94 Section I / Overview and Background Surgical Information

J-tube	Jejunostomy tube; used for feeding; may
	be a small-needle catheter (remember to
	flush after use or it will clog) or a large,
	red rubber catheter
Cholecystostomy tube	Tube placed surgically or percutaneously
	with ultrasound guidance to drain the
	gallbladder
T-tube	Tube placed in the common bile duct with
	an ascending and descending limb that
	forms a “T”
	Drains percutaneously; placed after com-
	mon bile duct exploration

CHEST TUBES

What is a thoracostomy tube?

What is the purpose of a chest tube?

How is a chest tube inserted?

Chest tube

To appose the parietal and visceral pleura by draining blood, pus, fluid, chyle, or air

1.Administer local anesthetic

2.Incise skin in the fourth or fifth intercostal space between the midand anterior-axillary lines

3.Perform blunt Kelly-clamp dissection over the rib into the pleural space

4.Perform finger exploration to confirm intrapleural placement

5.Place tube posteriorly and superiorly

Is the chest tube placed under or over the rib?

What are the goals of chest tube insertion?

In most cases, where should the chest tube be positioned?

How can you tell on CXR if the last hole on the chest tube is in the pleural cavity?

What are the cm measurements on a chest tube?

Chapter 16 / Drains and Tubes 95

Over to avoid the vessels and nerves

Drain the pleural cavity

Appose parietal and visceral pleura to seal any visceral pleural holes

Posteriorly into the apex

Last hole is cut through the radiopaque line in the chest tube and is seen on CXR as a break in the line, which should be within the pleural cavity

Centimeters from the last hole on the chest tube

96 Section I / Overview and Background Surgical Information

What is the chest tube	Suction, waterseal, collection system
connected to?	(three-chambered box, e.g., Pleuravac®)
	Suction	Water	Collection
	control	seal	chamber

To

From patient/

suction

chest tube

What are the three chambers

1.

Collection chamber

of the Pleuravac®?

2.

Water seal

3.

Suction control

Describe how each chamber of the Pleuravac® box works as the old three-bottle system:

Collection chamber Collects fluid, pus, blood, or chyle and measures the amount; connects to the water seal bottle and to the chest tube

	Chapter 16 / Drains and Tubes 97
Water-seal chamber	One-way valve—allows air to be removed
	from the pleural space; does not allow air
	to enter pleural cavity; connects to the
	suction control bottle and to the collection
	chamber

Suction-control chamber Controls the amount of suction by the height of the water column; sucking in room air releases excessive suction; connects to wall suction and to the water seal bottle

98 Section I / Overview and Background Surgical Information

Give a good example of a water seal.

Place a straw in a cup of water—you can blow air out but if you suck in, the straw fills with water and thus forms a one-way valve for air just like the chest tube water seal

How is a chest tube placed on water seal?

By removing the suction; a tension pneumothorax (PTX) cannot form because the one-way valve (water seal) allows release of air buildup

Should a chest tube ever be clamped off?

What does it mean to “run the system” of a chest tube?

No, except to “run the system” momentarily

To see if the air leak is from a leak in the pleural cavity (e.g., hole in lung) or from a leak in the tubing

Momentarily occlude the chest tube and if the air leak is still present, it is from the tubing or tubing connection, not from the chest

How can you tell if the chest tube is “tidling”?

Take the Pleuravac® off of suction and look at the water seal chamber: Fluid should move with respiration/ventilation (called “tidling”); this decreases and ceases if the pleura seals off the chest tube

How can you check for an Look at the water seal chamber on suction: air leak? If bubbles pass through the water seal fluid, a large air leak (i.e., air leaking into chest tube) is present; if no air

leak is evident on suction, remove suction and ask the patient to cough If air bubbles through the water seal,

a small air leak is present

What is the usual course for removing a chest tube placed for a PTX?

How fast is a small, stable PTX absorbed?

1.Suction until the PTX resolves and the air leak is gone

2.Water seal for 24 hours

3.Remove the chest tube if no PTX or air leak is present after 24 hours of water seal

1% daily; therefore, a 10% PTX by volume will absorb in 10 days