as a pleural space drain.
The part of the drain labeled (a) is made of teflon and is very nonirritating to tissues.
The small black spots are multiple drainage holes. The teflon portion and part of the
clear plastic tubing will be positioned in the pleural space. The other end of the clear
tubing is attached to the bulb. The bulb (b) can be compressed to create a source of
constant suction to enhance fluid removal from the pleural space. |
 |
Sedation and local anesthetic
infiltration are generally adequate for drain placement. The chest wall should be clipped
of hair and scrubbed with antiseptic solutions. The animal is placed in lateral
recumbancy. The drain should enter the skin surface at the 10th intercostal space, tunnel
subcutaneously, 2 to 3 spaces, and penetrate the chest wall at the 7th or 8th intercostal
space. The insertion site should be at the junction of the dorsal and middle thirds of the
chest. The dog's head is to your right.
A skin incision is made with a scalpel blade in the
10th intercostal space, caudel to the 10th rib, at the junction of the dorsal and middle
thirds of the chest wall.
 |
|
Placement of a flexible, rubber
feeding tube is demonstrated. Before placing the chest tube, estimate the length of tubing
that will be inserted into the pleural space. Excessive length of tubing in the pleural
space can lead to the tubing becoming bent or twisted. The ideal position of the tip of
the tube is to lie along the sternum, anterior to the heart. Be sure to have ready an
adapter that can be firmly attached to the chest drain to allow attachment of a syringe.
The tubing should be clamped closed during placement. The feeding tube is held between the
jaws of a curved hemostat. Make sure that the jaws of the hemostat extend beyond the tip
of the catheter. The tip of the hemostat is used to puncture through the muscle of the
chest wall. It is difficult to puncture the chest wall if the tube is at the end of the
hemostat.
Pass the hemostat in an anterior direction
in the subcutaneous space for a distance of 2 or 3 rib spaces, then firmly drive the
hemostat through the chest wall at the 7th or 8th intercostal space. Keep the hemostat
close to the cranial aspect of the rib, in order to avoid the intercostal vessels located
on the caudel border of the ribs. It takes a considerable amount of force to drive the
hemostat through the chest wall. The hemostat should be at a 90 degree angle to the chest
wall when being driven through it. When the hemostat enters the pleural space, open the
jaws of the instrument and push the tube into the pleural space. Remove the hemostat.
Before the thoracic drain is sutured in place, attach a syringe to the catheter and remove
fluid and/or air to improve the patient's breathing ability. Then the catheter is clamped
closed and sutured in place.
 |
|
You can see the subcutaneous tunnel
traversing 3 intercostal spaces anterior to the skin incision and entering the pleural
space at the 7th intercostal space.
 |
Another technique that can
be used during insertion of any of the catheter types presented is to pull the skin in an
anterior direction so the skin over the 10th intercostal space is located over the 7th or
8th intercostal space. With the skin pulled forward, you can incise the oblique
musculature of the chest wall to make it easier to bluntly force the catheter through the
rest of the chest wall musculature. The catheter is driven through the chest wall at ~ 80
to 90 degree angle. The operator is pushing the catheter through the chest wall with her
right hand and is using her left hand as a "stop" to control the depth of
insertion into the pleural space.The subcutaneous tunnel is created when the skin is
released. This slide demonstrates placement of a styletted catheter. After penetrating the
chest wall, the catheter and stylet are angled forward and parallel to the chest wall, to
direct the catheter forward when it is slid off the stylet. (the dog's head is to your
right) |
 |
After the catheter is inserted into the
pleural space, a purse string suture is placed in the skin incision around the catheter.
The ends of the suture are left long and wrapped up and along the length of the tubing in
a finger trap or friction type suture. |
The subcutaneous tunnel is collapsed around
the tube with a suture. A 20 gauge hypodermic needle is passed underneath the subcutaneous
segment of the thoracic tube, taking care not to penetrate the tube with the needle.
Suture is threaded through the hypodermic needle, the needle is removed, and the suture
tied around the subcutaneous segment of the tube.
| 