This is your large bore percutaneous chest tube set. This is the 20 French Falquick set. Unlike the tray, this is missing a few pieces that you would need to utilize for placement. This set has an introducer needle, your guide wire, a scalpel for your incision, your available dilators, in this kit a 14 and a 22, and has your 20 French Falquick chest tube with an obturator. 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. Drape please. 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. Now I'm 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 insert the introducer needle into the pleural space, applying negative pressure as we insert our needle to ensure the visualization of aspirated free air or fluid, depending on the indication for chest tube placement. Up the rib, perpendicular to the chest wall, aspirate, getting air. Again, depending on the indication, the needle can be oriented at this point. I'm orienting it cephalad and anterior while continuing to aspirate to assure you're still in an air bucket. The syringe is now removed and the guide wire is inserted through the introducer needle. That's by stabilizing the needle. Patient may feel some discomfort at this point, especially if the wire touches the diaphragm. The guide wire should be inserted to at least 10 centimeters. And once it's inserted, the introducer needle is removed and a small skin incision should be made. The size of the incision will depend on the size of the thalpic tray that you are using as these tubes come in a variety of sizes. Here we are placing A20 French. Again, small, 0.5 to 1 centimeter incision. It should be not too tight to the skin to allow for an atraumatic dilation. And we dissect until we see some subcutaneous fat protruding through the incision. We will now proceed with sequential dilation of the tract, beginning with the 14 French dilator. The guide wire is retrieved at the distal aspect of the dilator, ensuring free movement of the guide wire as we insert the dilator. Once we've had successful dilation into the pleural space, we will use our second dilator, in this kit, A22 French dilator. This will be a little harder, obviously. We again verify free movement of the wire and remove the dilator. We will now insert our 20 French chest tube with the obturator over the guide wire. The chest tube and the obturator will be advanced as one unit over the guide wire. Like with any modified Seldinger technique, we need to see the wire at the proximal aspect of the tube. Like now, holding the wire as we advance the tube. The chest tube has now advanced to the desired depth. We're at 15 centimeters. And the obturator and the wire are removed in block. We will now connect our chest tube to our drainage device. Connecting to the atrium on water seal or suction if desired. For extra safety, one could secure the tube here using zip ties. And then we close the incision and secure the tube at the skin. We are closing our incision using a curved needle with silk suture. We begin with a simple interrupted suture to create an air knot. Cut. And once we are secured at the skin, we will secure our chest tube. And again, depending on your style, you may choose to make a surgical knot or just kind of double the knot here. And for extra security, you may want to go one more time. And again, double. We have completed securing our chest tube and removed our drape and are now ready to place our dressing. We've placed one 4x4 gauze underneath the chest tube to prevent kinking, and we'll place additional gauze over the top of the chest tube. This can then be secured in place using either a Tegaderm or foam tape.

large bore percutaneous chest tube

pneumothorax

ultrasound

local anesthesia

sequential dilation