This is small-bore percutaneous chest tube placement. In this session, we will review the placement techniques for two available kits on the market, reviewing the placement of the Wayne Pneumothorax kit, as well as a slightly larger galvanic chest tube placement. My name is Laura Frey and I'm faculty at the University of Wisconsin and a member of the Bronchoscopy Domain Task Force. Hi, I'm Tim Urgo. I'm faculty at the University of Chicago and I'm the chair of the Education Committee for Chest. Hi, I'm Eduardo Reyes. I'm faculty at the University of Wisconsin and a member of the Education Committee for Chest. We will quickly review the items that are in your Wayne Pneumothorax kit that will be used for insertion. This includes a Chloraprep to sterilize your space and a small drape. You may choose to use something larger than this finished drape, including OR towels or a whole-body drape. A small bottle of 1% lidocaine is also in the kit, as is a 25 and a 22 gauge needle. Once local anesthesia has been administered, we will perform an exploratory thoracentesis with a finder needle with two different lengths available in the kit. After the needle has been inserted, we will transition to guide wire placement with a small incision made with the scalpel. A 14-inch dilator is in your kit, followed by the chest tube, including a three-way stopcock and the obturator for the chest tube placement. Once the chest tube is in place, it is connected to vinyl connector tubing. And you do have a Heimlich valve in your kit, though you may choose to connect this up to a pleurovac. Again, the Heimlich is blue to body for connection. We've been called to the bedside to place a chest tube in a patient with a pneumothorax. Our patient is already positioned in the left lateral decubitus position for a right-sided pneumothorax seen on imaging. We will begin by identifying our landmarks for our triangle of safety, identifying the axilla, the posterior aspect of the pectoralis major, the anterior aspect of the latissimus dorsi, and then the dome of the diaphragm at approximately the nipple line. This can be verified with ultrasound as well. We're using ultrasound first in the 2D mode, in the intercostal space. There is no lung sliding. Please switch to M mode. And on M mode, we see the classic barcode or stratosphere sign confirming the presence of pneumothorax at this point of contact. And that is where we will proceed with our catheter insertion. We will now proceed with sterilizing the space and placing a small fenestrated drape. We are prepping the space with tented chlorhexidine. And the fenestrated drape is placed over our previously identified entry site. We will now proceed with local anesthesia using 1% lidocaine, beginning with our small 25-gauge needle. Feel the rib. Numb up slightly just above the rib, making a wheel. And the intercostal space. And then transitioning to our slightly longer 22-gauge needle. We will use the 22-gauge needle to anesthetize the subcutaneous tissue, and potentially up to the pleura, depending on the patient's body habitus. We got there. Pull back two millimeters and inject more lidocaine on the parietal pleura. We will now advance our introducer needle over the rib into the pleural space, applying negative pressure as we advance the needle, so that we can see free aspiration of air or pleural fluid, depending on the indication for chest tube placement. Tangential to the rib, perpendicular to the chest wall, getting bubbles. Once we have free aspiration of air, the syringe will be removed, and a guide wire will be inserted into the pleural space. Sometimes at this point, we orient the needle in the direction where we want the catheter. In this case, it will be anterior and apical, because we're doing the procedure for the pneumothorax. Guide wire, please. Stabilizing the needle. Advance the guide wire. Once the guide wire is inserted, the needle can be removed, and we will make a small incision into the skin and subcutaneous tissue using the scalpel available in the kit. Again, if possible, parallel to the rib. For a small bore chest tube like this, probably 0.5 to 1 centimeter incision will suffice. As you make your incision, ensure that you have free movement of your wire within the incision. Go for it. Now that the guide wire is inserted and a skin incision has been made, we will proceed with dilation of our tract using a 14 French dilator. The wire is fed through the dilator, and once it passes through the other side, is grasped by the operator. It doesn't need to go deep, just enough to dilate the intercostal space. Once dilation is complete, we will take our chest tube and our obturator, passing the obturator through the chest tube and the three-way stopcock. Of note, the obturator does not go beyond the tip of the tube, and it locks right here at the three-way stopcock. Once the obturator is in place, the catheter and the obturator can be inserted over the guide wire as one unit. The wire is withdrawn until it comes out the distal aspect of the obturator, and then the chest tube is advanced through the chest tube and the three-way stopcock. The chest tube is then pulled out of the obturator. The chest tube is then pulled out of the obturator, and the chest tube is advanced through the chest tube. And to the pleural space. We will now remove both the guide wire and the obturator end block, and be prepared to connect our vinyl connector tubing. The vinyl connector tubing can be connected to the Heimlich valve in the setting of a pneumothorax, or potentially to a drainage device, like an atrium. We are now ready to secure our chest tube. We will now secure our chest tube using a 3-0 silk suture. We again begin with a simple interrupted suture to create an air knot at the patient's skin, and then we will secure the chest tube using a 3-0 silk suture. We will now secure the chest tube using a 3-0 silk suture. Cut the needle, please. And then just secure the suture around the tube. Again, everyone is different at this point. I personally like to double the knot, just because it doesn't slide that easily. Cut. Cut. The final step is to place the dressing. We will place one small 4x4 gauze underneath the chest tube to prevent kinking at the exit site, and then an additional 4x4 over the chest tube site. This will then be secured in place using a Tegaderm or tape.

small-bore percutaneous chest tube placement

Wayne Pneumothorax kit

galvanic chest tube placement

ultrasound guidance

chest tube insertion